Health inspection·November 15, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not administer medication as ordered by a physician for Resident 1. Residents Affected - Few Finding: Review of Resident 1's medical record indicated Resident 1 was admitted on [DATE] and had diagnoses including essential hypertension (HTN-high blood pressure). Review of Resident 1's physician's order, dated 7/31/24, indicated Norvasc (a hypertension medication) oral tablet 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth one time a day related to essential hypertension, hold for SBP (systolic blood pressure) <110 and HR (heart rate) <60. Review of Resident 1's November 2024 Medication Administration Record (MAR) indicated Norvasc oral tablet was administered from 11/1/24 to 11/11/24, except on 11/3/24, which documented sleeping. There was no documented BP or HR to administer Norvasc to Resident 1 on the MAR from 11/1/24 to 11/11/24. During an interview and record review on 11/15/24 at 1:30 p.m. with the director of nursing (DON), she confirmed the above record review and acknowledged that Resident 1's BP and HR should have been checked prior to administering Norvasc. Review of Resident 1's care plans indicated there was no care plan to address hypertension. During a telephone interview and record review on 11/25/24 at 10:05 a.m. with the DON, she confirmed there was no care plan to address Resident 1's hypertension and acknowledged a care plan should have been developed to address the resident's hypertension. During a review of the facility's undated policy and procedure titled Administering Medications, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary. During a review of the facility's policy and procedure titled Physician Orders, effective date 3/22/2022, the P&P indicated, Documentation pertaining to physician orders will be maintained in the resident's medical record. Current month's administration records will be maintained in the MAR/TAR Page 1 of 2 555060 555060 11/15/2024 Windsor the Ridge Rehabilitation Center 350 Iris Drive Salinas, CA 93906

F 0684 binders. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled Care Plan Comprehensive, effective date 8/25/2021, the P&P indicated, The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. Residents Affected - Few 555060 Page 2 of 2