Heritage Plaza Nursing Center

During an interview on 0n 08/18/2025 at 02:02 PM, the Director of Rehabilitation stated Resident #1 was not acting her normal self.

The Director of Rehabilitation stated Resident #1 was drowsy and unable to hold a conversation.

The Director of Rehabilitation stated she notified the DON of the change and stated she did not take Resident #1 for therapy that AM.

The Director of Rehabilitation stated the DON came to Resident #1's room and was able to arouse her and continued to get Resident #1 dressed.

During an interview on 08/10/2025 at 01:10 PM, the DON said she was not aware LVN A had not completed the required pain assessment documentation on Resident #1 until today.

The DON said when a prn medication was administered, the medication was entered on the electronic medication administration record.

Then, the assessment record for pain would open for further documentation by the administering nurse to complete.

The DON said it was important for coordination of care between staff and to monitor the proper effectiveness or lack of effectiveness that the Resident had experienced after taking the medication.

The DON said if the medications were not documented after being administered, the resident was at risk of having too much or too little which could result in harm.

The DON said she expected the staff to follow the protocol for medication administration.

Record review of the facility's policy titled, Medication Administration General Guidelines, Pharmacy Policy & Procedure Manual Section 7.1 dated 01/24, indicated, .2.

Facility staff administering medication shall comply with the following.1.

The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Facility ID: