**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents' ordered medications were available for administration and were administered to residents as prescribed by the physician for four out of five sampled residents (Residents 1, 2, 3, and 4). The facility failed to: 1. Ensure Resident 1 received Seroquel [Quetiapine] a medication used to treat psychotic disorders [a mental disorder characterized by a disconnection from reality]), 150 milligrams [(mg) unit of measurement] twice a day (BID) as ordered for behavioral management. 2. Ensure Resident 2 received Prednisone (a medication used to decrease inflammation [body's response to injury marked by redness, heat, swelling and pain]) 10 mg three-times a day (TID) as ordered for knee inflammation. 3. Ensure Resident 3 received Empagliflozin ([Jardiance] a medication used to improve glucose [blood sugar (BS)] control in people with type 2 diabetes [(DM) a chronic condition which affects the way the body processes BS]), 10 mg daily as ordered for DM. 4. Ensure Resident 4 received injectable Dulaglutide ([Trulicity]) a medication used to improve BS in people with type 2 DM) 0.75 mg/0.5 milliliters ([ml] a unit of measurement) subcutaneously (under the skin) once a week as ordered for DM management. 5. Ensure the licensed nurses did not document the administration of Seroquel, Prednisone, Empagliflozin and Trulicity as given to Residents 1, 2, 3 and 4 when neither of the medications were present in the facility and available for administration. 6. Ensure the licensed nurses verified receipt of ordered medications Seroquel, Prednisone, Empagliflozin and Trulicity and followed-up with the pharmacy when medications were not available for administration to Resident 1, 2, 3 and 4. 7. Ensure the facility had a system in place to determine if the pharmacy received medications orders and to verify medications were dispensed/delivered. 8. Ensure the licensed nurses followed the facility policy and procedure (P/P) titled, Medication Ordering and Receiving from Pharmacy Provider, by contacting the pharmacy and informing of the need for prompt delivery of missing medications for Resident 1, 2, 3 and 4 and requesting delivery within four hours. a. These failures resulted in Residents 1, 2, 3 and 4 not receiving their prescribed medications as ordered placing the residents at risk for ineffective medication management. b. These failures placed Residents 1 at risk for exacerbation of symptoms of uncontrolled behavior compromising Resident 1's safety and safety of other residents and staff. Also, these failures placed Resident 1 and others at risk for injuries. c. These failures placed Resident 2 at risk for unresolved knee inflammation and pain and placed at risk for the potential for deteriorating physical function of a knee. d. These failures placed Resident 3 and Resident 4 at risk for hyperglycemia (high BS) with related adverse effect including coma (state of prolonged unconsciousness, including lack of response from which it is impossible to rouse a person) and possible death. On 8/18/2023 at 3:15 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to lack of the system to ensure the residents receive ordered medications per physician's order was called in the presence of the Administrator (ADM) and the Director of Nursing (DON). On 8/21/2023 at 3:14 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 8/21/2023 at 3:42 p.m., in the presence of the ADM and the DON. The IJRP included the following: 1. On 8/3/2023, Resident 1 was transferred to a General Acute Care Hospital (GACH) for hypotension (low blood pressure) and bradycardia (slow heart rate) and did not return to the facility. Resident 1 was discharged from the facility on 8/10/2023. 2. On 7/14/2023, Resident 3 was transferred to the GACH for chest pain and did not return to the facility. Resident 3 was discharged from the facility on 7/21/2023. 3. On 8/18/2023 and 8/19/2023, the primary physicians and the residents Responsible Partys (RP) were notified regarding the residents' not receiving medications as ordered. A licensed nurse assessed Residents 2 and 4 to determine if there were any adverse effects identified related to their missed medications, no adverse effects were found. 4. On 8/14/2023, the facility's pharmacy nurses conducted a cart audit of the two medication carts in the facility to ensure all medications prescribed to residents were present and available for administration. The pharmacy nurses identified 19 medications that were not available in the medication carts and those medications were immediately ordered from the pharmacy. For those residents whose medications were unavailable, they were assessed by the facility's licensed nurses and the resident's physicians and RPs. There were no adverse effects identified. 5. On 8/18/2023, a repeat medication cart audit was conducted on the two medication carts in the facility, by the facility's pharmacy nurses, to ensure all medications prescribed to residents were present and available for administration. The pharmacy nurses identified four medications that were not available in the medication carts and those medications were immediately ordered from the pharmacy. For those residents whose medications were unavailable, they were assessed by the facility's licensed nurses and the resident's physicians and RPs. There were no adverse effects identified. 6. On 8/18/2023, the facility's Clinical Resource Registered Nurse (CRRN 1) observed a 5 p.m. medication administration to ensure residents received all medications prescribed to them. All 70 residents received their medications as ordered. 7. On 8/18/2023, in-services were initiated for all licensed nurses on documenting the correct medication to prevent falsification of medication administration records. 8. On 8/18/2023, in-services were initiated for all licensed nurses on the correct way (how, when, and what time) to document administration of medication on the electronic medical record ([EHR] an electronic version which automates the documentation, storage, and retrieval of patient records). 9. On 8/18/2023 and 8/19/2023, the facility's clinical resource nurses conducted an audit of all active residents (70) medication administration records (MAR) against the pharmacy delivery receipts to determine the extent to which other residents in the facility may not have received prescribed/ordered medications. There were two residents identified who did not receive their medications. A licensed nurse assessed the two resident and notification to the resident's physician and RP was made. There were no adverse effects identified. 10. On 8/18/2023, in-services were initiated for all licensed nurses on when and how to order medications from the pharmacy, how to follow up with the pharmacy to ensure medications were received, and how to follow up with the pharmacy if the medications were not received. 11. On 8/18/2023, in-services were initiated for all licensed nurses on the contents of the facility's emergency kits ([E-Kit] a small quantity of medications which can be dispensed when pharmacy services are not available). On narcotics (a medication which causes insensibility [unconsciousness] or stupor [unresponsiveness from which a person can be aroused only by vigorous, physical stimulation]), E-Kit intravenous ([IV] within a vein), E-Kit, intramuscular ([IM] in the muscle), nonantibiotic E-Kit medications, and on Kayexalate (medication used to treat high levels of potassium [a mineral found in the body which helps the body work properly] in the blood). The in-services also included the process to utilize medications from the E-Kit and the process for ordering a replacement E-Kit. 12. Twenty-five licensed nurses were identified as needing one-to-one in-services. 16 of the licensed nurses were registry staff who will not be returning to the facility and the other 9 licensed nurses received written disciplinary action and one to one ([1:1] one teaching or giving information to the other) in-service by the DON/designee. Findings: A. A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizoaffective disorder (a mental condition which causes both a loss of contact with reality and mood problems). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/12/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired and he was sometimes understood by others. The MDS indicated Resident 1 exhibited physical (which can include hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) and verbal (which can include threatening others, screaming at others, and cursing at others) behaviors that were directed towards others one to three days in a seven-day period. The MDS indicated Resident 1's behavioral symptoms put Resident 1 and others at significant risk for physical injury, significantly interfered with the Resident 1's care, significantly intruded on the privacy or activity of others, and significantly disrupted the care or living environment of others and received antidepressant medication (a class of medications used for the treatment of depression). A review of Resident 1's Care Plan (CP), untitled and dated 7/19/2023, indicated Resident 1 had a potential for mood problems related to depression and schizoaffective disorder. The CP's goal indicated Resident 1 would have an improved mood state through review date of 8/15/2023. The CP's interventions included to administer medications as ordered. A review of Resident 1's CP untitled and dated 7/19/2023, indicated Resident 1 had behavior problems as evidenced by aggressive, combative behaviors, and attempting to hit staff members related to his diagnosis of schizoaffective disorder. The CP's goal indicated Resident 1 would have fewer episodes of aggressive, combative behaviors, decreased episodes of attempting to hit staff members and would have no evidence of behavior problems through the review date of 8/15/2023. The CP's interventions included to administer medications as ordered. A review of Resident 1's Nurses Progress Notes (NPN), dated 7/13/2023 and timed at 3:26 p.m., and a Change of Condition ([COC] a document indicating a deterioration or improvement in a resident's physical or behavioral health which may require a modification in the resident's treatment) dated 7/14/2023 and timed at 6:35 a.m., and a NPN dated 7/20/2023 and timed at 4:30 p.m., indicated Resident 1 exhibited behaviors which included wiping feces on his body, kicking, slapping, making racial remarks to facility staff, irritability and being easily annoyed by staff. A review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 7/20/2023 indicated Resident 1 had a physician's order dated 7/20/23 for Seroquel 150 mg BID for behavior management for administration at 9 a.m. and 5 p.m. daily. A review of Resident 1's Pharmacy Delivery Receipt dated 8/16/2023, indicated 186 tablets of Seroquel 150 mg were delivered to the facility on 7/30/2023, which was 10 days later from the order date (7/20/23). A review of Resident 1's MAR, dated 7/2023, indicated Seroquel 150 mg was signed off as administered to Resident 1 from 7/20/2023 to 7/29/2023 at 9 a.m., and/or 5 p.m. The MAR indicated documentation that Seroquel 150 mg was not available from the pharmacy on 7/21/2023, 7/23/2023, 7/28/2023, and 7/30/2023 for the 9 a.m., and/or 5 p.m., doses. The MAR indicated Resident 1 missed 20 doses of Seroquel from 7/20/2023 to 7/29/2023 due to the medication not being available at the facility. A review of Resident 1's MAR, dated 7/2023, indicated Seroquel 150 mg was documented as given to Resident 1 when the medication was not available at the facility as follows: 1. On 7/20/2023, at 5 p.m. 2. On 7/21/2023, at 5 p.m. 3. On 7/22/2023, at 9 a.m. and 5 p.m. 4. On 7/23/2023, at 9 a.m. 5. On 7/24/2023, at 9 a.m. and 5 p.m. 6. On 7/25/2023, at 9 a.m. and 5 p.m. 7. On 7/26/2023, at 9 a.m. and 5 p.m. 8. On 7/27/2023, at 5 p.m. 9. On 7/28/2023, at 5 p.m. 10. On 7/29/2023, at 5 p.m. A review of Resident 1's MAR comments dated 7/2023, indicated the licensed nurses documented Resident 1's Seroquel 150 mg as not available from the pharmacy as follows: 1. On 7/21/2023, for the 9 a.m. dose. 2. On 7/23/2023, for the 5 p.m. dose. 3. On 7/28/2023, for the 9 a.m. dose. 4. On 7/30/2023, at 9 a.m. and 5 p.m. A review of Resident 1's NPN, dated 7/20/2023 to 7/31/2023, indicated there was no documentation by the licensed nurses indicating the facility's pharmacy was notified Resident 1's Seroquel had not been delivered to the facility. During an interview on 8/17/2023 at 4:35 p.m., Licensed Vocational Nurse 1 (LVN 1) acknowledged he documented that he administered Seroquel to Resident 1 on 7/21/2023, 7/26/2023, 7/27/2023, and 7/28/2023, at 5 p.m. LVN 1 stated he was probably in a hurry and did not verify Seroquel was in the medication cart prior to documenting he administered it to Resident 1. LVN 1 stated, it was hard to stay focused and pay attention during his medication pass because there were so many interruptions during his shift. During an interview on 8/18/2023 at 3:54 p.m., Registered Nurse (RN 2) stated on 7/30/2023 at 9 a.m., she documented on the NPN Seroquel was not available. RN 2 stated she did not call the pharmacy to follow up on the missing Seroquel because she thought someone else had already called the pharmacy and the Seroquel was going to be delivered. RN 2 stated she did not know Seroquel was available in the nonantibiotic Emergency-Kit. B. A review of Resident 2's admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including history of falling, difficulty in walking and displaced fracture (bone breaks into two or more parts) of the right femoral neck (region just below the hip joint [where two bones meet]). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision-making were severely impaired and Resident 2 was usually understood by other and was usually able to understand others. A review of Resident 2's History and Physical (H&P), dated 6/3/2023, indicated Resident 2 was able to make her own medical decisions. A review of Resident 2's OSR, dated 7/6/2023 indicated a physician's order for Prednisone 10 mg TID at 7:30 a.m., 12 noon and 5 p.m.) for knee inflammation. The OSR indicated Prednisone was to be discontinued on 7/9/2023 at 11:59 p.m. A review of Resident 2's Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation to indicate Prednisone 10 mg was delivered to the facility for Resident 2 and was available for administration. A review of Resident 2's MAR, dated 7/2023, indicated Prednisone 10 mg was administered to Resident 1 from 7/7/2023 to 7/9/2023 at 12 p.m., and/or 5 p.m. The MAR indicated the licensed nurses documented Prednisone 10 mg was not available on 7/8/2023 and 7/9/2023 at 7:30 a.m., and/or 12 p.m. The MAR indicated Resident 2 received five doses of Prednisone from 7/7/2023 to 7/9/2023 when the medication was not available at the facility. Resident 2 did not receive a total of seven doses of Prednisone. A review of the facility's nonantibiotic E-Kit Binder dated 7/2023 indicated there was no documentation that Prednisone 10 mg was removed from the E-Kit for administration to Resident 2. A review of Resident 2's NPN, dated 7/20/2023 to 7/29/2023, indicated there was no documentation by the licensed nurses they followed up with the facility's pharmacy regarding Resident 2's Prednisone order. During an interview on 8/16/2023 at 1:23 p.m., Resident 2 stated there were several days when she got a different number of pills when she received her medications, some days I got five pills, and some days six pills. Resident 2 stated, she asked the licensed nurses to explain what medications they were giving her and why the number of pills were inconsistent, and they (the licensed nurses) were not able to explain. During an interview on 8/21/2023 at 2:21 p.m., LVN 2 acknowledged she documented Prednisone as given to Resident 2 at 12 p.m., on 7/7/2023 and 7/12/2023 when she actually did not administer Prednisone to her (Resident 2). LVN 2 stated she thinks she was working too fast and documented the medication as given by accident. C. A review of Resident 3's admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including type 2 DM and congestive heart failure ([CHF] a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 made independent decisions that were reasonable and consistent. A review of Resident 3's OSR dated 3/28/2023, indicated a physician's order to Resident 3 for Empagliflozin 10 mg once a day for DM. A review of the facility's Pharmacy Consolidated Delivery Sheet dated 6/8/2023, indicated 14 tablets of Empagliflozin 10 mg were delivered to the facility for Resident 3 on 6/8/2023. If Resident 3 was receiving Empagliflozin 10 mg one tablet daily as ordered, 14 tablets received on 6/8/23 would have lasted until 6/22/2023. A review of Resident 3's MAR, dated 6/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 6/23/2023 to 6/30/2023. A review of Resident 3's Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation that Empagliflozin 10 mg was delivered to the facility for Resident 3 after 6/8/2023. A review of Resident 3's MAR, dated 7/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 7/1/2023 to 7/4/2023, and from 7/7/2023 to 7/11/2023. The MAR indicated documentation by the licensed nurses that Empagliflozin 10 mg was not available from the pharmacy on 7/5/2023, 7/6/2023 and 7/12/2023. The MAR indicated the licensed nurses documented Resident 3 received 17 doses of Empagliflozin from 6/23/2023 to 7/12/2023 when the medication was not available in the facility. Resident 3 subsequently missed a total of 19 doses of Empagliflozin 10 mg. A review of Resident 3's NPN, dated 6/23/2023 to 7/12/2023, indicated there was no documentation by the licensed nurses to indicate the licensed nurses notified the pharmacy of missing Empagliflozin 10 mg when the medication ran out. A review of Resident 3's Grievance Resolution Form (GRF) dated 7/4/2023, indicated Resident 3 had concerns with his diabetes medication. The GRF indicated the summary of findings/conclusion and corrective actions sections were left blank. D. A review of Resident 4's admission Records (Face Sheet) indicated the resident was admitted to the facility on [DATE] with diagnosis including type 2 DM and acute kidney failure (a sudden episode of kidney failure or kidney damage which happens within a few hours or days). A review of Resident 4's MDS, dated [DATE], indicated Resident 4's cognitive skills for daily decision-making were moderately impaired and the resident was usually understood others and was usually understood by others. A review of Resident 4's OSR dated 6/22/2023, indicated a physician's order for Trulicity 0.75 mg/0.5 milliliters ([ml] a unit of measurement) once a week, every Sunday at 9 a.m., for diabetes management. A review of Resident 4's MAR from 6/25/2023 to 7/16/2023 indicated Resident 4 missed three doses of Trulicity. A review of the facility's Pharmacy Delivery Receipt (PDR) dated 6/23/2023, indicated one dose of Trulicity 0.75 mg/0.5 ml was delivered to the facility on 6/23/2023 at 2:02 a.m. There were no additional PDRs for June 2023. A review of the facility's PDR dated 8/16/2023, containing information of medications delivered to the facility in July 2023, indicated there was no documentation to indicate Trulicity 0.75 mg/0.5 ml was delivered to the facility after 6/23/2023. A review of Resident 4's MAR dated 6/2023, indicated Resident 4's Trulicity 0.75 mg/0.5ml was not available from the pharmacy on 6/25/2023. A review of Resident 4's MAR dated 7/2023, indicated Resident 4's Trulicity 0.75 mg/0.5 ml was not available from the pharmacy on 7/2/2023 and 7/16/2023. A review of Resident 4's NPN, dated from 6/25/2023 to 7/16/2023 indicated there was no documentation by the licensed nurses that they notified the pharmacy and followed up on Resident 4's Trulicity order when it was not available for administration as prescribed. During a phone interview on 8/16/2023 at 3:49 p.m. with the Pharmacy Owner (PO 1), the PO 1 stated there was no documentation of Trulicity 0.75 mg/0.5 ml being delivered to the facility after 6/23/23. During a phone interview on 8/17/2023 at 1:38 p.m. with Pharmacy Receptionist (PR 1), PR 1 stated one dose of Trulicity 0.75 mg/0.5 ml was delivered to the facility on 6/23/2023 at 2:02 a.m. The PR 1 stated this was the only dose of Trulicity delivered to the facility for Resident 4. During an interview on 8/17/2023 at 2:28 p.m. with the DON, the DON stated the facility received one dose of Trulicity 0.75 mg/0.5ml on 6/23/2023 at 2:02 a.m. The DON stated he does not have any documentation indicating any additional doses of Resident 4's Trulicity 0.75 mg/0.5 ml was delivered to the facility after 6/23/2023. During an interview on 8/14/2023 at 12:59 p.m., Resident 4 stated the facility previously had issues with the pharmacy not delivering his medications timely. A review of the facility's Resident Council Minutes (RCM), dated 6/22/2023, indicated the residents' concerns included medications not being refilled in a timely manner. The RCM indicated in-services were given to the licensed nurses regarding medications refills. A review of the facility's RCM, dated 7/20/2023, indicated residents were concerned because medications were not being refilled, were not available, and the licensed nurses from the 3 p.m. to 11 p.m., shift were not able to find the resident's medications. During a concurrent interview and RCM review with the DON on 8/17/2023 at 10:06 a.m., the DON confirmed the RCM had no documented resolution to the residents' concerns about medications refill and availability. The DON stated he only looked at timeliness of the medication administration. During a telephone interview on 8/17/2023 at 11:47 a.m., the facility's Pharmacist Consultant (PC) stated accurate documentation of medication administration on the MAR is important because it is reviewed to determine the next time a dose of medication should be administered, to determine if the ordered dosage was effective or needs to be adjusted. The PC stated it is the licensed nurse's responsibility to follow-up with the pharmacy if the medications are not available so the resident can receive their medications as quickly as possible. The PC stated if residents go several days without taking their prescribed medications, it is considered a medication error and poses a risk to that residents to have a negative outcome including uncontrolled pain, behavioral issues, hyperglycemia potentially leading to unnecessary hospitalizations. During an interview on 8/17/2023 at 2:28 p.m., the DON stated the correct way to prepare medications for administration is to take the medication cart to the resident's doorway, verify using the resident's MAR with the medications ordered, prepare the medications, identify the correct resident, administer the medication to the resident, and document the medication as given. The DON stated the licensed nurses should not document medications as given when they (licensed nurses) have not actually administered the medications to the residents. The DON stated if residents do not get their medications as prescribed, the residents are at risk for adverse effects including hyperglycemia, pain, increased inflammation, uncontrolled behaviors which could potentially lead to hospitalizations. During an interview on 8/19/2023 at 10:39 a.m., the Pharmacy Owner (PO) stated the nonantibiotic E-Kit has a list of common medications which are available for the facility's use if there is a delay in receiving medications from the pharmacy or a medication order is not placed. The PO stated the medications in the E-kit can be used until the regular order arrives to the facility. The PO stated the purpose of having the E-Kit is to prevent a delay in medication administration. A review of the facility's undated P/P titled, Medication Ordering and Receiving from Pharmacy Provider, indicated new medications are ordered if needed before the next regular delivery, phone in the pharmacy after faxing the medication order. Inform the pharmacy of the need for prompt delivery and request delivery within four hours. Timely delivery of new orders is required so that medication administration is not delayed. The emergency kit is used when the resident needs a medication prior to the pharmacy delivery. A review of the facility's undated P/P titled, Specific Medication Administration Procedures, indicated after administration, the licensed nurses are to document the administration in the MAR. A review of the facility's LVN Job Description (JD), dated 12/17/2021, indicated duties and responsibilities include the following: 1. Prepares and administers medications as ordered by the physician. 2. Ensure accuracy of documentation. 3. Ensures that adequate stock levels of medications are maintained. A review of the facility's RN JD dated 12/17/2021 indicated duties and responsibilities of the RN include to ensure adequate stock levels of medications are maintained.