Bayshire San Dimas Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure a change in condition (COC, an alteration in a resident's physical health that differed from their previous baseline) was reported to the Medical Doctor (MD) 1 in a timely manner for one of one sampled resident (Resident 1). This deficient practice resulted in delayed treatment for Resident 1 who had a displaced femoral fracture (a break in the thigh bone where the fragments shift out of their normal alignment). [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive, individualized, person-centered care plan (CP), for two of two sampled residents (Resident 1 and Resident 53), that addressed:A. The use of an anticoagulant medication [Eliquis] apixaban (medication used to treat and prevent harmful blood clots from forming or getting bigger) for Resident 1. B. The use of an anticoagulant (medications used to help prevent harmful blood clots) medication [Xarelto] rivaroxaban (a medication that helps keep the blood from forming dangerous clots) for Resident 53. This deficient practice had the potential to result in unmet individualized anticoagulant therapy needs for Residents 1 and 53 and the potential to affect the resident's physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:a. Their process for OTC product self-administration (the process where patients manage and take their own medications) of medications was followed, for two of two sampled residents (Resident 12 and Resident 9), when Resident 12 and Resident 9 had a non-legend product (drug that can be purchased over-the-counter [OTC] without a prescription) at their bedside without a physician's order or a consent (permission for something to happen or an agreement to do something) for self-administration.b. One of one sampled resident's (Resident 47) physician was notified of Resident 47's, who was newly admitted to the facility, soiled surgical dressing on 4/7/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate interventions to prevent the development or worsening of existing pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony area that results in damage of underlying tissue) for two of two sampled residents (Residents 29 and 46) when:a. Resident 29's alternating pressure pump (APP - a device that inflates and deflates parts of a mattress to reduce pressure on the body and help prevent PIs, redistributing weight and improving circulation) was not set according to Resident 29's weight or Resident 29's comfort level.b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in one of one kitchen (Kitchen 1) when:a. An opened package of cheese in the walk-in refrigerator was unlabeled and not marked with the open date.b. One of two shelving racks in the walk-in refrigerator had amber discoloration, peeling paint, and was not smooth to touch.c. The walk-in freezer was observed with food and debris on the ground. These failures had the potential to result in pests, foodborne illnesses (an illness from eating contaminated food), and cross-contamination (transfer of harmful bacteria from one place to another) placing residents (in general) at risk and significantly impacting the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices when:a. Certified Nursing Assistants (CNA) 3 and CNA 5 failed to don (put on) proper PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while taking care for one of six sampled residents (Resident 5) who was on EBP (enhanced barrier precautions - an infection-control practice to prevent the spread of bacteria in nursing homes)b. One of one sampled staff (LA, Laundry Attendant) failed to store LA's personal belongings away from the clean area of the facility's laundry room.c. [...]

Inspectors wroteBased on interview and record review, the facility's licensed staff failed to obtain and/or ensure an accurate informed consent for the administration of a psychotropic medication, (a drug that affects the brain and changes how an individual feels, thinks, or behaves) alprazolam (Xanax, a medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations] and panic disorders [treatable anxiety disorder characterized by recurrent, unexpected panic attacks - sudden episodes of intense fear accompanied by physical symptoms like a racing heart, dizziness, and shortness of breath] by calming the brain and nerves), was obtained prior to the medication's administration for one of one sampled resident (Resident 15). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents' (Resident 27) assessment accurately reflected Resident 27's status in the Minimum Data Set (MDS - a resident assessment tool). This deficient practice could potentially result in compromised care to Resident 27 and the potential for Resident 27 not to receive the necessary care and services according to Resident 27's specific needs and due to improper care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was treated with dignity and respect when Licensed Vocational Nurse (LVN) 1 made Resident 4 use a bedpan (a shallow, portable receptacle shaped like a toilet bowl, used as a toilet by people who are too ill, injured, or immobile to get out of bed to use a regular toilet for urination or defecation) instead of assisting Resident 4 to the toilet in the bathroom. This failure made Resident 4 verbalized Do they (staff) wanted me (Resident 1) to die and had the potential to result in Resident 4 feeling disrespected and had the potential for Resident 4 experience a decline in psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was notified when Resident 1's medication was changed from tramadol (a medication used to treat pain) to norco (a medication used to treat pain) on 9/11/2025. This failure resulted in the violation of Resident 1's right to be informed of Resident 1's treatment for pain and had the potential in Resident 1 to experience unrelieved pain. (Cross Reference F580, F755, F806, and 5842)

Inspectors wroteBased on interview and record review, the facility failed to promptly notify Resident 1's doctor of Resident 1's complaint of pain and feeling that Resident 1's right hip was dislocated. This failure had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation. (Cross Reference F552, F755, F806, and F842)

Inspectors wroteBased on interview and record review, the facility failed to provide routine drugs for one of three sampled residents (Resident 1) when Resident 1 was not provided scheduled medications on 9/10/2025 at 9:00 PM. This failure had the potential to result in Resident 1 experiencing increased pain due to neuropathy (damage or dysfunction of nerves).(Cross Reference F552, F580, F806, and F842)

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) food allergy to bananas was:a. documented in Resident 1's assessment notes according to the facility's Policy and Procedure (P&P), titled Food Allergies and Intolerances, revised August 2017.b. Indicated on Resident 1's tray card (or tray ticket/meal ticket, a document that accompanies a resident's meal tray during preparation and delivery) according to the facility's P&P, titled Dietary Tray Card, revised 3/21/2024. These failures had the potential for Resident 1 to experience an allergic reaction to bananas.(Cross Reference F552, F580, F755, and F842)

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when:a. Licensed Vocational Nurse (LVN) 2 failed to document Resident 1's acute condition change on 9/30/2025.b. LVN 2 documentation regarding Resident 1's acute condition change, which was recorded on 10/1/2025, contained inaccurate information. This failure resulted in Resident 1's medical record to contain inaccurate information, Registered Nurse (RN) 1 to not be aware of Resident 1's acute condition change, and had the potential for Resident 1 to not receive timely treatment for pain and correction of the hip dislocation (a medical emergency where the thigh bone pops out of the hip socket).(Cross reference F552, F580, F755, and F806)

Inspectors wroteBased on interview and record review, the facility failed to provide care and services needed for one of three sampled residents (Resident 2), who required dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) by failing to ensure Resident 2 was provided with a means of transportation to and from dialysis treatments three times a week between 7/25/2025 and 8/13/2025. As a result of this failure, Resident 2 did not receive nine (7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/13/2025) dialysis treatments. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 8/13/2025 at 9:30 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 7, 27, and 83) and/or their Responsible Parities (RP) were offered and provided information regarding the right to formulate an advance directive (AD, legal documents that provide instructions for medical care and only goes into effect if the resident cannot communicate their wishes). This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making and the potential for Residents 7, 27 and 83 to receive unwanted care/treatment or unnecessary life-sustaining treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen when: a. [NAME] (CK) 1 was not wearing a hair net over CK 1's beard. b. A banana cream pie was observed in one of one walk-in freezer to be undated (not provided or marked with a date). c. A tray of green beans was observed in one of one walk-in refrigerator to be uncovered and undated. These failures had the potential for improper food storage and handling, which could lead to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 3) with dignity and respect when Certified Nursing Assistant (CNA) 1 referred to Resident 3 as a feeder. This failure had the potential for Resident 3 to feel disrespected.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician regarding pharmacy delays and inability to carry out the physician's order for Vagisil (a medication used to relieve vaginal itching, irritation, and burning) for one of one sampled resident (Resident 11). This deficient practice resulted in delayed provision of necessary care and services for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 27) was provided a safe and homelike environment when Resident 27's toilet leaked and caused water to puddle on the bathroom floor. This failure had the potential for Resident 27 to be injured from a fall and had the potential for Resident 27 to not be comfortable in his environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled staff members (Certified Nursing Assistant 5, CNA 5) maintained current BLS (Basic Life Support, generally refers to the type of care first-responders, healthcare providers, and public safety professionals provide) with Cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) certification. This deficient practice had the potential for CNA 5 not being able to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to any resident requiring such care during an emergency and prior to the arrival of emergency medical personnel. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing services on 2/3/2025, 2/5/2026 and 2/6/2025, for two of two sampled residents (Resident 19 and Resident 27), as indicated in the facility's policy and procedure (P&P), titled, Staffing, Sufficient and Competent Nursing. This deficient practice had the potential to affect the care provided to residents, quality of life, and the potential for the residents not to receive nursing services in a timely matter.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six facility staff (Certified Nurse Assistant 6, CNA 6) had necessary competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and skill sets required during a medical emergency. [...]

Inspectors wroteBased on interview and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff who were directly responsible for resident care per shift, daily. This information was not posted in a prominent location readily accessible to residents and visitors for viewing. This failure resulted in no posting of nurse staffing hours and had the potential to result in lack of nurse staffing hour knowledge for residents and family members.

Inspectors wroteBased on interview and record review, the facility failed to follow through with the Consultant Pharmacists recommendations during the Medication Regiment Review (MRR, a review of all medications the resident is currently using to minimize adverse consequences and potential risks associated with medications) for one of five sampled residents (Resident 21). This failure had the potential for Resident 21 to not receive the necessary blood tests for Resident 21's health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medication administration documentation for one of one sampled resident (Resident 11) when, the facility inaccurately documented the administration of Resident 11's Vagisil (a medication used to relieve vaginal itching, irritation, and burning) on 2/4/2025. This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for one of one sampled resident (Resident 11) by failing to ensure Resident 11's wound vacuum (a suction device that is applied after a wound is dressed) drainage tubing did not have direct contact with the floor. This deficient practice had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used by residents was maintained in a safe and operable condition, by failing to ensure the wheelchair brakes were fully functional for one of one sampled resident (Resident 11). This deficient practice had the potential to result in harm and could have negatively impacted the safety, and well-being of Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise (observe/watch) one of three sampled residents (Resident 1), who was at risk for elopement (leaving the facility without notice, leaving a safe area unsupervised without notice and permission) as indicated in the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, and Wandering and Elopements, by failing to: 1. Ensure Resident 1 did not leave the facility unsupervised on 10/17/24. 2. Ensure Laundry Attendant 1 (LA 1) identified and reported Resident 1 was seen standing by the storage room located in the Assisted Living (AL, housing facility for people with disabilities or for adults who cannot live independently) side of the facility's premise on 10/17/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely care was provided for eight of 11 sampled residents (Residents 4, 2, 3, 5, 6, 7, 8, and 10). This deficient practice resulted in the delay of care for Residents 4, 2, 3, 5, 6, 7, 8, and 10 and had the potential for other residents to not receive timely assistance for basic and/or emergent needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely discharge planning was implemented for one of three sampled residents (Resident 2) by failing to: 1. Consider Resident 2's caregiver (Resident 2's Representative [R2R]) capacity and capability to perform the required discharge care for Resident 2 and provide R2R with caregiver training prior to discharge of Resident 2. 2. Assess Resident 2 for the need of assistive device/s at home to safely perform activities of daily living (ADLs) and for mobility. 3. Arrange and confirm home health services (medical services provided at a person's home to treat a chronic health condition or help with recovery from illness, injury, or surgery) as ordered by Resident 2's physician before Resident 2 was discharged from the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) had an accurate discharge summary by failing to accurately assess and document Resident 2's discharge care needs and post-discharge plan to ensure Resident 2's safe and effective transition to Resident 2's home. These failures resulted in the lack of continuity of care and a delay in the provision of care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient and appropriate social services to meet the needs of one of three sampled residents (Resident 1) by failing to: 1. Ensure the Social Services Director (SSD) documented evidence of timely referrals to long-term care (LTC- health-related care and services [above the level of room and board] not available in the community, needed regularly due to a mental of physical condition) facilities certified under Medicaid (a joint federal and state program that helps cover medical costs for people with limited income and resources) for Resident 1. 2. Ensure the SSD updated and individualized Resident 1's discharge care plan. These failures had the potential to cause a physical and psychosocial impact to Resident 1's well-being due to unsatisfactory discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 2) when the facility did not accurately document Resident 2's legal decisionmaker/representative (R2R) on Resident 2's admission record. This failure had the potential to cause a delay in providing the care and services for Resident 2 related to the undocumented decision-making capacity of R2R regarding Resident 2's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of three sampled residents (Residents 2 and 3). This deficient practice had the potential to result in the delay of care for Residents 2 and 3 when Residents 2 and 3 were unable to reach their call lights to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge from the facility for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Transfer or Discharge, Preparing a Resident for. This deficient practice resulted in Resident 1 being discharged from the facility without the needed services ordered by the physician. This had the potential to put Resident at risk for injury, harm, and/or rehospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 14), to prevent the development of new pressure ulcers [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the others)] by failing to: Provide a Bariatric bed (specialized, heavy duty, wider and longer than a standard bed for tall resident) for Resident 14 who was six feet and five inches (6'5) tall. As a result, Resident 14 developed four facility acquired PIs (new PIs developed after the resident's admission to the facility) on the bilateral (both sides, left and right) great toes and heels.

Inspectors wrote2. During a review of Resident 173's admission Record, (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and neoplasm (cancer, a new and abnormal growth of tissue in some part of the body) related pain. During a review of Resident 173's BIMS (Brief Interview Mental assessment) SNF (Skilled Nursing Facility) Resident Interview, dated 1/25/23, the BIMS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). During a review of Resident 173's Order Summary Report, the Order Summary Report (OSR), with active orders as of 1/26/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP) for two for two of two sampled residents (Residents 174 and 12): a. For Resident 174, who required oxygen (O2) therapy, the resident's care plan did not address Resident 174's respiratory (related to breathing) issues. b. For Resident 12, the facility did not develop a comprehensive CP that addressed Resident 12 had an indwelling Foley catheter (F/C, a brand for one of many brands of urinary catheters [flexible tube used to empty the bladder and collect urine in a drainage bag] and the need for dialysis (hemodialysis, a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 173 and 174) were provided with appropriate care and/or services for oxygen (O2) treatment: a. Resident 173 had an order for O2 at 2 liters (L, unit of volume) via nasal cannula (N/C, a tube used to deliver oxygen to help with breathing) and was observed to be receiving 4 L on 1/26/24. b. Resident 174 was receiving 2 L of O2 via N/C without a physician's order to administer O2. In addition, the facility failed to post a sign indicating Oxygen in Use outside of Resident 174's room door as indicated in the facility's P&P titled, Oxygen Administration. These failures had the potential to result too much O2 administration and the potential to result in physical declines to Residents 173 and 174. (Cross Reference F655 and F656)

Inspectors wroted. During a concurrent interview and record review on 1/28/24 at 4:33 p.m. with the Director of Plant Operations (DPO), updated 5/31/23, the facility's WMP, was reviewed. The WMP indicated the purpose of the WMP was to identify where bacteria can grow and/or spread and reduce that risk [of contracting Legionnaire's disease (LD, type of pneumonia [infection that inflames the air sacks in the lungs] cause by legionella bacteria). The WMP indicated If residents contract LD, it is often a result of exposure to inadequately managed building water systems which can be prevented. The WMP indicated the WMP included measures to monitor the identified areas that may promote growth of waterborne bacteria. The WMP indicated would monitor weekly the Cold Main and Hot Water Services. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Policy and Procedure (P&P) titled COVID-19 Vaccination, dated 10/25/23 when: a. For two of five sampled residents (Residents 10 and 15), the facility failed to offer a COVID-19 (a respiratory illness that can spread from person to person) vaccination (vaccine, a preparation that is used to stimulate the body's immune response against diseases). b. The facility failed to maintain documentation related to COVID-19 vaccinations for staff currently employed at the facility. These failures had the potential to result in residents and staff to acquire, transmit, or experience complications from COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective training program for facility staff: a. The facility's previous Director of Staff Development (DSD) failed to conduct staff training to address a known facility problem regarding residents experiencing pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This failure had the potential to result in unsafe and incompetent care provided to residents by facility staff.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an assessment was completed upon readmission to the facility for one of one sampled resident (Resident 71). This failure had the potential to result in unsafe and incompetent care provided to Resident 71 and had the potential to result in unaddressed changes of condition and a physical decline to Resident 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) who was receiving enteral feeding (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) through a gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach) received appropriate care and services to prevent complications and in accordance with the facility's policy and procedure (P&P), titled, Care and Treatment of Feeding Tubes. This deficient practice had the potential to cause complications such as skin irritation and local infection to Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to, for two of 30 daily nurse staffing posting information, post actual worked nursing hours at the start of each shift. This failure resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members to obtain misleading information posted.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10) was free of medication error (means the observed or identified preparation or administration of medications or biologicals) which was not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication, Duloxetine (a delayed-release capsule[medication designed to last longer in the body] used to treat certain mental/mood disorders and used to help relieve nerve pain). This failure could result by passing the extended time release of the capsule that could increase the risk of serious complications such as abdominal cramping, convulsions, and severe skin reactions to Resident 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: a. Label, date food items and ensure opened food items were covered in one of one kitchen (Kitchen 1). These deficient practices could result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food served to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Quality Assurance Performance Improvement (QAPI, governing body, a group of people that meet regularly, data driven approach to maintaining and improving safety and quality of care, a proactive approach to quality improvement) corrected identified quality facility issues regarding pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This deficient practice had the potential for residents to not receive appropriate PI care and treatment and the potential for the development of new PI's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 4) was provided a safe, sanitary, and comfortable environment. On 1/26/24, Resident 10's ceiling had a leak. This failure resulted in Resident 4 having trouble sleeping and feeling unnerving and Responsible Party (RP) 1 concerned about the safety of Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the controlled medications for one of one sampled resident (Resident 1) were accounted for during the controlled medication reconciliation. 34 tablets of Resident 1 ' s Clonazepam (Klonopin, a Schedule IV controlled medication used for treatment of panic disorder and epilepsy [seizures]) were unaccounted for during controlled medication reconciliation. This failure had the potential risk for this medication to be used inappropriately and may result in adverse effects to the residents.