**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Reorder medications five (5) days in advance of need to assure an adequate supply was on hand (current availability) as per facility policy for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 2. Follow-up for delivery and availability of medications for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 3. Remove and destroy and not use another resident's medication (Resident 18, a discharged resident) to provide Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke, a loss of blood flow to part of the brain, which damages brain tissue]) to Resident 31 from [DATE] to [DATE]. These deficient practices resulted in: 1. Resident 5 not receiving two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to treat hypertension [a condition in which the blood vessels have persistently raised pressure]) and one (1) dose on [DATE] at 8 a.m. of bumetanide (a medication used to treat edema [swelling of feet, ankles, legs, and other parts of the body, such as the face, hands, and abdomen caused by fluid retention]) on [DATE], increasing the potential to cause Resident 5 serious harm, serious impairment, and serious complications, potentially resulting in elevated blood pressure, hospitalization, and/or death. 2. Resident 31 not receiving two (2) doses on [DATE] at 9 a.m. and 5 p.m. of Eliquis, two (2) doses on [DATE] at 9 a.m. and 5 p.m. of brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]), one (1) dose on [DATE] at 9 a.m. of finasteride (a medication used for benign prostatic hyperplasia [BPH] - a condition in men where the prostate gland - a small gland located inside the groin - is enlarged]), one (1) dose on [DATE] at 9 a.m. of folic acid (a medication used for anemia [a condition with lower-than-normal number of red blood cells]), and one (1) dose on [DATE] at 9 a.m. of tamsulosin (a medication used for BPH) increasing the potential to cause Resident 31 serious harm, serious impairment, and serious complications, potentially resulting in blood clots, blindness, stroke, hospitalization, and/or death. 3. Resident 31 receiving 60 doses of Eliquis between [DATE] and [DATE] from Resident 18's medication supply. On [DATE] at 3:36 p.m. the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for the facility's failure to provide routine and emergency medications to its residents, and the facility's failure to acquire medications to meet the needs of the residents. The Administrator (ADMIN) and the Director of Nursing (DON) were notified of the IJ from the failure to ensure Residents 5 and 31 had medication available for administration at the scheduled times per physician orders. On [DATE] at 3:47 p.m., the IJ was removed in the presence of the ADMIN and the DON while onsite, after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered on [DATE]. 2. Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR - a communication framework used to share information about a resident that needs attention tool) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1). 3. LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1). 4. P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31. 5. Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT - a team of health care professionals from different disciplines who work together to provide personalized care for residents) and MD 1 of the medication omissions (not giving/skipping), lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions. 6. The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31. 7. The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 on [DATE] to reconcile (the process of identifying the most accurate list of all medications that the resident is taking) medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand. 8. MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31 on [DATE]. As of [DATE], no untoward (unexpected) findings or side effects related to medication omission have been noted for either Resident 5 or 31. 9. The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications. 10. The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered. 11. A Root Cause Analysis (RCA - a structured process for identifying the underlying cause of a problem and developing solutions to prevent it from happening again) was initiated on [DATE] by the ADMIN and the DON to determine causative factors for the systemic breakdown. 12. The DON conducted in-service (a type of training that takes place while an employee is on the job, and is designed to improve their skills and knowledge to enhance their performance) for the licensed nursing staff on [DATE] regarding the following: - Daily review of resident medication supply for availability, - Ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, - Ensuring all licensed nurses are following facility policy and procedures (P&P) on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, - Following through daily with the dispensing pharmacy for timely delivery of all ordered medications, - How to utilize the Medication Refill Audit Tool. 13. The DON or designee will track the following during the Daily Nursing Huddles (short, regular meeting where a healthcare team discusses resident safety and care, and plans for the day ahead) Monday through Sunday: - Timely (5 days) Ordering of Medications - Timely Delivery of Medication - Timely Administration of Medication 14. The DON or designee will present findings at the Daily Stand-Up Meeting (short, daily meeting where healthcare team members share updates on their work and discuss progress) Monday through Friday for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved. 15. The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved. 16. The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at monthly Quality Assurance Performance Improvement (QAPI - a systematic, comprehensive, and data-driven approach conducted by the facility to improve the quality of care and services provided to the residents) meetings for three months with modifications to the process as warranted. Cross references: F759 and F760 Findings: a. During a review of Resident 5's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die,) atrial fibrillation (irregular heartbeat,) essential hypertension (high blood pressure that develops over time), and heart disease (a general term for conditions that affect the heart or blood vessels, and how they function which can lead to edema.) During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, and lying to sitting on side of bed. The MDS also indicated Resident 5 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds the trunk or limbs and provides more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 5's IDT Care Plan Conference Summary dated [DATE], the IDT Care Plan Conference Summary indicated Resident 5 is forgetful, able to express (make self understood), and able to understand others. During a review of Resident 5's Physician Orders (a report listing the physician order for the resident) from [DATE] to [DATE], the Physician Orders indicated Resident 5 was prescribed the following: 1. bumetanide 0.5 milligrams (mg - a measure of unit of mass) tablet by mouth once a day at 8 a.m. for fluid retention, starting [DATE], 2. metoprolol 25 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for hypertension, starting [DATE]. During a review of Resident 5's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered bumetanide 0.5 mg at 8 a.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered metoprolol 25 mg at 9 a.m. and 5 p.m. During a medication administration observation on [DATE] at 9:18 a.m. by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 5: 1. metoprolol 25 mg 2. bumetanide 0.5 mg LVN 1 informed Resident 5 that the metoprolol and bumetanide were not available that morning (9:18 a.m.) and that Resident 5 would have to wait for the pharmacy to deliver the medication to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer metoprolol 25 mg on [DATE] at 9 a.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. to Resident 5, since the medications were not available in the medication carts, in the facility or in the emergency kits ([eKIT] - a kit with limited supply of medications needed during emergent situations). LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated that by missing doses of those critical medications (such as metoprolol) it increased the risk that Residents 5 could experience high blood pressure and stroke possibly resulting in hospitalization and/or death. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 5 was not administered metoprolol 25 mg on [DATE] at 9 a.m. and 5 p.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. due to the medications not being available. The DON stated those (metoprolol and bumetanide) medications were not available in the medication carts and not available in the eKIT. The DON stated Resident 5 was prescribed metoprolol for high blood pressure and bumetanide for edema. The DON stated missing the administrations of those critical medications (such as metoprolol) can cause elevated blood pressure by not maintaining normal pressures leading to potential stroke resulting in hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 5. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. dose of metoprolol 25 mg for Resident 5 on [DATE] since the medication was not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like metoprolol can potentially increase the risk of elevated heart rate and elevated blood pressure resulting in hospitalization. During a review of the facility's pharmacy delivery manifests (detailed statement or invoice for shipment of medications) faxed to the facility on [DATE], the pharmacy delivery manifest indicated the facility received a 30-day supply of Resident 5's bumetanide 0.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets (record that includes the medications delivered to the facility from the dispensing pharmacy) faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 5's metoprolol 25 mg tablets on [DATE] and did not receive an additional supply until [DATE]. b. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was originally admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack,) atrial fibrillation (irregular heartbeat,) BPH, hypertensive heart disease (heart disease caused by constant high blood pressure). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 31 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a review of Resident 31's Physician Orders, from [DATE] to [DATE], the Physician Orders indicated Resident 31 was prescribed the following: 1. Eliquis 2.5 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for CVA prophylaxis (the prevention of disease or the measures taken to maintain health), starting [DATE], 2. brimonidine 0.2% one (1) drop each eye twice a day at 9 a.m. and 5 p.m. for glaucoma, starting [DATE], 3. finasteride five (5) mg tablet by mouth once a day at 9 a.m. for BPH, starting [DATE], 4. folic acid one (1) mg tablet by mouth once a day at 9 a.m. for anemia, starting [DATE], 5. tamsulosin 0.4 mg capsule by mouth once a day at 9 a.m. for BPH, starting [DATE]. During a review of Resident 31's MAR for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered Eliquis 2.5 mg at 9 a.m. and 5 p.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered brimonidine 0.2% at 9 a.m. and 5 p.m. 3. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered finasteride five (5) mg at 9 a.m. 4. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered folic acid one (1) mg at 9 a.m. 5. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered tamsulosin 0.4 mg at 9 a.m. During a medication administration observation on [DATE] at 8:49 a.m. with LVN 1 at Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 31: 1. Eliquis 2.5 mg tablet 2. Brimonidine 0.2% eye drops 3. finasteride five (5) mg tablet 4. folic acid one (1) mg tablet 5. Tamsulosin 0.4 mg tablet LVN 1 informed Resident 31 that the Eliquis, Brimonidine, finasteride, folic acid, and Tamsulosin were not available and that Resident 31 would have to wait for pharmacy to deliver the medications to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg, and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. During a concurrent observation and interview on [DATE] at 1:35 p.m. by Medication Cart 1 with LVN 1 and the DON, LVN 1 stated that due to the unavailability of Eliquis 2.5 mg from [DATE] to [DATE], LVN 1 used Resident 18's supply of Eliquis 2.5 mg to ensure that Resident 31 did not miss any doses of the critical medication. LVN 1 stated that he (LVN 1) should not have used another resident's medication supply. LVN 1 stated that according to facility policy, discharged resident's medications should be destroyed. LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either, and LVN 1 pulled out Resident 18's medication bubble pack (medication packaging system that contains individual doses of medication per bubble) from the bottom drawer of Medication Cart 1. The medication bubble pack indicated Resident 18 was prescribed Eliquis 2.5 mg tablet to be given by mouth twice a day. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. The DON stated per facility policy, medication refills should be re-ordered from the pharmacy about three (3) to five (5) days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated licensed nurses were expected to re-order medications timely (5 days) and follow-up on the refills to ensure medications were available to residents. The DON also stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times. The DON stated per facility policy, medications supplied for one resident should not be used for another resident, and when a resident was discharged the medications should have been destroyed or returned to the resident. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 31 was not administered Eliquis 2.5 mg, brimonidine 0.2% drops, finasteride five (5) mg, folic acid one (1) mg, and tamsulosin 0.4 mg for the 9 a.m. and 5 p.m. doses on [DATE] due to the medications not being available. The DON stated those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) were not available in the medication carts and not available in the eKITS. The DON stated Resident 31 was prescribed Eliquis for CVA prophylaxis, finasteride and Tamsulosin for BPH, Brimonidine for glaucoma, and folic acid for anemia management. The DON stated missing the administrations of those critical medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) can cause clotting (sticky lump that forms when blood dries up or becomes thick) of blood due to the blood not being properly thinned, the clot traveling the heart and brain forming an embolism (obstruction caused by clots) potentially causing a heart attack and stroke, elevated eye pressure by not maintaining normal pressures leading to potential stroke and vision impairment such as blindness, all resulting in potential hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 31. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 2:10 p.m. with LVN 3, LVN 3 stated that medications should be re-ordered from the pharmacy five (5) to six (6) days in advance of using the last available dose to ensure timely delivery by pharmacy. LVN 3 stated that she (LVN 3) informed the DON that the Eliquis 2.5 mg for Resident 31 was not available (unable to recall the date). LVN 3 stated it was important for Resident 31 to receive Eliquis to prevent blood clots, heart attack, stroke, hospitalization, and/or death. LVN 3 stated she (LVN 3) used Resident 18's supply of Eliquis 2.5 mg from [DATE] to [DATE] nsure that Resident 31 did not miss any doses. LVN 3 stated that she (LVN 3) knew not to use another resident's medication supply but used it in desperation, and that it was wrong to do so. LVN 3 stated that she (LVN 3) did not inform anyone that she (LVN 3) was using another resident's Eliquis supply, and that discharged resident's medications should be destroyed according to facility policy. During an interview on [DATE] at 2:25 p.m. with the DON, in the presence of LVN 3, the DON stated that on [DATE] was the first day the DON followed up with pharmacy regarding the refill and delivery of Eliquis 2.5 mg for Resident 31. The DON stated she (DON) had not called or communicated with pharmacy personnel prior to [DATE] and only faxed Eliquis refill requests to the pharmacy on [DATE] and [DATE] and assumed the medication was delivered. The DON stated she (DON) failed to follow-up with the requests and that going forward there needs to be a system put in place for following up on medication refills. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. doses of Eliquis 2.5 mg and brimonidine 0.2% for Resident 31 on [DATE] since the medications were not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that medications supplied for one resident should not be used for another resident. The CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like Eliquis and brimonidine for Resident 31 can potentially increase the risk of blood clotting, CVA, and elevated internal pressure of the eye resulting in hospitalization and/or death. During a review of the facility's P&P, titled Medication Administration - General Guidelines, dated [DATE], the P&P indicated: B. Administration 2) Medications are administered in accordance with written orders of the attending physician. 10) Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . routine medications are administered according to the established medication administration schedule for the facility. 12) Medications supplied for one resident are never administered to another resident. During a review of the facility's P&P, titled Ordering and Receiving Medications from The Dispensing Pharmacy, dated [DATE], the P&P indicated that Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure adequate supply is on hand. c. The refill is called in, faxed, or otherwise transmitted to the pharmacy. 3.a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery. During a review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, dated [DATE], the P&P indicated: D. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency supply or from the provider pharmacy. During a review of the facility's P&P, titled Medication Error Reporting, dated 1/2023, the P&P indicated: Medication errors will include but not be limited to: d. dose skipped t. wrong Resident's card used to give medication. During a review of facility's P&P titled, Discontinued Medications, dated [DATE], the P&P indicated that When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. During a review of facility's P&P titled, Medication Destruction, dated [DATE], the P&P indicated that Discontinued medications and medications left in the facility after a resident's discharge .are destroyed. A. All medications are placed in the proper waste container per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate below five (5) percent (% - unit of measure) by having seven (7) medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92% affecting two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. The medication errors were as follows: 1. Resident 5 did not receive the following medications as ordered by Resident 5's physician: - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) - one (1) dose on [DATE] at 8 a.m. of bumetanide (a medication used for edema [swelling of feet, ankles, legs, and other parts of the body, such as the face, hands, and abdomen caused by fluid retention]) 2. Resident 31 did not receive the following medications, as ordered by Resident 31's physician: - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke] - an interruption in the flow of blood to cells in the brain caused by blood clots and high blood pressure]), - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]), - one (1) dose on [DATE] at 9 a.m. of finasteride (a medication used for benign prostatic hyperplasia ([BPH] - a condition in men where the prostate gland - a small gland located inside the groin - is enlarged), - one (1) dose on [DATE] at 9 a.m. of folic acid (a medication used for anemia [a condition with lower-than-normal number of red blood cells]), - one (1) dose on [DATE] at 9 a.m. of tamsulosin (a medication used for BPH) On [DATE] at 3:36 p.m. the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADMIN) and the Director of Nursing (DON) under 42 Code of Federal Regulations (CFR) §483.45(f)(1) Medication error rates are not 5 percent or greater. The facility had seven (7) medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92 %. These deficient practices had the potential to cause Resident 5 serious harm, serious impairment, and serious complications, potentially resulting in elevated blood pressure, hospitalization, and/or death; and had the potential to cause Resident 31 serious harm, serious impairment, and serious complications, potentially resulting in blood clots, blindness, stroke, hospitalization, and/or death. On [DATE] at 3:47 p.m., the IJ was removed in the presence of the ADMIN and the DON while onsite, after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered on [DATE]. 2. Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR - a communication framework used to share information about a resident that needs attention tool) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1). 3. LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1). 4. P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31. 5. Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT - a team of health care professionals from different disciplines who work together to provide personalized care for residents) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions. 6. The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31. 7. The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 on [DATE] to reconcile (the process of identifying the most accurate list of all medications that the resident is taking) medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand. 8. MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31 on [DATE]. As of [DATE], no untoward (unexpected) findings or side effects related to medication omission have been noted for either Resident 5 or 31. 9. The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications. 10. The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered. 11. A Root Cause Analysis (RCA - a structured process for identifying the underlying cause of a problem and developing solutions to prevent it from happening again) was initiated on [DATE] by the ADMIN and the DON to determine causative factors for the systemic breakdown. 12. The DON conducted in-service (a type of training that takes place while an employee is on the job, and is designed to improve their skills and knowledge to enhance their performance) for the licensed nursing staff on [DATE] regarding the following: - Daily review of resident medication supply for availability, - Ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, Ensuring all licensed nurses are following facility policy and procedures (P&P) on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, - Following through daily with the dispensing pharmacy for timely delivery of all ordered medications, - How to utilize the Medication Refill Audit Tool. 13. The DON or designee will track the following during the Daily Nursing Huddles (short, regular meeting where a healthcare team discusses resident safety and care, and plans for the day ahead) Monday through Sunday: - Timely (5 days) Ordering of Medications - Timely Delivery of Medication - Timely Administration of Medication 14. The DON or designee will present findings at the Daily Stand-Up Meeting (short, daily meeting where healthcare team members share updates on their work and discuss progress) Monday through Friday for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved. 15. The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved. 16. The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at monthly Quality Assurance Performance Improvement (QAPI - a systematic, comprehensive, and data-driven approach conducted by the facility to improve the quality of care and services provided to the residents) meetings for three months with modifications to the process as warranted. Cross references: F755 and F760 Findings: a. During a review of Resident 5's admission Record (a document containing demographic and diagnostic information), the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die,) atrial fibrillation (irregular heartbeat,) essential hypertension (high blood pressure that develops over time), and heart disease (a general term for conditions that affect the heart or blood vessels, and how they function which can lead to edema.) During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, and lying to sitting on side of bed. The MDS also indicated Resident 5 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds the trunk or limbs and provides more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 5's IDT Care Plan Conference Summary dated [DATE], the IDT Care Plan Conference Summary indicated Resident 5 is forgetful, able to express (make self understood), and able to understand others. During a review of Resident 5's Physician Orders (a report listing the physician order for the resident) from [DATE] to [DATE], the Physician Orders indicated Resident 5 was prescribed the following: 1. bumetanide 0.5 milligrams (mg - a measure of unit of mass) tablet by mouth once a day at 8 a.m. for fluid retention, starting [DATE], 2. metoprolol 25 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for hypertension, starting [DATE]. During a review of Resident 5's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered bumetanide 0.5 mg at 8 a.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered metoprolol 25 mg at 9 a.m. and 5 p.m. During a medication administration observation on [DATE] at 9:18 a.m. by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 5: 1. metoprolol 25 mg 2. bumetanide 0.5 mg LVN 1 informed Resident 5 that the metoprolol and bumetanide were not available that morning (9:18 a.m.) and that Resident 5 would have to wait for the pharmacy to deliver the medication to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer metoprolol 25 mg on [DATE] at 9 a.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. to Resident 5, since the medications were not available in the medication carts or in the facility. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated that by missing doses of those critical medications (such as metoprolol) it increased the risk that Residents 5 could experience high blood pressure and stroke possibly resulting in hospitalization and/or death. During an interview on [DATE] at 1:35 p.m. with the DON, the DON stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times by following the five (5) rights of medication administration, which includes: right patient, right drug, right dose, right time, right route. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 5 was not administered metoprolol 25 mg on [DATE] at 9 a.m. and 5 p.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. due to the medications not being available. The DON stated those (metoprolol and bumetanide) medications were not available in the medication carts and not available in the emergency kits ([eKIT] - a kit with limited supply of medications needed during emergent situations). The DON stated Resident 5 was prescribed metoprolol for high blood pressure and bumetanide for edema. The DON stated missing the administrations of those critical medications (such as metoprolol) can cause elevated blood pressure by not maintaining normal pressures leading to potential stroke resulting in hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 5. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. dose of metoprolol 25 mg for Resident 5 on [DATE] since the medication was not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like metoprolol can potentially increase the risk of elevated heart rate and elevated blood pressure resulting in hospitalization. During a review of the facility's pharmacy delivery manifests (detailed statement or invoice for shipment of medications) faxed to the facility on [DATE], the pharmacy delivery manifest indicated the facility received a 30-day supply of Resident 5's bumetanide 0.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets (record that includes the medications delivered to the facility from the dispensing pharmacy) faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 5's metoprolol 25 mg tablets on [DATE] and did not receive an additional supply until [DATE]. b. During a review of Resident 31's admission Record, the admission Record indicated Resident 31 was originally admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack,) atrial fibrillation (irregular heartbeat,) BPH, hypertensive heart disease (heart disease caused by constant high blood pressure). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 31 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a review of Resident 31's Physician Orders, from [DATE] to [DATE], the Physician Orders indicated Resident 31 was prescribed the following: 1. Eliquis 2.5 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for CVA prophylaxis (the prevention of disease or the measures taken to maintain health), starting [DATE], 2. brimonidine 0.2% one (1) drop each eye twice a day at 9 a.m. and 5 p.m. for glaucoma, starting [DATE], 3. finasteride five (5) mg tablet by mouth once a day at 9 a.m. for BPH, starting [DATE], 4. folic acid one (1) mg tablet by mouth once a day at 9 a.m. for anemia, starting [DATE], 5. tamsulosin 0.4 mg capsule by mouth once a day at 9 a.m. for BPH, starting [DATE]. During a review of Resident 31's MAR for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered Eliquis 2.5 mg at 9 a.m. and 5 p.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered brimonidine 0.2% at 9 a.m. and 5 p.m. 3. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered finasteride five (5) mg at 9 a.m. 4. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered folic acid one (1) mg at 9 a.m. 5. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered tamsulosin 0.4 mg at 9 a.m. During a medication administration observation on [DATE] at 8:49 a.m., with LVN 1 by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 31: 1. Eliquis 2.5 mg tablet 2. brimonidine 0.2% eye drops 3. finasteride five (5) mg tablet 4. folic acid one (1) mg tablet 5. tamsulosin 0.4 mg tablet LVN 1 informed Resident 31 that the Eliquis, brimonidine, finasteride, folic acid and tamsulosin were not available and that Resident 31 would have to wait for pharmacy to deliver the medications to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. During an interview, on [DATE] at 1:35 p.m. with the DON, the DON stated per facility policy, medication refills should be re-ordered from the pharmacy three (3) to five (5) days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated licensed nurses are expected to re-order residents' medications timely (5 days) and follow-up on the refills to ensure medications are available to residents. The DON also stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated Eliquis, brimonidine, finasteride, folic acid, and tamsulosin were not available in the medication carts and not available in the eKITS. The DON stated Resident 31 was prescribed Eliquis for CVA prophylaxis, finasteride and Tamsulosin for BPH, Brimonidine for glaucoma, and folic acid for anemia management. The DON stated missing the administrations of those critical medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) can cause clotting (sticky lump that forms when blood dries up or becomes thick) of blood due to the blood not being properly thinned, the clot traveling the heart and brain forming an embolism (obstruction caused by clots) potentially causing a heart attack and stroke, elevated eye pressure by not maintaining normal pressures leading to potential stroke and vision impairment such as blindness, all resulting in potential hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 31. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 2:10 p.m. with LVN 3, LVN 3 stated that medications should be re-ordered from the pharmacy five (5) to six (6) days in advance of using the last available dose to ensure timely delivery by pharmacy. LVN 3 stated that she (LVN 3) informed the DON that the Eliquis 2.5 mg for Resident 31 was not available (unable to recall the date). LVN 3 stated it was important for Resident 31 to receive Eliquis to prevent blood clots, heart attack, stroke, hospitalization, and/or death. During an interview on [DATE] at 2:25 p.m. with the DON, in the presence of LVN 3, the DON stated that on [DATE] was the first day the DON followed up with pharmacy regarding the refill and delivery of Eliquis 2.5 mg for Resident 31. The DON stated she (DON) had not called or communicated with pharmacy personnel prior to [DATE] and only faxed Eliquis refill requests to the pharmacy on [DATE] and [DATE] and assumed the medication was delivered. The DON stated she (DON) failed to follow-up with the requests and that going forward there needs to be a system put in place for following up on medication refills. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like Eliquis and brimonidine for Resident 31 can potentially increase the risk of blood clotting, CVA, and elevated internal pressure of the eye resulting in hospitalization and/or death. During a review of the facility's pharmacy delivery manifests to the facility on [DATE], the pharmacy delivery manifests indicated the facility received a 30-day supply of Resident 31's brimonidine 0.2% drops on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy delivery manifests faxed to the facility on [DATE], indicated the facility received 14-day supply (28 tablets) of Resident 31's Eliquis 2.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 31's finasteride five (5) mg tablets, folic acid one (1) mg tablets, and tamsulosin 0.4 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's P&P, titled Medication Administration - General Guidelines, dated [DATE], the P&P indicated: B. Administration 2) Medications are administered in accordance with written orders of the attending physician. 10) Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . routine medications are administered according to the established medication administration schedule for the facility. During a review of the facility's P&P, titled Ordering and Receiving Medications from The Dispensing Pharmacy, dated [DATE], the P&P indicated that Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure adequate supply is on hand. c. The refill is called in, faxed, or otherwise transmitted to the pharmacy. 3.a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery. During a review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, dated [DATE], the P&P indicated: D. The ordered medication is obtained either from the emergency supply or from the provider pharmacy. During a review of the facility's P&P, titled Medication Error Reporting, dated 1/2023, the P&P indicated: Medication errors will include but not be limited to: d. dose skipped.