**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Post IDR [DATE] revision Based on observation, interview and review of clinical records and other documentation as indicated, it was determined that for two (R1 and R2) out of four residents reviewed for follow-up appointments, the facility failed to ensure that the correct resident (R1) was sent to a cardiology appointment on [DATE]. R2, a newly admitted cognitively impaired resident, was sent with R1's medical paperwork and accompanied by a facility aide, who did not know the resident. At the appointment, R2 was slumped in a wheelchair with altered mental status and the facility aide did not know the resident's baseline. 911 was called and R2 was emergently sent to the emergency room (ER) with R1's medical paperwork. In the ER, R2 was initially registered under R1's name until it was brought to the ER's attention. The facility's failure placed R2 at risk for a serious adverse outcome or death as R2 had the potential to receive treatment based on R1's medical paperwork provided to the Cardiologist's office, to the EMTs for transfer to the ER and to the ER staff with respect to the different code status, medications, allergies and treatments. Due to this failure, an Immediate Jeopardy (IJ) was called at 2:31 PM on [DATE]. The IJ was abated on [DATE] at 4:30 PM. Also, for one (R3) out of one resident reviewed for injuries of unknown origin, the facility failed to ensure that nursing staff immediately reported an observed facial injury and implement interventions; failed to ensure that an RN documented her assessment after the resident's fall with a visible head injury; and failed to safely transfer the resident off the floor to protect the resident from further injury. Findings include: 1a. Review of R1 and R2's clinical records revealed: For R1: - admitted to the facility on [DATE] with diagnoses including, but not limited to, recent fall, supraventricular tachycardia, atrial fibrillation, acute kidney injury, hyperkalemia, cardiomyopathy, diabetes mellitus type 2; - full code status (requiring CPR); - no known allergies; - assigned room was XXX; and - the hospital Interagency Discharge Orders, dated [DATE] at 1:10 PM, documented that R1 had a follow-up cardiology appointment on [DATE] at 10:00 AM. - admission MDS assessment, dated [DATE], documented the BIMS (Brief Interview of Mental Status) of 14, revealing that R1 was cognitively intact. For R2: - admitted to the facility on [DATE] with diagnoses including, but not limited to, recent fall, several facial fractures, dementia, carotid artery stenosis, diabetes mellitis type 2, morbid obesity, obstructive sleep apnea, dysphagia, hypernatremia and atrial fibrillation; - DNR (Do Not Resuscitate) code status; - allergy to Sulfa antibiotics; - assigned room was YYY; and - admission MDS assessment, dated [DATE], documented the BIMS of 3, revealing that R2 was cognitively impaired. [DATE] at 7:25 AM - An appointment form was completed and faxed to the transport company for R1's 10:00 AM appointment with a pick-up time of 9:00 AM. The patient information section documented R1's name, facility name, address, phone number and a room number. The room number documented was incorrect as it was R2's room number (YYY). [DATE] at 12:00 Noon - The facility's incident report documented the following: - . [R2] was transported to a cardiologist appointment with [E6 TNA] as his escort. The appointment time and location was for a scheduled follow up but was intended for a different resident [R1] During the exam, the resident had a change in condition and was transferred via EMS/911 to the (hospital) ED (emergency department) . [DATE] - The hospital record documented: - at 12:29 PM, the patient (R2) arrived at the ER; - upon arrival at the ER, R2 was registered under R1's name; - at 12:41 PM under R1's name, C4 (ED Physician) documented, . [AGE] year-old gentleman history of ischemic cardiomyopathy with ejection fraction of 20 to 25%, atrial fibrillation/flutter on Eliquis, type 2 diabetes mellitus, chronic kidney disease stage III . reviewed discharge summary from [DATE] when he was admitted to the hospital after a fall Coming into the emergency department from cardiology outpatient follow-up visit noted to be altered and hypotensive, reviewed the note from cardiology from today, apparently he had been altered for about 3 hours prior to presenting to the cardiology office but the nursing facility staff who was with him was unfamiliar with his baseline . - at 2:06 PM, C3 (ED Physician) documented, . [AGE] year-old male with past medical history of cognitive decline, HTN, HLD (hyperlipidemia), obesity, OSA (obstructive sleep apnea) on BiPAP, diabetes, A-fib previously on Eliquis who was discharged on 3/19 after admission for a fall. Patient is actually benign and presents from a cardiology office for altered mental status. Unfortunately patient was taken to the cardiology appointment that was for a different resident of his skilled nursing facility. That patient is reportedly alert and oriented x4 at baseline however (R2) has cognitive decline and is alert to only self at baseline. Patient was brought with documentation of the other patients (sic) that was unfortunately registered under that patient's name. Patient's (R2) wife did arrive with patient's actual chart from the skilled nursing facility. She was able to clear out his medical history for me. Patient is at his mental baseline currently. She states he has had no recent complaints and has heard nothing from the facility about changes in mental status, vitals, any new symptoms. She states that if he had not been sent out for the cardiology appointment today, he likely would not have ever ended up in the emergency department. Of note however patient was noted to be hypotensive on arrival into the 80s. He is a poor historian and is unable to answer any questions. Was noted to be into the upper 80s while lying flat . (at) 12:37 (blood pressure) 85/54 . (at) 2:56 PM (blood pressure) 87/56 . Pulse Ox:98% . Nasal Cannula 4 L/min (placed on oxygen) . was also noted to be hypoxic . Disposition: pending labs, CT (diagnostic test), anticipate admission . [DATE] at 3:56 PM - C1 (PA) with the Cardiologist Office documented in a note, I was scheduled for a hospital follow-up today with (R1's name and date of birth ). Patient was brought in by aide from [NAME] rehab with the paperwork for (R1's name). Due to altered mental status patient was unable to provide his own name or date of birth . Patient was unable to respond to questions or follow commands. Aide stated she was not familiar with the patient but this had been his current mental status for the past 3 hours. I called (Cardiologist Physician name) to discuss clinical findings and new altered mental status compared to baseline. 911 was notified and on EMS arrival discussed patient's condition. After patient left via EMS patient's aide returned and stated they had brought the wrong patient to the office. Discussed over phone with (facility staff person) that the patient brought in was actually (R2's name and date of birth ). At the [NAME] ER patient had been identified as (R1's name) and had no previous identification bracelet from rehab. Discussed with clerk who changed encounter to appropriate patient. Patient's wife arrived and identified that he was in fact (R2's name) and mental status was at baseline given history of dementia and fall last month. Case was discussed with ED resident who resumed care at that time . The facility's investigative documentation provided to the Surveyor captured their immediate response: ([DATE] at 12:20 PM) Immediately upon notification of situation . - (at 12:14 PM) Facility was made aware that it was the wrong resident at the doctor's (sic) office and he was sent to the hospital. - (at 12:30 PM) Nurse called the wife to advise of his location and that he was being sent to the hospital . - (at 12:40 PM) Facility called the hospital to educate the hospital that the wrong resident was there and that his wife was there and could ID him and obtained information to fax correct residents paperwork to ER . On [DATE], the facility's investigation included the following typed and untimed statements: - E6 (TNA): Around 8:30 AM I was asked to go on an escort with a resident named (R1's first name) and I was directed to his room on the Arcadia unit with the transport team. He was dressed and, in his wheelchair, ready to go. Shortly after getting him off the unit, I was approached by his wife, and she was asking where he was going because she wasn't informed of any appointments. She stated she was informed of an appointment for [DATE]th but not for today. I asked [E5, Unit Clerk] where the resident was going, and she said the cardiologist. I directed his wife to [E5] because I wasn't aware of any other information from the resident and knew [E5] could better answer her questions. After we left the facility, the transport company stopped and picked up another person from a different facility. This person was dropped off before (R1's first name) and we didn't arrive at the appointment until 11 AM. He was checked in with his name and birthday based on the paperwork I was giving them. The resident was brought to the exam room and seen by [NAME] (Medical Office Assistant) and a PA (Physician Assistant). During this time, he put his hand on his chest and stated, 'help me'. The PA nor the [NAME] could get a BP (blood pressure) on (R1's first name). In the exam room, he would be alert then in a state of disorientation like he was sleeping. The PA notified the cardiologist who usually sees the resident (R1's first name) and based on this information, the PA informed me they were calling 911 and sending him to the ED. This was around 12 PM. About 12:20 PM, [E5] called my cell phone to let me know the wrong resident was at the appointment. The resident I have is [R2]. She asked to speak to the nurse, so I took the phone to the PA. - E5 (Unit Clerk): (R2's name) had left to go to the doctor's appointment when I realized it was the wrong resident. I checked the calendar and immediately called the Drs (Doctors) office. I let the staff know it was not (R1's name) but they had seen (R2's name). I let them know [R2] would be transported back to the facility. The nurse said he was a patient of theirs (sic) and they would see him. A few minutes later the TNA [E6] who escorted him called to let me know they were sending him to the ED. The nurse told me to send [R2's] info (information) to [NAME] Care ED in [NAME]. I sent everything the nurse told me to send. I gave the cardiology number to his direct nurse then sent his entire chart. The nurse notified his wife. - E7 (R2's Nurse): The TNA [E6] was with the resident and the transport company was here to pick up resident. His name was not on the schedule, so I asked the TNA to check with [E5, Unit Clerk]. E5 said he had an appointment. [E6], the TNA left with [R2] was working the morning (R2's name) was picked up for his appointment. The TNA [E6] reported to [E7] that the resident's wife was asking what the appointment was for as she had no knowledge of an appointment this week. [E7] directed the TNA [E6] to seek out clarification from [E5 Unit Clerk] who schedules the appointments . - E8 (Nurse): [E5, Unit Clerk] was upset and reached out to me for help. She explained to me what had happened with the resident mix up. [E5] asked me to call the wife and let her know about the appointment, his change of condition, and he was being transported to . ED. At this time, [E5] was on the phone with the cardiology office. The wife called me [E8] back when she arrived at the ED. She was asking for [R2], and being told he was not a patient. I spoke with the ED nurse and explained what had occurred, verified the resident in their care is [R2] and his wife was there. - E2 (DON): Soon after I gathered information leading up to the event, I spoke with [E5, Unit Clerk] in the presence of [E1 NHA]. She [E5] recalled giving the TNA [E6] . the room number of [YYY], not the room number of the scheduled resident. She agrees the scheduled appointment was for [R1] . with his cardiologist. We discussed the chain of events that led up to her giving the incorrect room number. She had printed the correct resident information, and this envelope was passed to the TNA [E6] . On [DATE], the facility documented the following actions taken: - (at 7:30 PM) NHA went into calendar on EHR (electronic health record) program and pulled up all upcoming appointments for the next 48 hours. She printed the appointments and the corresponding face sheets. These packets were put on each nursing station for staff who care for them . - (untimed) E2 (DON) documented an Employee Corrective Action for E5 (Unit Clerk) for Resident placed in unfamiliar environment. Became anxious and agitated. Spouse was given incorrect information. Was put in an eventful situation causing emotional & (and) physical stress. In addition, E2 documented .Soon after I gathered information leading up to the event, I spoke with [name of E5] in the presence of the Administrator . We discussed the chain of events that led up to her giving the incorrect room number . Following our conversation, we implemented a plan of correction immediately and started educating all staff. This education was given to [name of E5], and she verbalized understanding and signed the documentation. On [DATE], the facility documented the following actions taken: - (at 5:30 AM) Staff present were educated on below process change with staff education continuing on the following process. System changes to prevent reoccurrence: * All residents are to have a current photo uploaded into PCC within 72 hours from admission. At times a resident will refuse, however a second attempt to obtain a picture is to be made. * All scheduled appointments must be entered into the calendar. This calendar will be printed out daily and given to the front desk. Along with this, there will be a printout of the individual's face sheet. The night supervisor and or designee will be responsible to print these out. * Transportation companies are to be stopped at the receptionist desk and asked the name of patient/resident. Then they will be directed to the proper room. At which time a copy of the face sheet will be given to transport who will have a staffing member to verify identification. Validation made from photo, right name, and right appointment. Nursing staff will then sign the face sheet and direct transport back to the receptionist desk. * The reception desk will collect the signed face sheet and document the time they left the building. * If the appointment doesn't appear on the calendar, then a face sheet will not be printed. Facility will not release patient/resident until proper verification is made. DON and/or Administrator will also be notified. Education will be completed with nursing staff on the above process by [DATE]. - (at 8:00 AM) Receptionist was trained to stop everyone at the front door to verify the correct resident is leaving for the appointment and verify resident with signed face sheet. - (at 9:24 AM) The facility reported the following to the State Agency: Incorrect resident was transported out of the facility to a follow up appointment scheduled for another resident. It should be noted that despite the incident occurring on [DATE], the facility failed to report this incident within the required 8 hours per State Regulation and failed to disclose to the State Agency that the incorrect resident was emergently sent to the hospital from the appointment. - (at 9:45 AM) Administration team was notified of incident to be on alert and informed of the new system change. An Ad Hoc QAPI sign-in sheet was dated [DATE]. - (untimed) E2 (DON) documented an Employee Corrective Action for E7 (LPN) for Resident placed in unfamiliar environment. Became anxious and agitated. Spouse was given incorrect information. In addition, E2 documented . In my conversation with [name of E7], I pointed out she, as the nurse, should seek clarification herself, so as not to have it go through multiple staff. She also was given the place of correction steps and education . [DATE] at 1:24 PM - During an interview with the Surveyor, C2 (Nurse Manager) with the cardiology office confirmed that R2 was not a patient of this cardiology practice. C2 stated that she observed the resident (R2) sitting in a wheelchair in an evaluation room slumped over to the right and was somnolent with the aide present. Surveyor observed that R1's paperwork printed for the office appointment did not have a identification picture of the resident (R1). [DATE] by 5:00 PM - The facility documented that each resident's picture was uploaded into PCC except the two that were out at an appointment. [DATE] at 8:30 AM - The facility documented that (second) receptionist was trained regarding the new process. [DATE] at 9:15 AM - The facility documented that a written notification was sent to all employees through Hosted Time with the above education outlined on [DATE] at 5:30 AM. Those educated via Hosted Time will receive education again in person prior to starting their next shift. [DATE] at 10:00 AM - The facility documented that the remaining two residents (pictures) and the two admissions were uploaded in PCC. [DATE] at 10:29 AM - During an interview with the Surveyor, F2 (R2's wife) stated the following: - On [DATE], F2 arrived at the facility for a visit at approximately 9 AM. - Transport personnel and E6 (TNA) were taking R2 out of the Arcadia unit. F2 asked Where are you going? F2 was told that R2 was going to a follow-up with the cardiologist. F2 said that she did not know about the appointment. F2 followed them up in the elevator. F2 stated that E5 wrote the address down. F2 asked if the appointment was at (name of building) and was told it was in [NAME]. (It should be noted that the building F2 named was also located in [NAME].) F2 stated that she got into her car to follow the transport van. F2 stated that the transport van made a left hand turn onto to [NAME] Road and both back doors of the van opened. The van stopped on [NAME] Road and the back doors were closed from the inside. F2 stated that she could not follow the transport van and lost site of it. At 9:55 AM, F2 arrived at the cardiologist at the (name of building) and was told that R2 was not here. F2 stated that she went back to the car and looked at the paperwork with the cardiologist office address she was provided and went there. At approximately 10:15 AM, F2 arrived at the address she was provided and was told there was no one here by that name (R2) nor scheduled. F2 stated that R2's vascular surgeon was located in the same building, so she went to that office and no one knew anything there. F2 stated that she even went to the 3rd floor cardiologist office, which is affiliated with the 2nd floor, and no one knew anything. At approximately 11:30 AM, F2 stated she called the facility to find out the location of my husband, R2. F2 stated that she believed she spoke with E14 (PTA) and was told that she would find out. At 11:50 AM, F2 stated that she went home to get changed because she was soaked from getting in and out of her car as it rained all morning and called her son. At approximately 12:30 PM, F2 stated that she received a call from a facility nurse (E8) that said her husband, R2, was taken to the ER for a heart attack. F2 stated that she called both kids about this. At approximately 1:20 to 1:30 PM, F2 arrived at the ER receptionist desk and explained that she was told her husband (R2) was brought here with a heart attack. F2 said that she was told by the ER receptionist desk that they do not have him (R2's name) in the system. F2 stated that she called the facility back to find out what was going on and was asked if she was at the (name of) ER. A facility staff person asked to speak to the ER receptionist. At approximately 2:10 PM, F2 said she was taken back by an ER nurse, where R2 said What's up? to F2 when she entered his ER room. F2 stated that R2 did not have a heart attack, but was later admitted and treated for a urinary tract infection. [DATE] at 11:30 AM - During an interview with the Surveyor, E14 (PTA) stated that she believed she received two calls from F2 (R2's wife) but could not recall the exact times. E14 stated that F2 called and said she could not find R2. E14 stated that she would check with E5 (Unit Clerk) and would get back to her. E14 then said that F2 called from the hospital and told her that no one was here by R2's name. E14 said she handed the phone over to E8 (Nurse). [DATE] at 11:45 AM - During an interview with the Surveyor, E5 (Unit Clerk) stated that there were two unit clerks about six months ago who were scheduling appointments for residents. Currently, E5 schedules appointments and arranges transportation, coordinates with the Scheduler for those residents who need an escort, and E14 had recently been assisting E5 with the scheduling appointments. E5 stated that she was not in the facility on [DATE], the day that R1 was admitted . E14 entered his appointment on the calendar (but did not arrange transportation). E5 stated that she did not completely open the facility's electronic appointment calendar to review all the details regarding the [DATE] appointment. E5 stated that she made a mistake thinking it was R2's name, but the calendar actually had R1's name on it. E5 went to the scheduler to ask for someone to go to the appointment with R2. It should be noted that all appointments scheduled for the day are listed on the (name of electronic health record) electronic dashboard, which was accessible to all nursing staff. [DATE] at approximately 12:20 PM - During an interview with the Surveyor, E6 (TNA) stated she mainly does 1:1 observation, will help out in the kitchen and escorts residents to outside appointments (approximately 3 times since she started with the facility). E6 stated she was assigned a 1:1 with another resident on [DATE] when she reported to work at 7 AM. E6 stated that E5 (Unit Clerk) came a little after 9 AM to get me and take me to R2's room (YYY) and transport staff were already there in his room. E7 (Assigned Nurse) gave me the packet (medical records) for the appointment at the nurse's station. E6 stated that she asked where was R2 going and E7 checked the computer and could not find anything and told her to check with E5 (Unit Clerk). At approximately 9:20 AM, transport staff was taking R2 off the unit and we ran into R2's wife, who asked where was he going? E6 told F2 to the cardiologist and F2 asked where. E6 stated F2 then went to go talk to E5. E6 stated they left the facility at approximately 9:30 AM and confirmed that the two back doors of the transport van opened while turning left onto [NAME] Road. E6 stated that the transport van stopped at another facility to pickup a second patient in a stretcher and dropped that patient off at the (name of location) at 10:30 AM. E6 stated that the transport driver called the cardiologist office because the 10:00 AM appointment was missed and cardiologist office stated they had another opening at 11:30 AM. E6 stated that they arrived at the cardiologist office and to check in she entered the resident's name and date of birth (R1) based on the paperwork she had with her. E6 stated that the cardiologist office medical assistant was trying to get a blood pressure reading and could not. The PA consulted with R1's cardiologist by phone and decided to send patient to the ER to be evaluated. E6 stated that she called the facility at approximately 11:45 AM and spoke to E5 (Unit Clerk) and was put on hold, then the phone hung up and she kept calling. E6 stated that the EMTs (emergency medical technicians) stated the patient was in 'aFib' and had low blood pressure. E6 stated that she handed the EMTs R1's paperwork, which included the medication list. At approximately 12:20 PM, E5 told me that it was the wrong resident and transport would be returning to pick her up and the resident's wheelchair. E6 stated that she gave the phone to the cardiology PA and then waited for transport to pick her up. E6 stated that some appointment packets have photos, but there was no photo on R1's packet. [DATE] at 12:56 PM - During an interview with the Surveyor, C1 (Cardiology PA) stated that the resident who was at the appointment was minimally responsive. C1 called R1's Cardiologist and the resident's presentation was not typical as R1 was fully alert. After consulting and based on the altered mental status, the office called 911. Resident was transferred to the ER. The facility escort came back into the office and C1 learned that the wrong resident was sent to the appointment. C1 stated that she went over to the hospital ER on [DATE] at approximately 1 PM and spoke with the ER Triage and bedside nurses and the Resident Physician to make sure the ER was aware that they had the correct patient information. C1 stated that she was present when R2's wife arrived. [DATE] at 2:31 PM - An Immediate Jeopardy was called with E1 (NHA), E2 (DON) and E3 (RN RDCS). [DATE] at 4:30 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated and timed by E1 (NHA), as outlined below: System changes to prevent reoccurrence: * All residents are to have a current photo uploaded into PCC at time of admission by the activities department and/or nursing supervisor. Nursing supervisor educated on uploading pictures into [name of EHR] at [DATE] at 1602 (4:02 PM). At times a resident will refuse, a second attempt to obtain a picture is to be made by management staff/designee immediately upon notification and if they still refuse the facility will place an ID bracelet. If they refuse the ID bracelet, staff will . verbalize identification to verify residents identify (sic) (i.e. name and date of birth ). If resident is confused or non-verbal identification of resident will be made with 2 staff members who are familiar with the resident. * All scheduled appointments must be entered into the calendar. This calendar will be printed out daily and given to the front desk. Along with this, there will be a printout of the individual's face sheet. The night supervisor and or designee will be responsible to print these out. * Transportation companies are to be stopped at the receptionist desk and asked the name of patient/resident. Then they will be directed to the proper room. At which time a copy of the face sheet will be given to transport who will have a staffing member to verify identification. Validation made from photo, right name, and right appointment. Nursing staff will then sign the face sheet and direct transport back to the receptionist desk. * The reception desk will collect the signed face sheet and document the time they left the building. * If the appointment doesn't appear on the calendar, then a face sheet will not be printed. Facility will not release patient/resident until proper verification is made. DON and/or Administrator will also be notified. Education will be completed with nursing staff in person on the above process by [DATE] . Based on the facility's response to the [DATE] incident involving R2, interviews with staff and no further incidents observed where the incorrect resident was sent to the wrong appointment, the facility's IJ was abated on [DATE] at 4:30 PM. 1b. Observation of the facility's new process for resident's leaving the facility for appointments revealed: [DATE] at 9:30 AM - Surveyor's observation of the facility's abatement plan in action revealed that the Transport staff were in the lobby waiting to transport R6 to an appointment. However, R6's name was not on the Receptionist list of residents that had an appointment that day and was confirmed with E11 (Receptionist). [DATE] at 9:45 AM - Surveyor observed R6 being brought in a wheelchair to the reception desk along with E10 (LPN). [DATE] at 9:50 AM - During an interview, E10 stated she was aware that R6 had an appointment and had the paperwork. E10 verified that she confirmed the correct resident (R6) was sent out to the appointment using the resident identification process. [DATE] at 10:00 AM - During an interview, E1 (NHA) stated that she prints out the resident appointment list each day and provided it to the receptionist. E1 stated that R6 must have dropped off the list for an unknown reason. E1 stated that she had not verified that the names on the list matched up with the individual resident face sheets that were printed for each resident that had an outside appointment that day. Going forward, E1 stated that she will have another person compare the resident's list with appointments each day with the face sheets of residents with appointments that are used for identification purposes. 2a. Review of R3's clinical record revealed: [DATE] - R3 was care planned for aspirin therapy and at risk for adverse effects with intervention that included: report bruising. In addition, R3 was care planned for at risk for alteration in skin integrity with an intervention that included: observe skin condition with ADL (activities of daily living) care daily; report abnormalities. [DATE] - An active physician's order documented to administer R3 Aspirin 81 MG every day for a diagnosis of coronary artery disease (CAD). [DATE] - The annual MDS assessment documented that R3 was rarely understood or understands; had short-term and long-term memory problems; was severely impaired for daily decision making; dependent for toileting, personal hygiene, showers and lower body dressing; and weighed 99 lbs. [DATE] at 11:21 AM - The Skin Observation Tool form by E18 (RN) documented that R3 had no skin alterations. [DATE] at 8:17 AM - E16 (CNA) documented in R3's clinical record that R3 was provided a shower. [DATE] at 1:35 PM - The facility's incident report by E18 (RN) documented, . At (1:35 PM) after nurse (sic) was assisted back to bed, resident was noted with purple bruise on right side of chin and philtrum (upper lip). [R3] could not explained (sic) what happened . Assessment done body audit done no other abnormal bruise or cut noted. Resident denied any s/s (signs or symptoms) of pain. No swollen noted . Oriented to person . Family Member (notified) at (2:49 PM) and NP notified at (2 PM) . The facility's investigation included, but was not limited to, the following documented staff written statements: - E15's (LPN) untimed/undated statement: . What did you observe? . A bruise on resident chin . At 8:30 AM when I went to resident room to give morning medicine, I noted a small redness on her right chin. I did not tell my preceptor about it because I did not know the resident well . - E16's (CNA) untimed/undated statement: . What did you observe? . Started my care with the resident. Overlook the bruise. I don't normally have (R3's name) as my resident, didn't notice it was abnormal . - E17's (CNA) 3:58 PM on [DATE] phone statement: . What did you observe? . Cared for resident 3-11 & 11-7 (prior evening and night shifts on [DATE] through [DATE]). Constantly check on her re (regarding) adjusting her in bed. Last provided care at 6:15 AM. No skin issues . Review of R3's clinical record lacked evidence that neurochecks were initiated and completed after injuries of unknown origin (right chin and upper lip bruises) were identified and monitoring for bleeding as R3 was administered aspirin daily. The facility failed to ensure that nursing staff immediately reported R3's injury of unknown origin (redness on the right chin) when identified at 8:30 AM and failed to initiate monitoring for bleeding and completing neurochecks. [DATE] at 9:52 AM - During an interview, E16 (CNA) stated that she came in on an off day on [DATE]

Based on interviews, record review and review of other documentation as indicated, it was determined that for one (R23) out of three residents sampled for falls, the facility failed to ensure that readmission physician orders for two anti-seizure medications were accurately transcribed into the electronic health record for R23's immediate care of her seizure disorder. From 9/8/23 through 9/20/23, R23 did not receive 24 doses of Vimpat and was administered five (5) incorrect doses of Keppra. On 9/29/23, R23 had a seizure and fell during a therapy ambulation session and was transferred to the hospital, evaluated and treated with anti-seizure medication. Due to the facility's failure, an Immediate Jeopardy (IJ) was called at 3:20 PM on 10/26/23. The IJ was abated on 10/27/23 at 5:00 PM. Findings include: R23's clinical record revealed: 8/28/23 - R23 was admitted to the facility with diagnoses that included, but was not limited to, seizure disorder (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness). 9/8/23 at approximately 7:00 PM - On Friday evening, R23 was readmitted to the facility from the hospital. The hospital discharge orders documented the following anti-seizure medications: - Vimpat 50 mg (milligrams) oral tablet - give one (1) tablet two times a day with the next dose due on 9/8/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg, two times a day with the next dose due on 9/8/23 at 8:00 PM. 9/8/23 at 7:28 PM - E8 (RN) entered the following readmission physician orders into R23's electronic health record: - Vimpat 50 mg oral tablet - give one (1) tablet two times a day with a start date of 9/20/23 at 8:00 PM; and - Keppra 500 mg oral tablet - give one (1) tablet = 500 mg, two times a day. From 9/8/23 at 8:00 PM through 9/20/23 at 8:00 AM, R23 did not receive the physician ordered Vimpat medication, a total of 24 doses. From 9/8/23 at 8:00 PM until 9/11/23 at 8:44 AM, R23 was administered only one 500 mg tablet of Keppra twice a day for a total of five doses instead of 1,500 mg twice a day. 9/11/23 at 8:44 AM - R23's 9/8/23 Keppra physician's order was discontinued. A new physician's order was entered for Keppra 500 mg oral tablet - give three (3) tablets = 1,500 mg two times a day. R23 received the correct dosage of Keppra from 9/11/23 through 9/29/23. 9/29/23 at 10:30 AM - A nursing note documented, Therapist called a 'falling leaf' (fall prevention program identifying residents that are at highest risk of falls). Per therapist, pt (patient) seized up during ambulation and started to fall, did not hit her head, landed on therapist . Seizure suspected . Pt reports to therapist that she is unable to see . 9/29/23 at 4:06 PM - The hospital record documented that . at baseline she has seizures at least once a year, her last seizure was a month ago, about a month ago her Vimpat dosing was increased from once a day to twice a day, and the semiology (signs/symptoms) of her seizures is typically unilateral bilateral hand shaking or blank staring rather than full tonic-clonic presentation (type of seizure that affects both sides of the brain and causes a loss of consciousness and violent muscle contractions) . at 5:01 PM discussed case with . neurology (study of the nervous system, which controls our thoughts, sensations, movements and emotions) . amenable (agree) to increasing her Vimpat to 100 mg twice daily . at 6:04 PM about 30 minutes ago was in the room updating her (family member) when (R23) began speaking, then began having relatively rapid stuttering repeating a single syllable, tremors noted in the bilateral hands, her arms then raised up to a flexed (bent) position at the elbow, and her gaze was to the right. (R23) did not lose consciousness. (R23) then lowered her arms but continued to have tremors in the right hand and stuttering when she spoke. Given concern for an ongoing focal seizure (begin in one area of the brain, but can become generalized and spread to other areas) we did administer 0.5 mg of Ativan (used to treat active seizures) twice, about 2 minutes apart, with resolution of this activity. 10/12/23 at 10:51 AM - The hospital discharge summary documented that R23 presented to the hospital . with seizure-like activity, through her hospitalization underwent continuous EEG (electroencephalogram - diagnostic test that records brain waves) with titration (increase/decrease) of her anti-seizure medications with assistance of neurology. On discharge, R23's anti-seizure medications were changed to: - Vimpat 50 mg oral tablet - give three (3) tablets = 150 mg twice a day; and - Keppra 1,000 mg oral tablet - give one (1) tablet twice a day. 10/26/23 at 1:07 PM - During a combined interview, E2 (DON) and E3 (RCD) confirmed that the facility failed to identify that R23's Vimpat medication admission order had the incorrect start date and R23 did not receive the medication until 9/20/23; confirmed that the facility did not identify that R23's Keppra medication admission order had the incorrect dosage until three days after readmission during a Monday morning (9/11/23) review and was corrected, but no investigation was conducted. E2 and E3 confirmed that the facility completed Medication Error Reports for both medications today, 10/26/23. E2 and E3 stated that the facility's licensed nursing staff conduct 24 hour chart checks of physician orders, however the nursing staff do not document that this second check was performed in the resident's clinical record. R23's clinical record lacked evidence that a 24 hour chart check was completed. Despite identifying the Keppra incorrect dosage on 9/11/23 during a Monday morning review, the facility failed to complete an incident report and conduct an investigation as to why this medication error occurred. 10/26/23 - The facility provided copies of each Medication Error Report for Vimpat and Keppra. Each report documented .What was the effect of the error on the resident? Increased potential for seizure activity . 10/26/23 at 3:20 PM - An Immediate Jeopardy (IJ) was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), E3 (RCD) and E5 (VPO). The facility failed to ensure that R23's readmission physician orders for both Vimpat and Keppra were accurately entered into the electronic health record (EHR) to meet her immediate need and care of her seizure disorder. 10/27/23 at 12:00 Noon - An amended IJ template was provided to the facility. 10/27/23 at 2:17 PM - E1 (NHA) submitted an acceptable amended Abatement Plan signed, dated, and timed. 10/27/23 at 5:00 PM - The facility's Immediate Jeopardy was abated at this time. 11/7/23 - Based on verification of the facility's following immediate corrective actions listed below through interviews and review of residents' clinical records and facility documentation revealed that the IJ was abated on 10/27/23 at 5:00 PM: - R23's active physician orders were reconciled (reviewed) by the medical provider; - Facility's audit/reconciliation of all new admissions/readmissions physician orders in the last 30 days and any discrepancies identified to be communicated with the provider for further recommendations; - Education provided to NHA/DON on reviewing all new admissions/readmissions physician orders and reconciling those orders entered into the EHR; - New facility admission/readmission process: Admitting nurse will call and reconcile the resident's orders with the provider and will include start dates. The admitting nurse will document on the discharge summary/medication list the provider name, date and time. The admitting nurse will then enter the orders into the resident's EHR (electronic health record). A second nurse will validate those orders entered for accuracy within 24 hours. The second nurse will sign and date the discharge summary/medication list. The signed discharge summary/medication list will be placed in a file at the nurses' station. The medical records clerk will then remove the document and upload it into the resident's EHR within 5 business days; and - Education provided to all licensed nurses and the records clerk on the new facility process.

Based on observation, interview and record review, it was determined that for one out of one resident (R49) reviewed for respiratory/tracheostomy care, the facility failed to provide tracheal suctioning consistent with professional standards of practice. Findings included: The following was reviewed in R49's clinical record: 9/18/22 - R49 was admitted to the facility from an acute hospital with a diagnosis of respiratory failure. 10/29/20 - Per physician's order, trach care daily and as needed: for disposable: remove and dispose inner cannula. Replace with new inner cannula as needed for reduce risk of infection. 2/21/22 - Per physician's order, suction every shift and as needed for maintain patent airway. 10/3/22 - Per physician's order, cool air mist via trach collar at 70% humidification with O2 (oxygen) titrated in at 3 liters to maintain a pulse ox greater than 92%. Notify MD if pulse ox is equal to or less than 92%. Every shift. 7/19/23 at 10:40 AM - During observation of preparation to perform tracheal suctioning for R49, E66 (LPN) did not perform hand hygiene. After donning sterile gloves, E66 touched unclean surfaces (the suction canister tubing, outside of the bottle of sterile water, and the inside of the solution receptacle prior to pouring sterile water in it) using both gloved hands interchangeably. E66 was noted to switch between both hands when holding and/or grabbing items used for suctioning, including the suction catheter. During suctioning of R49, part of the suction catheter touched the clean, but unsterile trach dressing before being inserted in the inner cannula. The O2 (oxygen) level was set at 2 liters. The O2 tubing was not dated and labeled. The suction canister had not been emptied after prior use. Hand hygiene not observed being performed by E66 after removing gloves. 7/19/23 at 10:45 AM -During an interview and observation with E66, R49's oxygen was noted to be at 2 liters/minute. E66 stated that the order was for 3 liters/minute and adjusted the setting. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO)

4. The following was reviewed in R284's clinical record: 9/3/21 11:10 PM - R284 was admitted to the facility with diagnoses including a stroke with right sided weakness. 9/4/21 - R284's admission baseline care plan documented that R284 had urinary incontinence related to R284's limited ability to move. A care plan intervention included to provide incontinence care as needed to R284. 9/14/21 - A progress note documented that R284 left the facility AMA (Against Medical Advice) with the assistance of R284's wife (FM3) because FM3 was not happy with the care that the facility provided to her husband. 7/19/23 12:20 PM - During a telephone interview, FM3 stated that she had not been happy with the care that her husband received while he was a resident at the facility. FM3 stated that her husband was not kept clean while he was a resident at the facility, and that he was often left for lengthy periods of time in wet briefs. 7/20/23 - A review of the 9/3/21 CNA Documentation Survey Report for R284 documented that toileting care was not provided to R284 on the 11-7 shift. 7/20/23 - During an interview, E60 (CNA) stated that a blank section for documentation on a documentation survey report means that the task was not done. 7/27/23 - A review of employee timecards for 9/3/21 revealed that six CNAs called out for 9/3/21. Based on an analysis of the CNA timecards and the locations of work for CNAs on 9/3/21, the unit that R284's room was located had one CNA for the 11-7 shift, and the other unit on the same floor had no CNA timecard entries for the 11-7 shift. 7/27/23 - During an interview, E16 (HR) stated that the 9/3/21 timecard documentation does not reflect that Agency CNAs that may have worked, but E16 said that there was no way to produce a staffing sheet for 9/3/21. 7/31/23 -- During an interview, E61 (CNA) stated that a blank section for documentation on a documentation survey report means that the task was not done. Cross refer to F689, example 1 5. Review of R26's clinical record revealed the following: 12/13/21 - R26 was readmitted to the facility with diagnoses including but not limited to repeated falls. A care plan was developed for R26's (created on 6/28/21 and revised 3/31/23) disruptive/compulsive behaviors including, roaming into other residents' rooms. R26's interventions included but not limited to 1:1 supervision (one staff person assigned direct supervision of a resident) for safety (created 6/15/22 revised 2/16/23). 4/9/23 - A facility investigation report documented that R26 had an unwitnessed fall. R26 was noted in the hallway with blood on the face and scalp. The report further documented that R26 had been wandering in the unit during the shift and was also noted with laceration on top of scalp, left eye and bridge of nose. 7/28/23 - Review of the facility Weekend Staffing sheet dated 4/9/23 on the 11:00 AM - 7:00 AM shift lacked evidence that a staff person was assigned to R26 for the 1:1 supervision for safety as the care plan indicated. The facility failed to ensure there were sufficient nursing staff to meet the needs of R26 during the 11::00 PM to 7:00 AM shift on Sunday, 4/9/23 that resulted to R26's fall with injuries and transfer to the hospital. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO). 8/14/23 11:13 AM - Findings were communicated in an email correspondence with E1 (NHA), E2 (DON) and E3 (RDC). Based on observations, interviews and reviews of clinical records and other facility documentation, it was determined that the facility failed to ensure there were sufficient nursing staff to administer critical medications to meet the needs of the residents during the 7:00 AM to 3:00 PM shift on Friday, 7/21/23. For three residents (R22, R51 and R630) on the Dover Unit that were ordered Humalog insulin to be administered with breakfast (scheduled at 7:35 AM), revealed the following: - R22 was never administered insulin with breakfast. - R51 was administered insulin at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 was administered insulin at 9:56 AM and 9:57 AM, approximately 2.5 hours later. For one resident (R631) on the Heritage Unit that was ordered Humalog insulin with breakfast revealed that R631 never received the ordered insulin. The lack of available nurses to administer medications timely had the potential to cause a serious adverse outcome or death. An Immediate Jeopardy (IJ) was called at 2:50 PM on 7/21/23. The IJ was abated at 9:00 AM on 7/24/23. Additionally, two previous night shifts (11:00 PM to 7:00 AM), specifically 7/1/23 to 7/2/23 and 7/15/23 to 7/16/23, failed to have sufficient nursing staff where the residents in the two units were not administered medications, provided treatments and lacked monitoring/supervision by a nurse. Findings include: 1. Cross refer to F760, example 1 7/21/23 at 9:12 AM - Review of the daily Staff Posting posted at the second floor nurse's station revealed two blank spots for a second nurse's name assigned to the Dover Unit and a second nurse's name assigned to the Heritage Unit. 7/21/23 at 9:15 AM - An observation on the Dover Unit (rooms 226-244) noted two medication (med) carts: the first med cart with no nurse present and the second med cart with E36 (Agency LPN) waiting next to it. During an interview, E36 stated that she was still waiting for her PointClickCare (PCC) login to start the morning medication pass for 22 residents in her assigned area (rooms 234 to 244). E36 stated that this was her first day on the floor and she asked for her PCC login multiple times this morning. When asked who was working the other med cart in the unit, E36 stated that she did not know and she did not see anyone passing medications from that med cart. Review of the Dover Unit revealed three residents (R22, R51 and R630) with physician orders for Humalog insulin to be administered with breakfast. 7/21/23 at 9:20 AM - An observation on the Heritage Unit (rooms 200-225) revealed two nurses passing medications. It was noted and confirmed that E37 (LPN/Wound Care) was reassigned to a med cart on this unit as the daily Staff Posting lacked evidence of a second nurse assigned to the Heritage Unit. Review of the Heritage Unit revealed one resident (R631) with a physician order for Humalog insulin to be administered with breakfast. 7/21/23 at 9:25 AM - An observation of the two units on the first floor revealed only one nurse on each unit, New Castle and Arcadia (locked dementia unit). At 9:35 AM, E22 (LPN/UM) arrived on the New Castle Unit and start the morning medication pass. During an interview, E22 stated that she did not know her assignment and confirmed that she did not pass any medications on the assigned split med cart for the New Castle unit (rooms 126-130) and Arcadia unit (rooms 100-106) this morning. Review of the New Castle Unit revealed one resident (R1) with a physician order for Humulin N insulin scheduled for 8:00 AM, but was administered at 11:52 AM, approximately 4 hours later. Humulin N insulin was an intermediate-acting insulin that starts to work within 2 to 4 hours after injection, peaks in 4 to 12 hours, and does not require administration with meals. 7/21/23 at 10:31 AM - E2 (DON) informed the Surveyor that the facility had a census of 132 residents. Review of nursing staff timecards for the 7:00 AM to 3:00 PM shift on 7/21/23 revealed: On the Dover Unit: -E36 (Agency LPN) clocked in at 6:52 AM, assigned to a med cart on the Dover Unit. -E40 (RN/Staff Development) clocked in at 7:00 AM. She was reassigned to the second med cart on the Dover Unit. On the split med cart covering New Castle Unit and Arcadia Unit: - E22 (LPN/UM) - clocked in at 7:54 AM, and clocked out at 2:49 PM. Despite the day shift hours for facility nursing staff were 7:00 AM to 3:00 PM, E22 arrived almost one hour after the day shift started and left 10 minutes before the end of the shift. 7/21/23 at 11:31 AM - During an interview, E41 (LPN) stated that she just finished med pass in the New Castle Unit and will continue to pass meds to the following five residents in rooms 100-103 (R19, R44, R55, R70 and R92) in the Arcadia Unit. 7/21/23 at 12:31 PM - During a follow-up interview, E41 (LPN) stated that she was working a double (shift) as she had the New Castle Unit on night shift and this morning she was assigned the second med cart in the New Castle Unit. E41 stated that she performed the narcotic count with E22 (LPN/UM). 7/21/23 at 12:57 PM - During an interview, E30 (Agency LPN) stated that she received shift report and performed the narcotic count for her assigned residents in the Arcadia Unit. E30 also stated that she administered meds to some of the Arcadia residents who were assigned to the split med cart. 7/21/23 at 1:03 PM - During an interview, E22 (LPN/UM) stated that she checks the schedule at the nurse's station. E22 also stated that she already performed a narcotic count, but she doesn't believe that she signed the narcotic count book for today (7/21/23). 7/21/23 at 1:50 PM - During a follow-up interview, E22 (LPN/UM) stated that she received shift report from E41 (LPN). E22 stated that two other nurses (E41 and E30) assisted in administering meds in the Arcadia Unit today as she was administering meds in the New Castle Unit. 7/21/23 at 2:00 PM - During an interview, E40 (RN/Staff Development) stated that she was working with orientees this morning when E2 (DON) alerted her that she would need to work on the floor. E40 was assigned a med cart in the Dover Unit. E40 stated that she received shift report from E2 (DON) and performed a narcotic count with a nurse from the Heritage Unit. 7/21/23 at 2:15 PM - During an interview, E36 (Agency LPN) stated that she arrived at 7:00 AM and received shift report and performed a narcotic count with the offgoing nurse in the Dover Unit. 7/21/23 at 2:18 PM - During a follow-up interview, E22 (LPN/UM) was asked if she received shift report this morning. E22 stated that sometimes not much report is given because oncoming staff arrives late and the departing staff gets tired of waiting. 7/21/23 at 2:45 PM - During an interview, E37 (LPN/Wound Care) stated that she was reassigned to a med cart on the Heritage Unit. E37 stated that did not receive shift report nor did she perform a narcotic count at the start of her shift. 7/21/23 at 2:50 PM - Based on observations, interviews and review of facility documentation, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON), and E4 (RCD). 7/21/23 at 9:50 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated, and timed. 7/24/23 at 9:00 AM - The facility's Immediate Jeopardy was abated at this time. Further observations of facility staffing and timely insulin administration revealed that the IJ was abated on 7/24/23 at 9:00 AM based on the verification of the facility's immediate corrective actions: - staffing was reviewed for 7/21/23, 7/22/23, 7/23/23, 7/24/23; - staffing agencies added for additional support; - implementation of a staffing agency orientation package and location in the nurse's stations; - process in place to address call outs and no call no shows to ensure sufficient staffing; - completed education with NHA, DON and Staffing Coordinator; - observations of blood glucose checks and timely insulin administrations; - review of the residents' clinical records; and - observations of facility staffing over the weekend and 7/24/23 by two Surveyors. 2. Cross refer to F684, example 1a Review of the facility's Staff Posting for the 11:00 PM to 7:00 AM shift on Saturday, 7/1/23, to Sunday, 7/2/23, revealed that there was no nursing supervisor listed, no nurse assigned to the Arcadia Unit (locked dementia unit) with 34 residents, and no CNA assigned to 1:1 supervision for R26, a resident with known aggressive behaviors. The Staff Posting listed two CNAs in the Arcadia Unit for this shift: E5 and E6. The facility's timecards for nurses on the 11:00 PM to 7:00 AM shift on Saturday, 7/1/23, into Sunday, 7/2/23, revealed: - E43 (RN) clocked in at 3:57 PM and clocked out at 9:02 AM, assigned to the Dover Unit. - E44 (LPN) clocked in at 10:48 PM and clocked out at 7:30 AM, assigned to the Heritage Unit. - E41 (LPN) clocked in at 11:01 PM and clocked out at 9:29 AM, assigned to the New Castle Unit. Review of the July 2023 eMARs and eTARs for 34 residents in the Arcadia Unit (first floor) revealed that E43 (RN), assigned to the Dover Unit on the second floor, administered and signed off medications, treatments and monitoring at the beginning of the night shift. Further review revealed that 15 residents were not administered medications or provided treatments at the end of the shift. 7/28/23 at 5:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (RCD). 3. Cross refer to F684, example 1b, and F760, example 2 Review of the facility's Staff Posting for 11:00 PM to 7:00 AM shift on Saturday, 7/15/23, into Sunday, 7/16/23, revealed that there was no nurse assigned to the New Castle Unit with 37 residents and E43 (RN) was listed as the night shift Supervisor and also assigned to a med cart on the Dover Unit. The Staff Posting listed two CNAs in the New Castle Unit for this shift: E46 and E47. The facility's timecards for nurses on the 11:00 PM to 7:00 AM shift on Saturday, 7/15/23, into Sunday, 7/16/23, revealed: - E48 (LPN) clocked in at 3:19 PM and clocked out at 7:30 AM, assigned to the Arcadia Unit. - E44 (LPN) clocked in at 10:43 PM and clocked out at 7:47 AM, assigned to the Heritage Unit. - E43 (RN) clocked in at 3:47 PM and clocked out at 7:47 AM, assigned to the Dover Unit. Review of the July 2023 eMARs and eTARs for 37 residents in the New Castle Unit revealed that 36 residents did not receive medications, treatments and monitoring during the night shift due to no assigned New Castle unit nurse on the night shift. 7/28/23 at 5:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E4 (RCD).

Based on observations, interviews, and reviews of clinical records and other documentation as indicated, it was determined that for four (R22, R51, R630 and R631) out of seven residents reviewed in three hallways, the facility failed to ensure these residents received timely administration of insulin due to no staff being available to provide the medication. The facility's failure placed the residents at risk for a serious adverse outcome, hypoglycemia and hyperglycemia. Due to this failure, an Immediate Jeopardy (IJ) was called at 3:40 PM on 7/21/23. The IJ was abated on 7/24/23 at 9:00 AM. Additionally, R80 was not administered physician ordered insulin on 7/16/23 at 6:00 AM due to no staff being available on the night shift. Findings include: The manufacturer's instructions documented, .Humalog is a .fast-acting insulin used to control high blood sugar . for Use of Humalog insulin for subcutaneous use, last revised on 7/2023, documented, . Humalog starts acting fast, so give . injection within 15 minutes before or right after you eat a meal. According to the facility's Food Cart Delivery Schedule, dated 3/8/22, estimated breakfast delivery times for the following units were: Heritage Unit - 7:20 AM; and Dover Unit - 7:35 AM. 1. Cross refer to F725, example 1 7/21/23 at 9:12 AM - Review of the daily Staff Posting posted at the second floor nurse's station lacked evidence of a second nurse assigned to the Dover Unit and a second nurse assigned to the Heritage Unit. 7/21/23 at 9:15 AM - An observation on the Dover Unit noted only one nurse, E36 (Agency LPN) present with two med carts. During an interview, E36 stated that she was still waiting for her PointClickCare (PCC) login to start the morning medication pass as she had asked multiple times since her arrival this morning. There was no nurse present on the other med cart. Review of E36's timecard for 7/21/23 revealed that E36 clocked in at 6:57 AM and had been waiting for approximately 2.25 hours with no PCC login access to start the medication pass. 7/21/23 at 9:20 AM - An observation on the Heritage Unit revealed that E37 (LPN/Wound Care) was reassigned to a med cart on this unit as the daily Staff Posting lacked evidence of a second nurse assigned to the Heritage Unit. 7/21/23 at 10:00 AM - The facility provided a list of all residents in the facility that receive diabetic medications, including insulin, per the Surveyor's request. Review of four residents' clinical records that had current insulin physician orders revealed: Dover Unit: - R22 had a physician order for Humalog insulin 9 units scheduled at 7:30 AM and at 11:30 AM to be given at breakfast and lunch. On 7/21/23, R22's eMAR lacked evidence of a blood glucose check at 7:30 AM and administration of Humalog insulin 9 units for 7:30 AM. The eMAR had an X marked in the spot where R22's blood glucose level (number) should have been documented. R22's blood glucose check was 113 and administration of the 11:30 AM Humalog insulin was signed off as administered at 12:57 PM by the E40 (RN/Staff Development). - R51 had physician orders for Humalog insulin 7 units scheduled at 7:30 AM and Humalog insulin per the sliding scale at 7:30 AM to be given before meals. On 7/21/23, R51's scheduled 7:30 AM blood glucose check was recorded in the clinical record under blood sugars as 253 at the same times of the administrations of Humalog insulin 7 units plus 4 units (sliding scale). E40 (RN/Staff Development) signed off both at 10:48 AM and 10:50 AM, approximately 3.5 hours later. - R630 had physician orders for Humalog insulin 6 units scheduled at 7:30 AM and Humalog insulin per the sliding scale at 7:30 AM to be given before meals. On 7/21/23, R630's scheduled 7:30 AM blood glucose check was recorded in the clinical record under blood sugars as 106 at the same times of the administrations of Humalog 6 units plus 2 units (sliding scale). E36 (Agency LPN) signed off both at 9:56 AM and 9:57 AM, approximately 2.5 hours later Heritage Unit - R631 had a physician order for Humalog insulin 6 units scheduled at 7:30 AM for DM breakfast. On 7/21/23, R631's eMAR lacked evidence of a blood glucose check and administration of Humalog insulin 6 units for 7:30 AM. The eMAR had an X marked in the spot where R631's blood glucose level (number) should have been documented. 7/21/23 at 3:29 PM - Based on observations and review of facility documentation, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA), E2 (DON) and E4 (RCD). 7/21/23 at 10:30 PM - E1 (NHA) submitted an acceptable Abatement Plan signed, dated, and timed. 7/24/23 at 9:00 AM - The facility's Immediate Jeopardy was abated at this time. Further observations of facility staffing, timely insulin administration and reviews of the residents' clinical records revealed that the IJ was abated on 7/24/23 at 9:00 AM based on the verification of the facility's following immediate corrective actions: - staffing was reviewed for 7/21/23, 7/22/23, 7/23/23, 7/24/23; - staffing agencies added for additional support; - implementation of a staffing agency orientation package and location in the nurse's stations; - process in place to address call outs and no call no shows to ensure sufficient staffing; - completed education with NHA, DON and Staffing Coordinator; - observations of blood glucose checks and timely insulin administration; - review of the residents' clinical records; and - observations of facility staffing over the weekend and 7/24/23 by two Surveyors. 2. Cross refer to F725, example 3 Review of R80's clinical record revealed: 7/20/22 - R80 had a physician's order for NPH Insulin inject 4 units subcutaneously in the morning for diabetes diagnosis. 7/16/23 at 6:00 AM - Review of the July 2023 eMAR revealed that R80 was not administered NPH Insulin because there was no assigned nurse on night-shift (11:00 PM to 7:00 AM) in the New Castle Unit. 7/31/23 at 2:00 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), E4 (RCD) and E15 (VPO)