**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to medications not being reconciled and accurately transcribed, not reporting abnormal lab values and abnormal blood pressures to a provider for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: An interview was conducted on 9/30/25 at 11:45 a.m. with the Resident Representative (RR) for Resident #1. The RR said Resident #1 was not given her required insulin from the time she arrived at the facility on 8/22/25 until the day she had to go to the hospital on 8/30/25. The RR said the facility called and informed them Resident #1 had not gotten her insulin because they did not know she needed it. The RR said when Resident #1 was admitted to the facility she spoke with staff at the facility and specifically told them the resident was on sliding scale insulin. The RR said Resident #1's hospital records clearly showed the resident took insulin daily. The RR said on 8/30/25 she was told a nurse noticed Resident #1 was not getting insulin and checked her blood glucose level and it was 380; they gave the resident insulin and sent her to the hospital. The RR said Resident #1 had dementia and was confused so she would have been unable to tell them she needed insulin during her stay. The RR said Resident #1's health went downhill after being admitted to the facility. The RR said the hospital thought Resident #1 might have had a stroke when she was readmitted and the resident had been more confused and not herself since this happened. A review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage intraventricular, type 2 diabetes mellitus, and hypertension. Review of Resident #1's Nursing admission Screening and History, dated 8/22/25, showed the resident did not have intact cognition and was confused. Review of Resident #1's hospital Discharge Instructions: Medications included but were not limited to:-Enoxaparin 30 milligram (mg)/0.3 milliliters (ml). 0.3 ml subcutaneous daily. (a medication to treat or prevent blood clots)-Insulin Lispro 100 units (u)/ml injectable solution. Low corrective scale subcutaneous three times a day with meals. (a fast-acting medication to lower blood glucose levels)-Tamsulosin 0.4 mg capsule. 1 capsule after breakfast. (a medication for urinary retention)-Amlodipine 10 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Dicyclomine 10 mg. 1 capsule two times a day. (a medication to relax muscles in the gastrointestinal tract.)-Gabapentin 100 mg. 1 capsule three times a day. (a medication to treat seizures or nerve pain)-Insulin glargine 100 u/ml. 30u subcutaneous daily at bedtime. (a long-acting medication to lower blood glucose levels)-Linagliptin 5mg. 1 tablet once a day. (a medication to help manage high blood glucose levels)-Pantoprazole 20 mg enteric coated. 2 tablets two times a day. (a medication to decrease the amount of acid produced in the stomach)-Carbamazepine 200 mg. 1 tablet three times a day. (a medication to treat seizures, nerve pain, or manage episodes of mania associated with bipolar disorder)-Clopidogrel 75 mg. 1 tablet one a day. Resume on 8/26/25. (medication used to prevent blood clots)-Duloxetine 20 mg delayed release. 1 capsule once a day. (a medication used to treat mental health conditions such as depression and anxiety as well as some chronic pain conditions)-Folic acid 1 mg. 1 tablet once a day. (medication used as a dietary supplement)-Lactulose 10 grams (g) oral. Once a day. (a medication used to treat constipation and to manage a brain condition caused by liver disease)-Losartan 100 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Melatonin 3mg. 1 tablet daily at bedtime as needed for sleep.-polyethylene glycol 3350 oral powder. 17 g as needed. (a medication to treat occasional constipation)-Propranolol 60 mg. 1 tablet two times a day. (a medication used to treat heart related issues such as high blood pressure and irregular heartbeats, migraines, tremors, and some types of anxiety)-Senna 8.6 mg. 2 tablets two times a day as needed for constipation. (a medication used for short term relief of constipation) Review of Resident #1's facility order listing report showed the above medications were not entered into the resident's medical record as a physicians' order at the facility. Resident #1's hospital Discharge Instructions: Medications showed: -Lidocaine topical 5%. 1 patch every 24 hours. (a medication used for local pain relief)-Atorvastatin 40 mg. 1 tablet daily at bedtime. (a medication used to lower cholesterol)-Clopidogrel 75 mg. 1 tablet once a day. Resume on 8/26/25. (a medication used to prevent blood clots) Review of Resident #1's facility order listing report showed upon admission the order entered for Lidocaine was for a 5% patch and the ordered entered for Atorvastatin was for 80 mg daily at bedtime. The order entered for Clopidogrel started on 8/23/25. Review of Resident #1's facility physician orders showed the following medications ordered at the facility upon admission that were not on the resident's hospital discharge medication list:-Albuterol-Budesonide Inhalation Aerosol 90-80 micrograms per actuation (mcg/act). 2 puffs inhale orally every 4 hours as needed for shortness of breath.- Ascorbic acid tablet 500 mg. 1 tablet two times a day for vitamin deficiency.-Azithromycin 500 mg. 1 tablet one time a day for antibiotic related to a urinary tract infection (UTI) for 5 days.-Carvedilol 3.125 mg. 1 tablet by mouth 2 times a day. Hold if systolic blood pressure (SBP) is <100 and pulse <50 related to essential hypertension.-Fluticasone propionate suspension 50 micrograms per actuation (mcg/act). 2 sprays in each nostril every 24 hours as needed for allergy symptoms.-Furosemide 20 mg. 1 tablet by mouth one time a day for edema.-Ipratropium-Albuterol 0.5-2.5 mg/2ml. 1 dose inhale orally every 4 hours as needed for shortness of breath.-Medrol oral therapy pack 4 mg. 1 tablet every morning and at bedtime related to chronic obstructive pulmonary disease (COPD) exacerbation.-Trelegy Ellipta Inhalation Aerosol powder breath activated 100-62.5-25 mcg/act. 1 puff inhale orally one time a day related to COPD exacerbation. Review of Resident #1's Medication Administration Record (MAR) for August 2025 showed:-Trelegy Ellipta inhalation aerosol 100-62.5-25 mcg/act for COPD (acute) was administered on August 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Ascorbic acid oral tablet 500 mg for Ascorbic Acid Deficiency, was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th (morning dose)-Carvedilol oral tablet 3.125 mg was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th-Medrol oral tablet therapy pack 4 mg for COPD (acute) was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Atorvastatin calcium oral tablet 80 mg was administered August 23rd through 29th.-Azithromycin oral tablet 500 mg for a Urinary tract infection was administered August 23rd through 27th.-Furosemide oral tablet 20 mg for edema was administered August 23rd through 30th.-Lidocaine external patch 4% for pain was administered August 23rd through 30th.-Pantoprazole sodium oral tablet 40 mg (incorrect dose was administered August 23rd through 30th. Review of Resident #1's Nursing Admission, readmission Screening and History, dated 8/22/25, completed by Staff A, Licensed Practical Nurse (LPN) showed:Medication ReconciliationAre these orders to be clarified? No - Reviewed and no clarification neededMedications recommended by Hospital that need clarification: (no documentation)Note Clarification needed: (no documentation)Results after physician notification (continue, stop, change): (no documentation). Are there medications taken before hospitalization NOT currently on the hospital recommended list? No - Reviewed and no clarification neededMedications taken before hospitalization not currently on hospital recommended list?Comments such as reason for med (medication) and reason it was stopped in hospital (if known): (no documentation)Results after Physician notification (continue, stop, change): (no documentation) Review of Resident #1's medical record did not show any documentation the medication orders from the hospital were reconciled with a medical provider prior to being entered into the computer. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 202/116 on 8/25/25 at 7:53 a.m. and 170/108 at 4:46 p.m. (Normal blood pressure 120/80). Review of a provider note dated 8/25/25 by Resident #1's primary care Nurse Practitioner (NP) showed . labs on 8/26/25. Patient blood pressure has been elevated and a new order for carvedilol was started today. Will monitor for medication efficacy. Review of Resident #1's lab results, reviewed by the NP on 8/26/25 at 2:03 p.m. showed: SODIUM 135 milliequivalents (mEq)/liter (L) reference range 136-145 LowCHLORIDE 89 mEq/L reference range 98-110 LowGLUCOSE 364 mg/deciliter (dL) reference range 74-109 HighBUN 43 mg/dL reference range 7-25 High CREATININE 1.62 mg/dL reference range 0.6-1.3 HighB/C RATIO 26.54 reference range 8.0-25.0 HighAST (SGOT) 12 Units (U)/L reference range 13-39 Low ALKALINE PHOSPHATASE157 U/L reference range 34-104 HighGlomerular Filtration Rate (GFR) 32 reference range >60 ml/min Low GFR Reference Range: Stage IIIB Moderate to Severe loss of kidney function 30-44 milliliters/minute (ml/min) Review of progress notes showed an 8/26/25 nurse's note revealing Advanced Registered Nurse Practitioner (ARNP) ordered Intravenous fluids (IVF) normal saline (NS) at 50 ml/hour (hr) for 1000 ml total related to (r/t) lab results today. Review of Resident #1 physician orders showed:Peripheral line catheter continuous infusion: 0.9% sodium chloride, 50ml/hr, 1000ml total. Every shift monitor infusion related to dehydration for 2 days. Dated 8/26/25. Review of Resident #1's medical record did not show any documentation the NP or the facility addressed the residents blood glucose level of 364 mg/dL and the resident did not receive insulin. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 189/112 on 8/28/25 at 7:26 a.m. and 164/102 on 8/28/25 at 4:09 p.m. Review of Resident #1's medical record showed no documentation the provider was notified of the elevated blood pressure on 8/28/25 at 7:26 a.m. There was a nursing note on 8/28/25 at 4:39 p.m. explaining the provider was notified of the blood pressure reading of 164/102 and new order was received for a one time does of medication. Review of Resident #1's orders showed a one-time order for Amlodipine 5 mg for blood pressure of 164/102 on 8/28/25. A follow up blood pressure revealed on 8/28/25 at 9:06 p.m. was 140/80. Review of Resident #1's Lab results showed repeat labs were reviewed by Staff B, LPN on 8/28/25 at 5:10 p.m. The lab results showed: SODIUM 132 mEq/L 136-145 LowCHLORIDE 89 mEq/L 98-110 LowGLUCOSE 487 mg/dL 74-109 HighBUN 45 mg/dL 7-25 HighCREATININE 1.58 mg/dL 0.6-1.3 HighB/C RATIO 28.48 8.0-25.0 HighAST (SGOT) 12 U/L 13-39 LowALKALINE PHOSPHATASE 155 U/L 34-104 HighGFR 33 >60 ml/min Low Review of Resident #1's medical record showed no documentation a provider was notified of the abnormal lab results after the nurse reviewed them on 8/28/25 at 5:10 p.m. There was no documentation showing the resident's elevated blood glucose level of 487 mg/dL was addressed. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 180/114 on 8/29/25 at 7:38 a.m. Review of Resident #1's medical record revealed there was no documentation a provider was notified of the resident's elevated blood pressure on 8/29/25 at 7:38 a.m. Review of Resident #1's progress notes showed:8/30/25 at 1:34 p.m. Resident BS [blood sugar] noted HI on meter, HI reading indicated a BS over 600. ARNP updated with new orders to give 15 units now after rechecking sugar then start lantus and insulin lispro low dose sliding scale8/30/25 3:29 p.m. Resident BS remains high on meter, ARNP updated with new orders to send to ER [emergency room] for eval [evaluation]. Review of Resident #1's MAR showed Insulin Lispro pen injector 200 u/ml. 15 units was administered at 1:40 p.m. on 8/30/25. Review of Resident #1's Summary for Providers, dated 8/30/25 showed:Change in ConditionNursing observations, evaluation, and recommendations are: Resident noted more lethargic than normal, able to arouse. BS reading HI on machine indicated over 600. 15 units units [sic] given per ARNP orders, recheck in 1 hour, re-checked and still showing HI. ARNP updated with new orders to send to the ER for evaluation. Review of Resident #1's vital signs did not show any documented blood glucose checks completed by the nurse from 8/22/25 until 8/30/25 when the resident was transferred to the hospital. An interview was conducted on 9/29/25 at 5:10 p.m. with Staff A, LPN. She said she had Resident #1 when she was admitted on [DATE]. She said another nurse, Staff C, LPN helped her by starting to put medications in the computer queue for the resident prior to her getting to the facility. Staff A said when the resident came, Staff C, continued to help with the paperwork then Staff C said these [orders] don't match you need to finish them because she had to assist her residents. Staff A said there was a lot going on that night and she didn't get to look at Resident #1's orders again until early the next morning when she finished putting them in the computer. She said she did not remember seeing insulin orders on the paperwork for the resident. Staff A said when the resident arrived Staff C sent the admission paper, the 3008, and the hospital medication list to the provider over the facility's text messaging system. Staff A said she did not remember the provider sending back or making any changes to Resident #1's orders. Staff A confirmed Resident #1 was confused and would not have known her medications. An interview was conducted on 9/29/25 at 2:58 p.m. with Staff C, LPN. Staff C said Staff A, LPN was assigned to Resident #1 on admission. She said all she did was start putting Resident #1's hospital orders in the queue. Staff C said she entered some of the medication orders in the computer then informed Staff A she needed to finish entering the orders and review everything. Staff C said she was just helping. An interview was conducted on 10/1/25 at 4:30 p.m. with Staff E, Certified Nursing Assistant (CNA). Staff E cared for Resident #1 on 8/25-8/28/25 on the 7: 00 a.m.-3:00 p.m. shift. Staff E said on 8/25/25 when she first met Resident #1, I thought maybe she was recovering from something, because she would kind of flop and throw herself back in bed. She said she had to get the nurse to assist her with transferring the resident. Staff E said a day, or two later Resident #1 must have gotten a new medication or maybe it was the IV fluids she got, but the resident was able to hold a good conversation. Staff E said she was able to get Resident #1 to shower and she made more sense. Staff E said she was off for a couple of days and when she returned, she was told the resident had gone back to the hospital. A follow-up interview was conducted on 10/1/25 at 3:18 p.m. with Staff C, LPN. She said she only assisted with entering medication orders for Resident #1 after the resident arrived at the facility. She said she entered orders from the paperwork the resident brought from the hospital. An interview was conducted on 9/29/25 at 1:43 p.m. with Resident #1's primary care NP. The NP said she did not get notified of Resident #1's abnormal lab results on 8/28/25. She confirmed it was a Thursday, and she would have been the person contacted. The NP said staff notified her about the abnormal labs on 8/26/25 and she ordered some IV fluids. She said Resident #1 did not say anything about her blood sugar levels. The NP did confirm Resident #1 was confused. During a follow-up interview on 10/1/25 at 5:51 p.m. the NP said she knew the resident had some high blood pressure readings and was put on a blood pressure medication. She said she had been notified of previous high blood pressures for Resident #1 but was not notified the resident's blood pressure was high on 8/29/25. She said for the abnormal labs she saw Resident #1's glucose level was high but thought maybe she was dehydrated and that is why she ordered IV fluids. She said she did not know about the second abnormal labs on 8/28/25. The NP did not want to comment on Resident #1 being on furosemide because she did not order it but said in general furosemide removes fluid from the body. The NP agreed it could cause dehydration. An interview was conducted on 9/29/25 at 1:52 p.m. with Staff B, LPN. Staff B confirmed she had cared for Resident #1, but she did not remember dates that far back and did not remember the resident very well. She said when a lab was reviewed by the nurse it is marked on the lab itself with the date and time it was reviewed. Staff B said if the results were abnormal they should have been sent to the provider and a nursing note put in the computer saying a provider was notified. An interview was conducted on 9/30/25 at 10:32 a.m. with Staff D, Registered Nurse (RN). Staff D said she remembered Resident #1 and was the supervisor in the facility when the resident was sent to the hospital. Staff D said she made rounds frequently on the units and touched base with nurses. She said on 8/30/25 a CNA came to her and said Resident #1 was different than she had been the weekend before. She said the CNA told her the previous weekend, August 23rd/24th, the resident had been up walking around and was busy. Staff D said on 8/30/25 Resident #1 was lying in bed, lethargic, and would talk, but barely. Staff D said she had seen Resident #1 the weekend she had been admitted to the facility. She said the resident had been confused, but the family said it was her baseline. She said the resident got up and walked around her room sometimes without waiting for assistance. Staff D said when she saw how the resident was on 8/30/25 she did a full assessment on Resident #1 and part of that was checking her blood glucose level since she was diabetic. Staff D said the resident's blood glucose was high and she worked with Resident #1's assigned nurse to update the provider and get orders. Staff D said she looked at the resident's medical record because she liked to gather what information she can provide to paramedics and the emergency department. She said during her review she noticed Resident #1 had two sets of labs since her admission that showed high blood glucose levels, one in the 300s and one in the 400s. Staff D said during her chart review she noticed the resident was not being administered any insulin or medication for diabetes by mouth. Staff D said she had not been informed the resident had any blood pressures issues but noticed Resident #1 had high blood pressure readings that week and was started on medication. Staff D said she pulled up Resident #1's admission paperwork from the hospital to compare to the orders the resident had in the computer, and she noticed Resident #1 had orders for some medications that had been on her hospital discharge list and some of her medications were not on the list. She said she did not recall the exact medications, but there were some wonky ones. She said she noticed the resident had been discharged on a few blood pressure medications but had not received them upon admission. Staff D said she notified nursing management and left all the paperwork she had gathered so it could be investigated. Staff D said she notified the on-call provider about the medication discrepancies. An interview was conducted on 9/30/25 at 9:40 a.m. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). They both reviewed Resident #1's hospital discharge medication list and the resident's physician orders in the facility. They confirmed the medication lists did not match. The DON said she did not know what happened and wanted to look into it further. A follow-up interview was conducted on 9/30/25 at 4:55 p.m. with the ADON and DON. They said the new admission process expectation would be the resident arrives at the facility with hospital discharge paperwork, and the admitting nurse is notified. The nurse takes the hospital medication orders and sends them to the provider for review. Once the medications are reconciled with the provider, the medication orders are entered into the computer. Then nurses on the 11:00 p.m. -7:00 a.m. shift are responsible for doing a chart check for all new admissions that day. The ADON and DON said the new admission paperwork was at the nurses' station, so the night shift nurse had it available to review orders to ensure they were transcribed correctly. The ADON and DON said if a nurse worked a double shift (from 3:00 p.m.-11:00 p.m. and then 11:00 p.m. -7:00 a.m.) that nurse could do their own chart check. They said there was no process in place to document chart checks were being completed on the 11:00 p.m.-7:00 a.m. shift; they were trusting it was being completed. The ADON and DON said the second chart check was completed after the morning clinical meeting, each morning Monday through Friday. They said the Unit Manager (UM) was responsible for bringing new admission charts to the meeting and reviewing the orders for accuracy. Review of the facility's admission packet checklist included the following items: -Notify MD [medical doctor] of admission-admission note completed in progress notes-Orders per 3008, medication list, and [vendor texting system with providers]-Hospital DC [discharge] summary-Add Order Sets-Parameters for blood pressure meds-BS [blood sugar] checks for diabetes (need to have labeled machine)-Hypoglycemic orders for all residentsHypoglycemia Policy1. Anti-diabetic medication-observed for signs and symptoms of hypoglycemia including but not limited to blurred vision, sweating, tachycardia, unable to swallow, or ability to follow instructions, slurred speech, AMS [altered mental status]. Notify PCP [primary care provider] with accu-check results. (Q [every] shift monitoring)2. (For all Residents, Diabetic or non-diabetic) Accu-check as needed for signs/symptoms of hypoglycemic/hyperglycemic. If BG [blood glucose] is below 70, is alert and able to swallow, give 15 grams glucose gel or carbohydrates to include but not limited to: one cup of fruit juice, one cup of non-diet soda, or sugar packets by mouth; followed by a protein snack, notify PCP.3. [blank]4. For severe hypoglycemic symptoms-Glucagon Emergency Injection Kit 1 mg- inject 1 mg IM [intramuscular] as needed for BG below 70 with lethargy and unable to swallow, may repeat x 1, notify PCP.This checklist does not have places to check off each item or a place to sign showing it was completed An interview was conducted on 9/30/25 at 5:00 p.m. with Staff G, LPN/UM. Staff G confirmed he was the UM for Resident #1. A copy of her admission packet checklist was requested. Staff G's office was observed to have large stacks of paper on a bookcase. Staff G stated those were admission packet checklists for residents, but he did not have an admission packet checklist completed by the nurse for Resident #1. Staff G explained that the admitted nurse filled out the admission check sheets then night shift nurses did a chart check and then management did a chart check the next morning. An interview was conducted on 9/30/25 at 11:31 a.m. with the RR for Resident #1. The RR said the resident had been on blood pressure medication prior to being admitted to the facility. She said the hospital never mentioned Resident #1 having urinary tract infection (UTI), but the nurse at the facility said she had a UTI coming from the hospital, which was confusing. The RR said Resident #1 did not have COPD or breathing issues and had not been on medications related to that. The RR said when Resident #1 admitted to the facility she had been talking, up walking around, and had been able to stand up from the bed on the lowest position by the floor. The RR said Resident #1 downgraded to not talking, not walking, and not getting up to go to the bathroom while in the facility. The RR said since leaving the facility, the resident had recovered some of her abilities but was not back to where she was prior to being admitted there. An interview was conducted on 10/1/25 at 1:22 p.m. with the facility's Medical Director of the facility. The Medical Director said he was informed of the admission errors with medication orders for Resident #1 but was not fully aware of the specifics. He said his expectation on admission was a picture of the resident's hospital orders were sent to the physician; the physician reviewed and verified the orders and sent clarification and/or new orders. The Medical Director said the provider is expected to review orders between visits to ensure accuracy. He said he expected the nurses to have completed audits to ensure accuracy. He confirmed he would have expected the nurse to have documented that medications were reconciled with the provider. The Medical Director said no doubt a provider should have been notified if a resident's vital signs and lab results were out of normal parameters. He said as the Medical Director of the facility, if the facility had difficulty with a provider not responding to a condition or if education to another provider was necessary, he should have been notified because it was his job to have discussions regarding protocols and standards of practice. Review of Resident #1's hospital records dated 8/30/25 showed:Presenting Problem: hyperglycemia, given 15 units of insulin at facility.History of Present Illness: [AGE] year-old female with a past medical history of diabetes, hyperlipidemia,hypertension, and prior breast cancer (status post left mastectomy and lymph node removal, in remission), [NAME] [inferior mesenteric artery] occlusion and SMA [superior mesenteric artery] stenosis presents with a 3-day history of abdominal pain and hyperglycemia. Glucose greater than 600 at facility given insulin prior to transport. Patient notes her pain is diffuse 8 out of 10 intensity nonradiating with no alleviating factors. Lab results in the emergency department showed:8/30/2025 5:58 p.m.WBC (white blood cell count) 16.42 x10^3/ microliter (uL) HIGHPlatelet 600 x10^3/uL HIGHNeutrophil Auto 72.5 % HIGHLymphocyte Auto 13.3 % LOWMonocyte Auto 12.4 % HIGHEosinophil Auto 0.3 % LOWAbsolute Neutrophil 11.91 x10^3/uL HIGHAbsolute Monocyte 2.03 x10^3/uL HIGHBUN 44 mg/dL HIGHCreatinine 1.47 mg/dL HIGHEstimated glomerular filtration rate (eGFR) Chronic kidney disease-equation for prediction and interpretation (CKD-EPI) 36 mL/min/1.73m^2 LOWCalcium Level 11.3 mg/dL HIGHAlkaline Phosphatase 182 U/L HIGHLipase Level 127 U/L HIGHPro b-type natriuretic peptide (PBNP) 1,010 pg/mL HIGHHS Troponin-T 60 ng/L CRITICALLY HIGHCarbamaz Level <2.0 ug/mL LOWT4 Free 1.86 ng/dL HIGHUrinalysis (UA) Appear ClearUA Color Pale yellowUA Glucose 4+UA Ketones 1+UA Protein 3+UA Bacteria Auto FewUA Epithelial Cells Auto None SeenUA Hyaline Cast Auto Few8/30/25 6:22 p.m.POC [point of care] Potassium 3.4 mmol/L LOWPOC Sodium 129 mmol/L LOWPOC [NAME] [lactate] 3.30 mmol/L HIGH Vital signs8/30/25 6:00 p.m.Blood pressure 158/93Heart rate 101Respiratory rate 18 breathes/minute Discussion of Management with Hospitalist revealed: [AGE] year-old female presents to the emergency department with diffuse abdominal pain in the setting of known severe atherosclerosis of the aorta [NAME] SMA. CT [comp[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure the nursing staff was competent to reconcile hospital discharge medication orders, blood glucose levels were monitored for a diabetic resident, or recognize and respond to elevated blood pressures and abnormal lab results for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.Findings included: An interview was conducted on 9/30/25 at 11:45 a.m. with the Resident Representative (RR) for Resident #1. The RR said Resident #1 was not given her required insulin from the time she arrived at the facility on 8/22/25 until the day she had to go to the hospital on 8/30/25. The RR said the facility called and informed them Resident #1 had not gotten her insulin because they did not know she needed it. The RR said when Resident #1 was admitted to the facility she spoke with staff at the facility and specifically told them the resident was on sliding scale insulin. The RR said Resident #1's hospital records clearly showed the resident took insulin daily. The RR said on 8/30/25 she was told a nurse noticed Resident #1 was not getting insulin and checked her blood glucose level and it was 380; they gave the resident insulin and sent her to the hospital. The RR said Resident #1 had dementia and was confused so she would have been unable to tell them she needed insulin during her stay. The RR said Resident #1's health went downhill after being admitted to the facility. The RR said the hospital thought Resident #1 might have had a stroke when she was readmitted and the resident had been more confused and not herself since this happened. A review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage intraventricular, type 2 diabetes mellitus, and hypertension. Review of Resident #1's Nursing admission Screening and History, dated 8/22/25, showed the resident did not have intact cognition and was confused. Review of Resident #1's hospital Discharge Instructions: Medications included but were not limited to: -Enoxaparin 30 milligram (mg)/0.3 milliliters (ml). 0.3 ml subcutaneous daily. (a medication to treat or prevent blood clots)-Insulin Lispro 100 units (u)/ml injectable solution. Low corrective scale subcutaneous three times a day with meals. (a fast-acting medication to lower blood glucose levels)-Tamsulosin 0.4 mg capsule. 1 capsule after breakfast. (a medication for urinary retention)-Amlodipine 10 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Dicyclomine 10 mg. 1 capsule two times a day. (a medication to relax muscles in the gastrointestinal tract.)-Gabapentin 100 mg. 1 capsule three times a day. (a medication to treat seizures or nerve pain)-Insulin glargine 100 u/ml. 30u subcutaneous daily at bedtime. (a long-acting medication to lower blood glucose levels)-Linagliptin 5mg. 1 tablet once a day. (a medication to help manage high blood glucose levels)-Pantoprazole 20 mg enteric coated. 2 tablets two times a day. (a medication to decrease the amount of acid produced in the stomach)-Carbamazepine 200 mg. 1 tablet three times a day. (a medication to treat seizures, nerve pain, or manage episodes of mania associated with bipolar disorder)-Clopidogrel 75 mg. 1 tablet one a day. Resume on 8/26/25. (medication used to prevent blood clots)-Duloxetine 20 mg delayed release. 1 capsule once a day. (a medication used to treat mental health conditions such as depression and anxiety as well as some chronic pain conditions)-Folic acid 1 mg. 1 tablet once a day. (medication used as a dietary supplement)-Lactulose 10 grams (g) oral. Once a day. (a medication used to treat constipation and to manage a brain condition caused by liver disease)-Losartan 100 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Melatonin 3mg. 1 tablet daily at bedtime as needed for sleep.-polyethylene glycol 3350 oral powder. 17 g as needed. (a medication to treat occasional constipation)-Propranolol 60 mg. 1 tablet two times a day. (a medication used to treat heart related issues such as high blood pressure and irregular heartbeats, migraines, tremors, and some types of anxiety)-Senna 8.6 mg. 2 tablets two times a day as needed for constipation. (a medication used for short term relief of constipation) Review of Resident #1's facility order listing report showed the above medications were not entered into the resident's medical record as a physicians' order at the facility. Resident #1's hospital Discharge Instructions: Medications showed: -Lidocaine topical 5%. 1 patch every 24 hours. (a medication used for local pain relief)-Atorvastatin 40 mg. 1 tablet daily at bedtime. (a medication used to lower cholesterol)-Clopidogrel 75 mg. 1 tablet once a day. Resume on 8/26/25. (a medication used to prevent blood clots) Review of Resident #1's facility order listing report showed upon admission the order entered for Lidocaine was for a 5% patch and the ordered entered for Atorvastatin was for 80 mg daily at bedtime. The order entered for Clopidogrel started on 8/23/25. Review of Resident #1's facility physician orders showed the following medications ordered at the facility upon admission that were not on the resident's hospital discharge medication list:-Albuterol-Budesonide Inhalation Aerosol 90-80 micrograms per actuation (mcg/act). 2 puffs inhale orally every 4 hours as needed for shortness of breath.- Ascorbic acid tablet 500 mg. 1 tablet two times a day for vitamin deficiency.-Azithromycin 500 mg. 1 tablet one time a day for antibiotic related to a urinary tract infection (UTI) for 5 days.-Carvedilol 3.125 mg. 1 tablet by mouth 2 times a day. Hold if systolic blood pressure (SBP) is <100 and pulse <50 related to essential hypertension.-Fluticasone propionate suspension 50 micrograms per actuation (mcg/act). 2 sprays in each nostril every 24 hours as needed for allergy symptoms.-Furosemide 20 mg. 1 tablet by mouth one time a day for edema.-Ipratropium-Albuterol 0.5-2.5 mg/2ml. 1 dose inhale orally every 4 hours as needed for shortness of breath.-Medrol oral therapy pack 4 mg. 1 tablet every morning and at bedtime related to chronic obstructive pulmonary disease (COPD) exacerbation.-Trelegy Ellipta Inhalation Aerosol powder breath activated 100-62.5-25 mcg/act. 1 puff inhale orally one time a day related to COPD exacerbation. Review of Resident #1's Medication Administration Record (MAR) for August 2025 showed:-Trelegy Ellipta inhalation aerosol 100-62.5-25 mcg/act for COPD (acute) was administered on August 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Ascorbic acid oral tablet 500 mg for Ascorbic Acid Deficiency, was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th (morning dose)-Carvedilol oral tablet 3.125 mg was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th-Medrol oral tablet therapy pack 4 mg for COPD (acute) was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Atorvastatin calcium oral tablet 80 mg was administered August 23rd through 29th.-Azithromycin oral tablet 500 mg for a Urinary tract infection was administered August 23rd through 27th.-Furosemide oral tablet 20 mg for edema was administered August 23rd through 30th.-Lidocaine external patch 4% for pain was administered August 23rd through 30th.-Pantoprazole sodium oral tablet 40 mg (incorrect dose was administered August 23rd through 30th. Review of Resident #1's Nursing Admission, readmission Screening and History, dated 8/22/25, completed by Staff A, Licensed Practical Nurse (LPN) showed:Medication ReconciliationAre these orders to be clarified? No - Reviewed and no clarification neededMedications recommended by Hospital that need clarification: (no documentation)Note Clarification needed: (no documentation)Results after physician notification (continue, stop, change): (no documentation). Are there medications taken before hospitalization NOT currently on the hospital recommended list? No - Reviewed and no clarification neededMedications taken before hospitalization not currently on hospital recommended list?Comments such as reason for med (medication) and reason it was stopped in hospital (if known): (no documentation)Results after Physician notification (continue, stop, change): (no documentation) Review of Resident #1's medical record did not show any documentation the medication orders from the hospital were reconciled with a medical provider prior to being entered into the computer. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 202/116 on 8/25/25 at 7:53 a.m. and 170/108 at 4:46 p.m. (Normal blood pressure 120/80). Review of a provider note dated 8/25/25 by Resident #1's primary care Nurse Practitioner (NP) showed . labs on 8/26/25. Patient blood pressure has been elevated and a new order for carvedilol was started today. Will monitor for medication efficacy. Review of Resident #1's lab results, reviewed by the NP on 8/26/25 at 2:03 p.m. showed: SODIUM 135 milliequivalents (mEq)/liter (L) reference range 136-145 LowCHLORIDE 89 mEq/L reference range 98-110 LowGLUCOSE 364 mg/deciliter (dL) reference range 74-109 HighBUN 43 mg/dL reference range 7-25 High CREATININE 1.62 mg/dL reference range 0.6-1.3 HighB/C RATIO 26.54 reference range 8.0-25.0 HighAST (SGOT) 12 Units (U)/L reference range 13-39 Low ALKALINE PHOSPHATASE157 U/L reference range 34-104 HighGlomerular Filtration Rate (GFR) 32 reference range >60 ml/min Low GFR Reference Range: Stage IIIB Moderate to Severe loss of kidney function 30-44 milliliters/minute (ml/min) Review of progress notes showed an 8/26/25 nurse's note revealing Advanced Registered Nurse Practitioner (ARNP) ordered Intravenous fluids (IVF) normal saline (NS) at 50 ml/hour (hr) for 1000 ml total related to (r/t) lab results today. Review of Resident #1 physician orders showed:Peripheral line catheter continuous infusion: 0.9% sodium chloride, 50ml/hr, 1000ml total. Every shift monitor infusion related to dehydration for 2 days. Dated 8/26/25. Review of Resident #1's medical record did not show any documentation the NP or the facility addressed the residents blood glucose level of 364 mg/dL and the resident did not receive insulin. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 189/112 on 8/28/25 at 7:26 a.m. and 164/102 on 8/28/25 at 4:09 p.m. Review of Resident #1's medical record showed no documentation the provider was notified of the elevated blood pressure on 8/28/25 at 7:26 a.m. There was a nursing note on 8/28/25 at 4:39 p.m. explaining the provider was notified of the blood pressure reading of 164/102 and new order was received for a one time does of medication. Review of Resident #1's orders showed a one-time order for Amlodipine 5 mg for blood pressure of 164/102 on 8/28/25. A follow up blood pressure revealed on 8/28/25 at 9:06 p.m. was 140/80. Review of Resident #1's Lab results showed repeat labs were reviewed by Staff B, LPN on 8/28/25 at 5:10 p.m. The lab results showed: SODIUM 132 mEq/L 136-145 LowCHLORIDE 89 mEq/L 98-110 LowGLUCOSE 487 mg/dL 74-109 HighBUN 45 mg/dL 7-25 HighCREATININE 1.58 mg/dL 0.6-1.3 HighB/C RATIO 28.48 8.0-25.0 HighAST (SGOT) 12 U/L 13-39 LowALKALINE PHOSPHATASE 155 U/L 34-104 HighGFR 33 >60 ml/min Low Review of Resident #1's medical record showed no documentation a provider was notified of the abnormal lab results after the nurse reviewed them on 8/28/25 at 5:10 p.m. There was no documentation showing the resident's elevated blood glucose level of 487 mg/dL was addressed. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 180/114 on 8/29/25 at 7:38 a.m. Review of Resident #1's medical record revealed there was no documentation a provider was notified of the resident's elevated blood pressure on 8/29/25 at 7:38 a.m. Review of Resident #1's progress notes showed:8/30/25 at 1:34 p.m. Resident BS [blood sugar] noted HI on meter, HI reading indicated a BS over 600. ARNP updated with new orders to give 15 units now after rechecking sugar then start lantus and insulin lispro low dose sliding scale8/30/25 3:29 p.m. Resident BS remains high on meter, ARNP updated with new orders to send to ER [emergency room] for eval [evaluation]. Review of Resident #1's MAR showed Insulin Lispro pen injector 200 u/ml. 15 units was administered at 1:40 p.m. on 8/30/25. Review of Resident #1's Summary for Providers, dated 8/30/25 showed:Change in ConditionNursing observations, evaluation, and recommendations are: Resident noted more lethargic than normal, able to arouse. BS reading HI on machine indicated over 600. 15 units units [sic] given per ARNP orders, recheck in 1 hour, re-checked and still showing HI. ARNP updated with new orders to send to the ER for evaluation. Review of Resident #1's vital signs did not show any documented blood glucose checks completed by the nurse from 8/22/25 until 8/30/25 when the resident was transferred to the hospital. An interview was conducted on 9/29/25 at 5:10 p.m. with Staff A, LPN. She said she had Resident #1 when she was admitted on [DATE]. She said another nurse, Staff C, LPN helped her by starting to put medications in the computer queue for the resident prior to her getting to the facility. Staff A said when the resident came, Staff C, continued to help with the paperwork then Staff C said these [orders] don't match you need to finish them because she had to assist her residents. Staff A said there was a lot going on that night and she did not get to look at Resident #1's orders again until early the next morning when she finished putting them in the computer. She said she did not remember seeing insulin orders on the paperwork for the resident. Staff A said when the resident arrived Staff C sent the admission paper, the 3008, and the hospital medication list to the provider over the facility's text messaging system. Staff A said she did not remember the provider sending back or making any changes to Resident #1's orders. Staff A confirmed Resident #1 was confused and would not have known her medications. An interview was conducted on 9/29/25 at 2:58 p.m. with Staff C, LPN. Staff C said Staff A, LPN was assigned to Resident #1 on admission. She said all she did was start putting Resident #1's hospital orders in the queue. Staff C said she entered some of the medication orders in the computer then informed Staff A she needed to finish entering the orders and review everything. Staff C said she was just helping. An interview was conducted on 10/1/25 at 4:30 p.m. with Staff E, Certified Nursing Assistant (CNA). Staff E cared for Resident #1 on 8/25-8/28/25 on the 7: 00 a.m.-3:00 p.m. shift. Staff E said on 8/25/25 when she first met Resident #1, I thought maybe she was recovering from something, because she would kind of flop and throw herself back in bed. She said she had to get the nurse to assist her with transferring the resident. Staff E said a day, or two later Resident #1 must have gotten a new medication or maybe it was the IV fluids she got, but the resident was able to hold a good conversation. Staff E said she was able to get Resident #1 to shower and she made more sense. Staff E said she was off for a couple of days and when she returned, she was told the resident had gone back to the hospital. A follow-up interview was conducted on 10/1/25 at 3:18 p.m. with Staff C, LPN. She said she only assisted with entering medication orders for Resident #1 after the resident arrived at the facility. She said she entered orders from the paperwork the resident brought from the hospital. An interview was conducted on 9/29/25 at 1:43 p.m. with Resident #1's primary care NP. The NP said she did not get notified of Resident #1's abnormal lab results on 8/28/25. She confirmed it was a Thursday, and she would have been the person contacted. The NP said staff notified her about the abnormal labs on 8/26/25 and she ordered some IV fluids. She said Resident #1 did not say anything about her blood sugar levels. The NP did confirm Resident #1 was confused. During a follow-up interview on 10/1/25 at 5:51 p.m. the NP said she knew the resident had some high blood pressure readings and was put on a blood pressure medication. She said she had been notified of previous high blood pressures for Resident #1 but was not notified the resident's blood pressure was high on 8/29/25. She said for the abnormal labs she saw Resident #1's glucose level was high but thought maybe she was dehydrated and that is why she ordered IV fluids. She said she did not know about the second abnormal labs on 8/28/25. The NP did not want to comment on Resident #1 being on furosemide because she did not order it but said in general furosemide removes fluid from the body. The NP agreed it could cause dehydration. An interview was conducted on 9/29/25 at 1:52 p.m. with Staff B, LPN. Staff B confirmed she had cared for Resident #1, but she did not remember dates that far back and did not remember the resident very well. She said when a lab was reviewed by the nurse it is marked on the lab itself with the date and time it was reviewed. Staff B said if the results were abnormal, they should have been sent to the provider and a nursing note put in the computer saying a provider was notified. An interview was conducted on 9/30/25 at 10:32 a.m. with Staff D, Registered Nurse (RN). Staff D said she remembered Resident #1 and was the supervisor in the facility when the resident was sent to the hospital. Staff D said she made rounds frequently on the units and touched base with nurses. She said on 8/30/25 a CNA came to her and said Resident #1 was different than she had been the weekend before. She said the CNA told her the previous weekend, August 23rd/24th, the resident had been up walking around and was busy. Staff D said on 8/30/25 Resident #1 was lying in bed, lethargic, and would talk, but barely. Staff D said she had seen Resident #1 the weekend she had been admitted to the facility. She said the resident had been confused, but the family said it was her baseline. She said the resident got up and walked around her room sometimes without waiting for assistance. Staff D said when she saw how the resident was on 8/30/25 she did a full assessment on Resident #1 and part of that was checking her blood glucose level since she was diabetic. Staff D said the resident's blood glucose was high and she worked with Resident #1's assigned nurse to update the provider and get orders. Staff D said she looked at the resident's medical record because she liked to gather what information she can provide to paramedics and the emergency department. She said during her review she noticed Resident #1 had two sets of labs since her admission that showed high blood glucose levels, one in the 300s and one in the 400s. Staff D said during her chart review she noticed the resident was not being administered any insulin or medication for diabetes by mouth. Staff D said she had not been informed the resident had any blood pressures issues but noticed Resident #1 had high blood pressure readings that week and was started on medication. Staff D said she pulled up Resident #1's admission paperwork from the hospital to compare to the orders the resident had in the computer, and she noticed Resident #1 had orders for some medications that had been on her hospital discharge list and some of her medications were not on the list. She said she did not recall the exact medications, but there were some wonky ones. She said she noticed the resident had been discharged on a few blood pressure medications but had not received them upon admission. Staff D said she notified nursing management and left all the paperwork she had gathered so it could be investigated. Staff D said she notified the on-call provider about the medication discrepancies. An interview was conducted on 9/30/25 at 9:40 a.m. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). They both reviewed Resident #1's hospital discharge medication list and the resident's physician orders in the facility. They confirmed the medication lists did not match. The DON said she did not know what happened and wanted to look into it further. A follow-up interview was conducted on 9/30/25 at 4:55 p.m. with the ADON and DON. They said the new admission process expectation would be the resident arrives at the facility with hospital discharge paperwork, and the admitting nurse is notified. The nurse takes the hospital medication orders and sends them to the provider for review. Once the medications are reconciled with the provider, the medication orders are entered into the computer. Then nurses on the 11:00 p.m. -7:00 a.m. shift are responsible for doing a chart check for all new admissions that day. The ADON and DON said the new admission paperwork was at the nurses' station, so the night shift nurse had it available to review orders to ensure they were transcribed correctly. The ADON and DON said if a nurse worked a double shift (from 3:00 p.m.-11:00 p.m. and then 11:00 p.m. -7:00 a.m.) that nurse could do their own chart check. They said there was no process in place to document chart checks were being completed on the 11:00 p.m.-7:00 a.m. shift; they were trusting it was being completed. The ADON and DON said the second chart check was completed after the morning clinical meeting, each morning Monday through Friday. They said the Unit Manager (UM) was responsible for bringing new admission charts to the meeting and reviewing the orders for accuracy. An interview was conducted on 9/30/25 at 11:31 a.m. with the RR for Resident #1. The RR said the resident had been on blood pressure medication prior to being admitted to the facility. She said the hospital never mentioned Resident #1 having urinary tract infection (UTI), but the nurse at the facility said she had a UTI coming from the hospital, which was confusing. The RR said Resident #1 did not have COPD or breathing issues and had not been on medications related to that. The RR said when Resident #1 admitted to the facility she had been talking, up walking around, and had been able to stand up from the bed on the lowest position by the floor. The RR said Resident #1 downgraded to not talking, not walking, and not getting up to go to the bathroom while in the facility. The RR said since leaving the facility, the resident had recovered some of her abilities but was not back to where she was prior to being admitted there. An interview was conducted on 9/30/25 at 11:16 a.m. with Staff G, LPN/Unit Manager (UM). He said he saw Resident #1 while she was admitted due to her being on his unit. He said the first time he saw her was on 8/25/25. He said Resident #1 stayed in bed mostly but would go to therapy. He said he did not recall any issues with her blood pressure that week, but he would notify a provider for a blood pressure of 180/114. Staff G said after Resident #1 was admitted he did check her medication list; specifically, the hospital discharge paperwork that came with the resident. Staff G said he did an audit after the resident went to hospital, and he saw that she had not been receiving insulin. Staff G was shown the resident's hospital discharge medication list and her facility orders to compare. He said the provided hospital discharge list was not what he had when he was reviewing her admission. Staff G was confused and said he did not understand. Staff G said he did not think he had another resident's discharge medication list because he always compared date of birth and social security number to ensure he was looking at the correct resident's information. He said he did not know what list he had used when he completed his review. Staff G said he did not understand how this happened. Review of education for Staff A, LPN showed she completed a Clinical Skill Review on 5/15/25. These skills included managing diagnostic results: What is the process for contacting physicians with normal and abnormal diagnostic results and admission evaluation and orders. The admission evaluation and order skills reviewed the nurse's role in the admission or new resident or readmission, review of necessary documentation and required evaluation, data collection, interim plan or care and initial nurse's note, process for transcribing orders, medication reconciliation, and system for obtaining medications for new admissions/readmissions. Review of education for Staff G, LPN showed she completed a Clinical Skill Review on 5/6/25. These skills included managing diagnostic results: What is the process for contacting physicians with normal and abnormal diagnostic results and admission evaluation and orders. The admission evaluation and order skills reviewed the nurse's role in the admission or new resident or readmission, review of necessary documentation and required evaluation, data collection, interim plan or care and initial nurse's note, process for transcribing orders, medication reconciliation, and system for obtaining medications for new admissions/readmissions. An interview was conducted on 10/1/25 at 11:55 a.m. with Staff G, LPN/UM. He said education to nurses occurred during orientation with another nurse. He said the new nurse received a checklist from the staffing coordinator and it was completed during shadowing with a tenured nurse that signed off on the items. Staff G said if the new nurse had any questions or if the tenured nurse felt the nurse needed additional education, management would complete additional one on one training with the new nurse. Staff G said competency checks are completed yearly and as needed in between. An interview was conducted on 10/1/25 at 11:24 a.m. with Staff F, LPN/UM. Staff F said upon hire the staff coordinator gives new nurses checklists to be completed while they are shadowing another nurse. She said if the new nurse had questions a member of nurse management would provide extra training for that nurse. Staff F said the education is always one to one and can sometimes be a topic specific to a nurse or the DON may determine education on topic is necessary for the entire clinical team. Staff F said education on the admission process is completed during orientation while shadowing another nurse or when they first receive an admission they would have assistance from another nurse. Staff F said the admission packet had a checklist that nurses needed to complete. She said the nurse took the orders from the admission packet for the resident and sent them to the physician for verification, when the physician replied and confirmed or changed orders the nurse entered them into the facility orders. Staff F said the 11:00 p.m.-7:00 a.m. shift was responsible for doing a chart check for accuracy and the unit manager completed a chart check the next morning to ensure accuracy. Staff F provided a manager checklist and stated she did not think other unit managers utilized the checklist. Review of the admission packet checklist, used by the admitting nurse, included the following items: -Notify MD [medical doctor] of admission-admission note completed in progress notes-Orders per 3008, medication list, and [vendor texting system with providers]-Hospital DC [discharge] summary-Add Order Sets-Parameters for blood pressure meds-BS [blood sugar] checks for diabetes (need to have labeled machine)-Hypoglycemic orders for all residentsHypoglycemia Policy1. Anti-diabetic medication-observed for signs and symptoms of hypoglycemia including but not limited to blurred vision, sweating, tachycardia, unable to swallow, or ability to follow instructions, slurred speech, AMS [altered mental status]. Notify PCP [primary care provider] with accu-check results. (Q [every] shift monitoring)2. (For all Residents, Diabetic or non-diabetic) Accu-check as needed for signs/symptoms of hypoglycemic/hyperglycemic. If BG [blood glucose] is below 70, is alert and able to swallow, give 15 grams glucose gel or carbohydrates to include but not limited to: one cup of fruit juice, one cup of non-diet soda, or sugar packets by mouth; followed by a protein snack, notify PCP.3. [blank]4. For severe hypoglycemic symptoms-Glucagon Emergency Injection Kit 1 mg- inject 1 mg IM [intramuscular] as needed for BG below 70 with lethargy and unable to swallow, may repeat x 1, notify PCP.This checklist does not have places to check off each item or a place to sign showing it was completed. Review of the admission chart review checklist, used by the unit managers, included the following items to be checked:-chart review-Hospital DC [discharge] summary if NO, notify medical records to fax request and keep confirmed fax on/in chart.-Hard scripts for narcotics, order summary. Get if needed ASAP [as soon as possible]-Parameters for blood pressure meds-BS [blood sugar] checks for diabetics (need to have a labeled machine)-Hypoglycemia PRN [as needed] protocolNew antibiotics-diagnosis-stop date-IV or PO (by mouth)-Surveillance infection criteria-Isolation yes or no An interview was conducted on 9/30/25 at 5:00 p.m. with Staff G, LPN/UM. Staff G confirmed he was the UM for Resident #1. A copy of her admission packet checklist was requested. Staff G's office was observed to have large stacks of paper on a bookcase. Staff G stated those were admission packet checklists for residents, but he did not have an admission packet checklist completed by the nurse for Resident #1. Staff G explained that the admitted nurse filled out the admission check sheets then night shift nurses did a chart check and then management did a chart check the next morning. An interview was conducted on 10/1/25 at 1:22 p.m. with the facility's Medical Director of the facility. The Medical Director said he was informed of the admission errors with medication orders for Resident #1 but was not fully aware of the specifics. He said his expectation on admission was a picture of the resident's hospital orders were sent to the physician; the physician reviewed and verified the orders and sent clarification and/or new orders. The Medical Director said the provider is expected to review orders between visits to ensure accuracy. He said he expected the nurses to have completed audits to ensure accura[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure one resident (#1) of three reviewed for new admission orders was free from significant medication errors as evidenced by the resident not receiving the correct medications order upon admission. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: An interview was conducted on 9/30/25 at 11:45 a.m. with the Resident Representative (RR) for Resident #1. The RR said Resident #1 was not given her required insulin from the time she arrived at the facility on 8/22/25 until the day she had to go to the hospital on 8/30/25. The RR said the facility called and informed them Resident #1 had not gotten her insulin because they did not know she needed it. The RR said when Resident #1 was admitted to the facility she spoke with staff at the facility and specifically told them the resident was on sliding scale insulin. The RR said Resident #1's hospital records clearly showed the resident took insulin daily. The RR said on 8/30/25 she was told a nurse noticed Resident #1 was not getting insulin and checked her blood glucose level and it was 380; they gave the resident insulin and sent her to the hospital. The RR said Resident #1 had dementia and was confused so she would have been unable to tell them she needed insulin during her stay. The RR said Resident #1's health went downhill after being admitted to the facility. The RR said the hospital thought Resident #1 might have had a stroke when she was readmitted and the resident had been more confused and not herself since this happened. A review of admission Records showed Resident #1 was admitted on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage intraventricular, type 2 diabetes mellitus, and hypertension. Review of Resident #1's Nursing admission Screening and History, dated 8/22/25, showed the resident did not have intact cognition and was confused. Review of Resident #1's hospital Discharge Instructions: Medications included but were not limited to:-Enoxaparin 30 milligram (mg)/0.3 milliliters (ml). 0.3 ml subcutaneous daily. (a medication to treat or prevent blood clots)-Insulin Lispro 100 units (u)/ml injectable solution. Low corrective scale subcutaneous three times a day with meals. (a fast-acting medication to lower blood glucose levels)-Tamsulosin 0.4 mg capsule. 1 capsule after breakfast. (a medication for urinary retention)-Amlodipine 10 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Dicyclomine 10 mg. 1 capsule two times a day. (a medication to relax muscles in the gastrointestinal tract.)-Gabapentin 100 mg. 1 capsule three times a day. (a medication to treat seizures or nerve pain)-Insulin glargine 100 u/ml. 30u subcutaneous daily at bedtime. (a long-acting medication to lower blood glucose levels)-Linagliptin 5mg. 1 tablet once a day. (a medication to help manage high blood glucose levels)-Pantoprazole 20 mg enteric coated. 2 tablets two times a day. (a medication to decrease the amount of acid produced in the stomach)-Carbamazepine 200 mg. 1 tablet three times a day. (a medication to treat seizures, nerve pain, or manage episodes of mania associated with bipolar disorder)-Clopidogrel 75 mg. 1 tablet one a day. Resume on 8/26/25. (medication used to prevent blood clots)-Duloxetine 20 mg delayed release. 1 capsule once a day. (a medication used to treat mental health conditions such as depression and anxiety as well as some chronic pain conditions)-Folic acid 1 mg. 1 tablet once a day. (medication used as a dietary supplement)-Lactulose 10 grams (g) oral. Once a day. (a medication used to treat constipation and to manage a brain condition caused by liver disease)-Losartan 100 mg. 1 tablet once a day. (a medication used to treat high blood pressure)-Melatonin 3mg. 1 tablet daily at bedtime as needed for sleep.-polyethylene glycol 3350 oral powder. 17 g as needed. (a medication to treat occasional constipation)-Propranolol 60 mg. 1 tablet two times a day. (a medication used to treat heart related issues such as high blood pressure and irregular heartbeats, migraines, tremors, and some types of anxiety)-Senna 8.6 mg. 2 tablets two times a day as needed for constipation. (a medication used for short term relief of constipation) Review of Resident #1's facility order listing report showed the above medications were not entered into the resident's medical record as a physicians' order at the facility. Resident #1's hospital Discharge Instructions: Medications showed: -Lidocaine topical 5%. 1 patch every 24 hours. (a medication used for local pain relief)-Atorvastatin 40 mg. 1 tablet daily at bedtime. (a medication used to lower cholesterol)-Clopidogrel 75 mg. 1 tablet once a day. Resume on 8/26/25. (a medication used to prevent blood clots) Review of Resident #1's facility order listing report showed upon admission the order entered for Lidocaine was for a 5% patch and the ordered entered for Atorvastatin was for 80 mg daily at bedtime. The order entered for Clopidogrel started on 8/23/25. Review of Resident #1's facility physician orders showed the following medications ordered at the facility upon admission that were not on the resident's hospital discharge medication list:-Albuterol-Budesonide Inhalation Aerosol 90-80 micrograms per actuation (mcg/act). 2 puffs inhale orally every 4 hours as needed for shortness of breath.- Ascorbic acid tablet 500 mg. 1 tablet two times a day for vitamin deficiency.-Azithromycin 500 mg. 1 tablet one time a day for antibiotic related to a urinary tract infection (UTI) for 5 days.-Carvedilol 3.125 mg. 1 tablet by mouth 2 times a day. Hold if systolic blood pressure (SBP) is <100 and pulse <50 related to essential hypertension.-Fluticasone propionate suspension 50 micrograms per actuation (mcg/act). 2 sprays in each nostril every 24 hours as needed for allergy symptoms.-Furosemide 20 mg. 1 tablet by mouth one time a day for edema.-Ipratropium-Albuterol 0.5-2.5 mg/2ml. 1 dose inhale orally every 4 hours as needed for shortness of breath.-Medrol oral therapy pack 4 mg. 1 tablet every morning and at bedtime related to chronic obstructive pulmonary disease (COPD) exacerbation.-Trelegy Ellipta Inhalation Aerosol powder breath activated 100-62.5-25 mcg/act. 1 puff inhale orally one time a day related to COPD exacerbation. Review of Resident #1's Medication Administration Record (MAR) for August 2025 showed:-Trelegy Ellipta inhalation aerosol 100-62.5-25 mcg/act for COPD (acute) was administered on August 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Ascorbic acid oral tablet 500 mg for Ascorbic Acid Deficiency, was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th (morning dose)-Carvedilol oral tablet 3.125 mg was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th-Medrol oral tablet therapy pack 4 mg for COPD (acute) was administered on August 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th.-Atorvastatin calcium oral tablet 80 mg was administered August 23rd through 29th.-Azithromycin oral tablet 500 mg for a Urinary tract infection was administered August 23rd through 27th.-Furosemide oral tablet 20 mg for edema was administered August 23rd through 30th.-Lidocaine external patch 4% for pain was administered August 23rd through 30th.-Pantoprazole sodium oral tablet 40 mg (incorrect dose was administered August 23rd through 30th. Review of Resident #1's Nursing Admission, readmission Screening and History, dated 8/22/25, completed by Staff A, Licensed Practical Nurse (LPN) showed:Medication ReconciliationAre these orders to be clarified? No - Reviewed and no clarification neededMedications recommended by Hospital that need clarification: (no documentation)Note Clarification needed: (no documentation)Results after physician notification (continue, stop, change): (no documentation). Are there medications taken before hospitalization NOT currently on the hospital recommended list? No - Reviewed and no clarification neededMedications taken before hospitalization not currently on hospital recommended list?Comments such as reason for med (medication) and reason it was stopped in hospital (if known): (no documentation)Results after Physician notification (continue, stop, change): (no documentation) Review of Resident #1's medical record did not show any documentation the medication orders from the hospital were reconciled with a medical provider prior to being entered into the computer. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 202/116 on 8/25/25 at 7:53 a.m. and 170/108 at 4:46 p.m. (Normal blood pressure 120/80). Review of a provider note dated 8/25/25 by Resident #1's primary care Nurse Practitioner (NP) showed . labs on 8/26/25. Patient blood pressure has been elevated and a new order for carvedilol was started today. Will monitor for medication efficacy. Review of Resident #1's lab results, reviewed by the NP on 8/26/25 at 2:03 p.m. showed: SODIUM 135 milliequivalents (mEq)/liter (L) reference range 136-145 LowCHLORIDE 89 mEq/L reference range 98-110 LowGLUCOSE 364 mg/deciliter (dL) reference range 74-109 HighBUN 43 mg/dL reference range 7-25 High CREATININE 1.62 mg/dL reference range 0.6-1.3 HighB/C RATIO 26.54 reference range 8.0-25.0 HighAST (SGOT) 12 Units (U)/L reference range 13-39 Low ALKALINE PHOSPHATASE157 U/L reference range 34-104 HighGlomerular Filtration Rate (GFR) 32 reference range >60 ml/min Low GFR Reference Range: Stage IIIB Moderate to Severe loss of kidney function 30-44 milliliters/minute (ml/min) Review of progress notes showed an 8/26/25 nurse's note revealing Advanced Registered Nurse Practitioner (ARNP) ordered Intravenous fluids (IVF) normal saline (NS) at 50 ml/hour (hr) for 1000 ml total related to (r/t) lab results today. Review of Resident #1 physician orders showed:Peripheral line catheter continuous infusion: 0.9% sodium chloride, 50ml/hr, 1000ml total. Every shift monitor infusion related to dehydration for 2 days. Dated 8/26/25. Review of Resident #1's medical record did not show any documentation the NP or the facility addressed the residents blood glucose level of 364 mg/dL and the resident did not receive insulin. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 189/112 on 8/28/25 at 7:26 a.m. and 164/102 on 8/28/25 at 4:09 p.m. Review of Resident #1's medical record showed no documentation the provider was notified of the elevated blood pressure on 8/28/25 at 7:26 a.m. There was a nursing note on 8/28/25 at 4:39 p.m. explaining the provider was notified of the blood pressure reading of 164/102 and new order was received for a one time does of medication. Review of Resident #1's orders showed a one-time order for Amlodipine 5 mg for blood pressure of 164/102 on 8/28/25. A follow up blood pressure was reading on 8/28/25 at 9:06 p.m. was 140/80. Review of Resident #1's Lab results showed repeat labs were reviewed by Staff B, LPN on 8/28/25 at 5:10 p.m. The lab results showed: SODIUM 132 mEq/L 136-145 LowCHLORIDE 89 mEq/L 98-110 LowGLUCOSE 487 mg/dL 74-109 HighBUN 45 mg/dL 7-25 HighCREATININE 1.58 mg/dL 0.6-1.3 HighB/C RATIO 28.48 8.0-25.0 HighAST (SGOT) 12 U/L 13-39 LowALKALINE PHOSPHATASE 155 U/L 34-104 HighGFR 33 >60 ml/min Low Review of Resident #1's medical record showed no documentation a provider was notified of the abnormal lab results after the nurse reviewed them on 8/28/25 at 5:10 p.m. There was no documentation showing the resident's elevated blood glucose level of 487 mg/dL was addressed. Review of Resident #1's vital signs showed the resident had an elevated blood pressure of 180/114 on 8/29/25 at 7:38 a.m. Review of Resident #1's medical record revealed there was no documentation a provider was notified of the resident's elevated blood pressure on 8/29/25 at 7:38 a.m. Review of Resident #1's progress notes showed:8/30/25 at 1:34 p.m. Resident BS [blood sugar] noted HI on meter, HI reading indicated a BS over 600. ARNP updated with new orders to give 15 units now after rechecking sugar then start lantus and insulin lispro low dose sliding scale8/30/25 3:29 p.m. Resident BS remains high on meter, ARNP updated with new orders to send to ER [emergency room] for eval [evaluation]. Review of Resident #1's MAR showed Insulin Lispro pen injector 200 u/ml. 15 units was administered at 1:40 p.m. on 8/30/25. Review of Resident #1's Summary for Providers, dated 8/30/25 showed:Change in ConditionNursing observations, evaluation, and recommendations are: Resident noted more lethargic than normal, able to arouse. BS reading HI on machine indicated over 600. 15 units units [sic] given per ARNP orders, recheck in 1 hour, re-checked and still showing HI. ARNP updated with new orders to send to the ER for evaluation. Review of Resident #1's vital signs did not show any documented blood glucose checks completed by the nurse from 8/22/25 until 8/30/25 when the resident was transferred to the hospital. An interview was conducted on 9/29/25 at 5:10 p.m. with Staff A, LPN. She said she had Resident #1 when she was admitted on [DATE]. She said another nurse, Staff C, LPN helped her by starting to put medications in the computer queue for the resident prior to her getting to the facility. Staff A said when the resident came, Staff C, continued to help with the paperwork then Staff C said these [orders] don't match you need to finish them because she had to assist her residents. Staff A said there was a lot going on that night and she did not get to look at Resident #1's orders again until early the next morning when she finished putting them in the computer. She said she did not remember seeing insulin orders on the paperwork for the resident. Staff A said when the resident arrived Staff C sent the admission paper, the 3008, and the hospital medication list to the provider over the facility's text messaging system. Staff A said she did not remember the provider sending back or making any changes to Resident #1's orders. Staff A confirmed Resident #1 was confused and would not have known her medications. An interview was conducted on 9/29/25 at 2:58 p.m. with Staff C, LPN. Staff C said Staff A, LPN was assigned to Resident #1 on admission. She said all she did was start putting Resident #1's hospital orders in the queue. Staff C said she entered some of the medication orders in the computer then informed Staff A she needed to finish entering the orders and review everything. Staff C said she was just helping. An interview was conducted on 10/1/25 at 4:30 p.m. with Staff E, Certified Nursing Assistant (CNA). Staff E cared for Resident #1 on 8/25-8/28/25 on the 7: 00 a.m.-3:00 p.m. shift. Staff E said on 8/25/25 when she first met Resident #1, I thought maybe she was recovering from something, because she would kind of flop and throw herself back in bed. She said she had to get the nurse to assist her with transferring the resident. Staff E said a day, or two later Resident #1 must have gotten a new medication or maybe it was the IV fluids she got, but the resident was able to hold a good conversation. Staff E said she was able to get Resident #1 to shower and she made more sense. Staff E said she was off for a couple of days and when she returned, she was told the resident had gone back to the hospital. A follow-up interview was conducted on 10/1/25 at 3:18 p.m. with Staff C, LPN. She said she only assisted with entering medication orders for Resident #1 after the resident arrived at the facility. She said she entered orders from the paperwork the resident brought from the hospital. An interview was conducted on 9/29/25 at 1:43 p.m. with Resident #1's primary care NP. The NP said she did not get notified of Resident #1's abnormal lab results on 8/28/25. She confirmed it was a Thursday, and she would have been the person contacted. The NP said staff notified her about the abnormal labs on 8/26/25 and she ordered some IV fluids. She said Resident #1 did not say anything about her blood sugar levels. The NP did confirm Resident #1 was confused. During a follow-up interview on 10/1/25 at 5:51 p.m. the NP said she knew the resident had some high blood pressure readings and was put on a blood pressure medication. She said she had been notified of previous high blood pressures for Resident #1 but was not notified the resident's blood pressure was high on 8/29/25. She said for the abnormal labs she saw Resident #1's glucose level was high but thought maybe she was dehydrated and that is why she ordered IV fluids. She said she did not know about the second abnormal labs on 8/28/25. The NP did not want to comment on Resident #1 being on furosemide because she did not order it but said in general furosemide removes fluid from the body. The NP agreed it could cause dehydration. An interview was conducted on 9/30/25 at 10:32 a.m. with Staff D, Registered Nurse (RN). Staff D said she remembered Resident #1 and was the supervisor in the facility when the resident was sent to the hospital. Staff D said she made rounds frequently on the units and touched base with nurses. She said on 8/30/25 a CNA came to her and said Resident #1 was different than she had been the weekend before. She said the CNA told her the previous weekend, August 23rd/24th, the resident had been up walking around and was busy. Staff D said on 8/30/25 Resident #1 was lying in bed, lethargic, and would talk, but barely. Staff D said she had seen Resident #1 the weekend she had been admitted to the facility. She said the resident had been confused, but the family said it was her baseline. She said the resident got up and walked around her room sometimes without waiting for assistance. Staff D said when she saw how the resident was on 8/30/25 she did a full assessment on Resident #1 and part of that was checking her blood glucose level since she was diabetic. Staff D said the resident's blood glucose was high and she worked with the resident's assigned nurse to update the provider and get orders. Staff D said she looked at the resident's medical record because she liked to gather what information she can provide to paramedics and the emergency department. She said during her review she noticed Resident #1 had two sets of labs since her admission that showed high blood glucose levels, one in the 300s and one in the 400s. Staff D said during her chart review she noticed the resident was not being administered any insulin or medication for diabetes by mouth. Staff D said she had not been informed the resident had any blood pressures issues but noticed Resident #1 had high blood pressure readings that week and was started on medication. Staff D said she pulled up Resident #1's admission paperwork from the hospital to compare to the orders the resident had in the computer, and she noticed Resident #1 had orders for some medications that had been on her hospital discharge list and some of her medications were not on the list. She said she did not recall the exact medications, but there were some wonky ones. She said she noticed the resident had been discharged on a few blood pressure medications but had not received them upon admission. Staff D said she notified nursing management and left all the paperwork she had gathered so it could be investigated. Staff D said she also notified the on-call provider about the medication discrepancies. An interview was conducted on 9/30/25 at 9:40 a.m. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). They both reviewed Resident #1's hospital discharge medication list and the resident's physician orders in the facility. They confirmed the medication lists did not match. The DON said she did not know what happened and wanted to look into it further. A follow-up interview was conducted on 9/30/25 at 4:55 p.m. with the ADON and DON. They said the new admission process expectation would be the resident arrives at the facility with hospital discharge paperwork, and the admitting nurse is notified. The nurse takes the hospital medication orders and sends them to the provider for review. Once the medications are reconciled with the provider, the medication orders are entered into the computer. Then nurses on the 11:00 p.m. -7:00 a.m. shift are responsible for doing a chart check for all new admissions that day. The ADON and DON said the new admission paperwork was at the nurses' station, so the night shift nurse had it available to review orders to ensure they were transcribed correctly. The ADON and DON said if a nurse worked a double shift (from 3:00 p.m.-11:00 p.m. and then 11:00 p.m. -7:00 a.m.) that nurse could do their own chart check. They said there was no process in place to document chart checks were being completed on the 11:00 p.m.-7:00 a.m. shift; they were trusting it was being completed. The ADON and DON said the second chart check was completed after the morning clinical meeting, each morning Monday through Friday. They said the Unit Manager (UM) was responsible for bringing new admission charts to the meeting and reviewing the orders for accuracy. An interview was conducted on 9/30/25 at 11:31 a.m. with the RR for Resident #1. The RR said the resident had been on blood pressure medication prior to being admitted to the facility. She said the hospital never mentioned Resident #1 having urinary tract infection (UTI), but the nurse at the facility said she had a UTI coming from the hospital, which was confusing. The RR said Resident #1 did not have COPD or breathing issues and had not been on medications related to that. The RR said when Resident #1 admitted to the facility she had been talking, up walking around, and had been able to stand up from the bed on the lowest position by the floor. The RR said Resident #1 downgraded to not talking, not walking, and not getting up to go to the bathroom while in the facility. The RR said since leaving the facility, the resident had recovered some of her abilities but was not back to where she was prior to being admitted there. An interview was conducted on 10/1/25 at 1:22 p.m. with the facility's Medical Director of the facility. The Medical Director said he was informed of the admission errors with medication orders for Resident #1 but was not fully aware of the specifics. He said his expectation on admission was a picture of the resident's hospital orders were sent to the physician; the physician reviewed and verified the orders and sent clarification and/or new orders. The Medical Director said the provider was expected to review orders between visits to ensure accuracy. He said he expected the nurses to have completed audits to ensure accuracy. He confirmed he would have expected the nurse to have documented that medications were reconciled with the provider. He said as the Medical Director of the facility, if the facility had difficulty with a provider not responding to a condition or if education to another provider was necessary, he should have been notified because it was his job to have discussions regarding protocols and standards of practice. An interview was conducted on 9/30/25 at 1:34 p.m. with the facility's consultant pharmacist. She said she had been notified about the medication errors for Resident #1, but she had only been told about the resident not receiving insulin; she was not aware of all the medication issues. The pharmacist was read the list of medications from the resident's hospital discharge medication list and the medications ordered in the facility. She said after hearing the list, she would be more concerned with the medication Resident #1 did not receive. She said it would depend on why Resident #1 was on some of the medication such as carbamazepine and lactulose. The pharmacist said carbamazepine could be used for seizures or depression and lactulose could be for constipation or for abnormal ammonia levels. The pharmacist said she had not seen anything like this happen before. She said when a new resident is admitted she completes a medication review, however she is looking at the medications in the facility orders to ensure there are no interactions or issues. She said unless she sees something that looks really off, she does not pull the hospital discharge medication list to review. The pharmacist said her expectation is for the facility to enter the medication orders correctly. Review of Resident #1's hospital records dated 8/30/25 showed:Presenting Problem: hyperglycemia, given 15 units of insulin at facility.History of Present Illness: [AGE] year-old female with a past medical history of diabetes, hyperlipidemia,hypertension, and prior breast cancer (status post left mastectomy and lymph node removal, in remission), [NAME] [inferior mesenteric artery] occlusion and SMA [superior mesenteric artery] stenosis presents with a 3-day history of abdominal pain and hyperglycemia. Glucose greater than 600 at facility given insulin prior to transport. Patient notes her pain is diffuse 8 out of 10 intensity nonradiating with no alleviating factors. Lab results in the emergency department showed:8/30/2025 5:58 p.m.WBC (white blood cell count) 16.42 x10^3/ microliter (uL) HIGHPlatelet 600 x10^3/uL HIGHNeutrophil Auto 72.5 % HIGHLymphocyte Auto 13.3 % LOWMonocyte Auto 12.4 % HIGHEosinophil Auto 0.3 % LOWAbsolute Neutrophil 11.91 x10^3/uL HIGHAbsolute Monocyte 2.03 x10^3/uL HIGHBUN 44 mg/dL HIGHCreatinine 1.47 mg/dL HIGHEstimated glomerular filtration rate (eGFR) Chronic kidney disease-equation for prediction and interpretation (CKD-EPI) 36 mL/min/1.73m^2 LOWCalcium Level 11.3 mg/dL HIGHAlkaline Phosphatase 182 U/L HIGHLipase Level 127 U/L HIGHPro b-type natriuretic peptide (PBNP) 1,010 pg/mL HIGHHS Troponin-T 60 ng/L CRITICALLY HIGHCarbamaz Level <2.0 ug/mL LOWT4 Free 1.86 ng/dL HIGHUrinalysis (UA) Appear ClearUA Color Pale yellowUA Glucose 4+UA Ketones 1+UA Protein 3+UA Bacteria Auto FewUA Epithelial Cells Auto None SeenUA Hyaline Cast Auto Few8/30/25 6:22 p.m.POC [point of care] Potassium 3.4 mmol/L LOWPOC Sodium 129 mmol/L LOWPOC [NAME] [lactate] 3.30 mmol/L HIGH Vital signs8/30/25 6:00 p.m.Blood pressure 158/93Heart rate 101Respiratory rate 18 breathes/minute Discussion of Management with Hospitalist revealed: [AGE] year-old female presents to the emergency department with diffuse abdominal pain in the setting of known severe atherosclerosis of the aorta [NAME] SMA. CT [computed tomography] angiogram above no evidence of ischemic colitis unclear etiology of the patient's pain white count is 17 she was given vancomycin and Zosyn. Glucose greater than 600 now in the 400s after insulin. Given further fluids and insulin in the emergency department. She will be admitted for further management of her hyperglycemia possible underlying sepsis blood cultures were sent. Lactate was 3.3. [normal is <2] Of note patient also with new ischemic appearing EKG [electrocardiogram] with lateral ST depressions elevated troponins of 60 and 54. She is not complaining of chest pain however concern for potential NSTEMI [Non-ST-Segment Elevation Myocardial Infarction] given elevated troponins and ischemic EKG. She will be admitted to the cardiac floor for further management of numerous above conditions.Diagnoses listed were hyperglycemia due to type 2 diabetes mellitus, abnormal EKG, elevated troponin, lactic acidemia, hypertension, and abdominal pain. A Cleveland Clinic article titled Troponin Test, reviewed on 3/17/22, explained: A troponin test looks for the protein troponin (there are two forms related to your heart, troponin I and troponin T) in your blood. Normally, troponin stays inside your heart muscle's cells, but damage to those cells - like the kind of damage from a heart attack - causes troponin to leak into your blood. Higher levels of troponin in[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Nursing Home Administer, the Director of Nursing, Assistant Director of Nursing, Nursing staff, Certified Nursing Aides, the resident's family members, the attending physician, Medical Director, and consultant pharmacist, and review of the facility's policies and the resident's medical record, the facility failed to prevent and report neglect for one (Resident #3) of three sampled residents. The facility failed to prevent neglect and report neglect for Resident #3 who had dementia and cognitive communication deficits, had an order for Fentanyl (narcotic to treat severe pain) patch every 72 hours 12 mcg (micrograms)/hour, apply 1 patch transdermal one time a day every 3 days related to pain and remove per schedule as of 04/26/22. On 02/10/23, Staff A, Licensed Practical Nurse (LPN) neglected to ensure the prior narcotic patch was removed at 8:59 a.m. prior to placing a new patch on at 9:00 a.m. Resident #3 went into an unresponsive state at approximately 5:45 p.m. in the dining room. Her vitals were taken, and her blood pressure was 67/43, pulse 60 and respirations 14. Her family was called and wanted her transferred to the hospital. EMS (Emergency Medical Services) arrived at approximately 6:00 p.m. They were told by the family she had a drug overdose prior. The EMS assessed her body and found 2 Fentanyl patches, one on each shoulder. They provided 2.0 mg (milligrams) or a total of 4 doses of Narcan (treats narcotic overdose in an emergency) and with each dose her respirations improved per the EMS record. The failure created a situation that resulted in a worsened condition and admission to the hospital for Resident #3 resulting in the determination of Immediate Jeopardy beginning 02/10/2023. The findings of Immediate Jeopardy were determined to be removed on 05/19/2023 and the scope and severity reduced to a D. Findings included: A review of the facility policy, Abuse, Neglect, Exploitation and Misappropriation, showed it was the policy of the facility to take appropriate steps to prevent abuse, neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensure all alleged violations of Federal and/or State law were reported immediately to the Administrator, the Risk manager, the Social Service Director, and the Director of Nursing. The Abuse coordinator/designee shall report any alleged violations of abuse or serious bodily injury immediately, but no later than 2 hours to the Agency for Health Care Administration (AHCA), the Adult Protective services and the local law enforcement if they feel a crime has occurred. 6. Reporting: all staff members are required to report suspected maltreatment. They may report to the abuse Hotline, however they are also obligated to report to a supervisor department manager in the facility so that the resident may immediately be protected from further maltreatment. The Administrator, the Risk Manager, Social Service Director, and Director of Nursing are to be informed of the situation immediately. The DON/designee shall notify the physician and the resident's representative concerning the suspected maltreatment and the findings of the assessment. Upon initial investigation, where there is a suspicion that abuse of serious bodily injury may have occurred the Abuse Coordinator/designee shall immediately but no later than 2 hours, report the alleged violation for the Agency for Health Care Administration, Adult Protective Services, and local law enforcement when appropriate. The Risk Manager/designee will file the immediate Federal report with AHCA, and then submit the summary and findings of the investigation within the 5-day Federal Report. A record review of the progress notes for Resident #3 showed on 02/10/23 at 10:19 p.m., At approximately 5:45 p.m. it was reported to me, [Staff D, Registered Nurse (RN)] that Resident #3 was unresponsive. She was in the dining room in her chair and had been through the shift. I performed a sternal rub in which she was slightly grimacing. Her vitals were taken, blood pressure 67/43, pulse 60, oxygen saturation 94%, respirations 14. Her family was with her, and she called Resident #3's son in which he stated that he wished for her to be sent to the hospital. Attending physician was notified at 5:50 p.m. At 5:52 p.m. orders were received to send her out by Emergency Medical Services (EMS). EMS arrived at approximately 6:00 p.m. She was escorted to the hospital by EMS via stretcher at approximately 6:10 p.m. I called the hospital and gave a report. Staff D, RN A review of the Emergency Medical Services (EMS) report showed they were at the scene on 02/10/23 at 5:57 p.m. They were at the resident at 6:00 p.m. EMS departed at 6:09 p.m. EMS was called to the facility for a resident with altered mental status. At resident contact there was no nursing staff in the room with the resident. Only another staff member who immediately walked out upon EMS arrival, and a friend visiting the resident. The resident was sitting in a wheelchair, completely comatose. No one was present to provide an accurate report of what was going on with the resident. The resident was moved to a stretcher to be adequately assessed. She was moved from the wheelchair to the stretcher using the sheet pull method. While initial vital signs were obtained, EMS questioned nursing staff at the nursing station about when the last time the resident was seen normal. They stated she was normal 20 minutes ago, prior to her visitor. The nursing staff had to be asked for paperwork on the resident and offered no other report as far as past medical history or events leading up to the current complaint. Staff handed EMS a packet of resident history and walked away. The resident's visitor stated the resident was unresponsive upon her arrival and was usually completely alert and oriented. The resident's visitor made a phone call to the family who stated the resident was overdosed on her pain medication in the past and requested that EMS administer Narcan prior to any assessment. EMS advised that after a thorough assessment we will treat the resident appropriately. The resident was moved to the EMS stretcher for further assessment and treatment after initial assessment of vital signs. The resident was treated under the following protocols: type adult only: drug overdose. Vital signs indicated that the resident was hypotensive, bradycardic, with shallow respirations. Blood glucose was 156 [within normal limits]. Nasal capnography [non-invasive measurement during inspiration and expiration to measure the respiratory rate and the amount of carbon dioxide exhaled in each breath] confirms shallow respirations; with each dose of Narcan, resident's respirations improved. Intravenous access was established. Immediately fluid bolus was initiated, resident was given her initial dose of Narcan 0.5 mg (6:04 p.m.), repeat dose was administered for the first 2.0 mg (6:04 p.m., 6:06 p.m., 6:08 p.m. 6:10 p.m.) of Narcan. At this point it was clear this was a significant overdose, and the resident's dosage was increased to 1.0 mg, each time Narcan was administered with better improvement in resident condition. At this point EMS was able to take a moment to review resident's medications and it was noted that the resident was administered Fentanyl via medication patches. Resident was checked once on scene for medication patches, but none was obvious. Resident was wearing a long sleeve sweater blocking EMSs view of her upper arm. Resident's shirt was cut away. Two Fentanyl patches were noted. One patch was on each shoulder. One looked freshly placed. The other looked very worn and dirty. No other patches were found. Both patches were removed by EMS. The resident received 1.0 mg of Narcan at 6:12 p.m., 6:14 p.m. and 6:16 p.m. Hospital Emergency records dated 02/10/2023 at 10:46 p.m., showed transient hypotension, medication overdose. Per EMS resident was initially hypotensive on scene with blood pressure in the 90's. The resident was known to have accidental overdose with Fentanyl patches so was given 4 mg of Narcan IV (intravenous) by EMS along with 400 cc (cubic centimeter) of normal saline. Resident presented with no Fentanyl patches on. The resident was not alert and oriented with no new complaints. The resident was given another 2 mg of Narcan while in the Emergency Department upon arrival as initial blood pressure was 80 systolic. This improved the mental status even further and brought the blood pressure up to the mid-90's systolic. Based on the hospital records, [Resident #3] was [AGE] year-old female, nursing home resident, history of paraplegia and advanced dementia, hypertension, bedbound. Presented to the ER today from nursing home with decreased responsiveness, apparently upon EMS arrival they found the patient to have 2 Fentanyl patches on bilateral upper extremities. Unfortunately, she is not able to provide meaningful information. Symptoms improved after the patient was given Narcan. Progress Note from hospital physician showed on 02/12/23 that the Fentanyl overdose was improving. A review of the physician orders revealed the following: Fentanyl patch every 72 hours 12 mcg/hour, apply 1 patch transdermal one time a day every 3 days related to pain and remove per schedule as of 04/26/22; Oxycodone-Acetaminophen 5-325 mg every 6 hours as need for pain as of 12/22/2022. Review of the February Medication Administration Record (MAR) showed on 02/10/23 Staff A, Licensed Practical Nurse (LPN) removed the Fentanyl patch at 8:59 a.m. and replaced the patch at 9:00 a.m. During an Interview on 05/15/23 at 3:30 p.m., Staff A, LPN stated he had worked at the facility for about 3 months. He stated his process regarding Fentanyl patches was to look over the body to find the prior (patch) and remove it. He would replace it with a new one. Another nurse would witness the removal and place it in the waste. The other nurse would sign the paper (2-nurse signature form). The paper to be signed was in the narcotic book. He stated in the interview, I took off her patch and replaced it with another on 02/10. During an interview on 05/16/23 at 9:11 a.m. with the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the (Assistant Director of Nursing) ADON, the NHA said, The hospital reported to us that [Resident #3] had two Fentanyl patches on her bilateral upper extremities. The family called Staff C, LPN Unit Manager (UM) and told her that the resident had two patches on. We put education into place. We did not want it to happen again. We instituted the two-nurse sign off when the patch was removed and destroyed. The DON reviewed Resident #3's February MAR, for the staff member who applied the patch on the day in question. The Consultant Nurse, RN entered at 9:28 a.m. Staff A, LPN was the staff member that applied the patch. The DON did not individually speak with Staff A, LPN about the incident. The DON stated, He was in on the education when it was performed, Staff I, RN, Risk Manager and Staff Development (SD) would have talked to him. The DON stated, They did no reporting. A Medication error form nor an investigation was performed. The Risk Manager and Staff Developer educated the nurses individually and would have told him he made the mistake. They stated that an Internal investigation was performed but was not reported. A record review of the face sheet showed Resident #3 was admitted on [DATE], readmitted on [DATE], and discharged on 2/10/23. A review of her face sheet revealed the diagnoses which included but not limited to quadriplegia Cervical-5 to Cervical-7 (bones in the neck region), muscle weakness, pain, stage 4 sacral pressure ulcer, fusion of spine, dementia, thoracic disc disorder, and cognitive communication. A review of the 5-day, Minimum Data Set (MDS) dated [DATE] showed in Section C a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Section G showed the resident was totally dependent on two for bed mobility, transfers, and toileting. She required extensive assistance for eating. Section N, the medication section, showed she was on diuretics and opioids. A record review of the care plans showed she was at risk for alteration related to pain/discomfort related to occipital condyle/maxillary fracture, intervertebral disc disease, compromised cardiac status, urinary catheter, and glaucoma. Interventions included but not limited to administering analgesia as per orders. Monitor for effectiveness/adverse effects initiated as of 05/16/2022. Review of the Situation, Background, Assessment, Recommendation (SBAR) dated 02/10/23 showed a change in condition of unresponsiveness. The resident appears to be in a stupor state. Suggest transferring to hospital. Family called on 02/12/23 at 6:05 p.m. The physician called on 02/10/23 at 5:50 p.m. During an interview on 05/18/23 at 12:45 p.m. with Staff D, RN, she stated she worked the 3:00 p.m.-11:00 p.m. shift. She was doing her 5:00 p.m. medication pass and gave Resident #3 her medications in the dining room. Staff D stated, We talked; she was alert. Staff D said the medication pass was usually between 4:00 p.m.-5:30 p.m. The patches were usually given on the 7:00 a.m.-3:00 p.m. shift. Resident #3 was sitting in the dining room with other residents in her day chair. The CNAs were doing vital signs. She could see her from the nursing station. She finished passing medications. The lady that was visiting her in the dining room stated she was unresponsive. We did vital signs and took the resident to her room. She texted the doctor that it was a priority. She called the family member, and he wanted her to go to the hospital. She had to get an order to send her out. She called the doctor and got an order to send her via EMS. The visitor and the CNA were in her room. She stated she was going in and out to the phone and things. She checked the residents blood sugar. The visitor called the family member also. The texts go to the doctor, the DON, the UMs and the ADON. She was not sure if they were still in the building at the time of the text. They responded to the texts. It was just her handling the situation. No other nursing staff. She did not see the patches on the resident because the resident was dressed and wore a jacket. EMS came and took her. She did not see EMS looking or finding the patches. During an interview with the consultant pharmacist on 05/18/23 at 12:25 p.m., she said the process for transdermal patches was to review the Electronic Medication Administration Report (EMAR) for orders, pull from the narcotic box, sign the narcotic sheet, go to resident's room, remove the old patch, and apply the new patch with a date and initials. They were to dispose of old patch according to facility policy and sign on the EMAR that it was given. Some facilities fold them on themselves and put it in the trash and some used a drug buster on their cart. She had not heard of any medication error for Resident #3. Related to narcotic sheets matching the EMAR for narcotics given, she stated they should match. The narcotic sheets would only go back to the pharmacy if the medication was refused at the time of delivery. She stated she audited the carts for expiration dates and opened dates. They have a nurse consultant do an audit related to EMAR to cart. The consultant visited every 4-6 weeks. The consultant pharmacist stated she would assist the facility in education, etc. if they requested it. During an interview with the Medical Director on 05/18/23 at 1:58 p.m., he stated he was aware of the two Fentanyl patches on Resident #3. The administrative staff and DON told him. He basically told them that especially with opioids to document and be extra careful with meds. A review of the facility's, undated, Root Cause Analysis showed. The Immediate Intervention: Resident never returned to the facility. Root Cause Analysis (RCA): #1 Describe event or incident: On 02/20/2023 at approximately 5:45 p.m., it was reported to, [Staff D, Registered Nurse (RN)] that Resident #3 was unresponsive. She was in the dining room in her chair and had been throughout the shift. [Staff D, Registered Nurse (RN)] performed a sternal rub in which she slightly grimaced. Her vitals were taken BP 67/43, pulse 60, O2 94% RA temp 97.7, respirations 14. Her family member was with her and called [Resident #3's] son in which he stated that he wished for her to be sent to the hospital. Attending physician was notified at 5:50 p.m. At 5:52 p.m. orders were received to send her out by EMS. EMS arrived at approximately 6:00 p.m. She was escorted to the hospital by EMS via stretcher at approximately 6:10 p.m. , [Staff D, Registered Nurse (RN)] called the hospital and spoke with her nurse and was able to give a report. #2 After thorough investigation: was blank. #3 Determine Root Cause of Incidents: educated staff on Patch Administration and Removing with second nurse verification. A record review of the education sign sheets for transdermal patches showed the facility began education related to applying and removing of transdermal patches (Fentanyl, Nitro, Nicotine, Scopolamine, Diclofenac, etc.) on 02/13/23 through 02/17/23. 1. Check order. 2. Prior to administering a new patch, PLEASE REMOVE THE OLD PATCH (if no patch is found in prior placement area, do a brief skin sweep to verify no patch can be removed). A second nurse must verify removal of patch (both nurse signatures in Narc [Narcotic] Book and in PCC). Dispose of patch properly in Drug Buster on cart. Both nurses will be held responsible if a resident is found with more than one patch applied. 3. Please DO NOT apply patch to previous placement area. Please review and sign the educational moment stating understanding!! Staff I was the presenter. 20 nurses out of 45 had signed the in-service sheet. The sign in sheets that were provided showed the education was given on 02/13 to 02/17/23. During an interview with Staff I, RN, RM, SD on 05/18/23 at 9:14 a.m., she revealed the 2-nurse signature process education was conducted between 2/13 and 2/17/23. She provided the only sign in sheet she had which showed 20 nurses names. She stated she had not educated anyone else. She stated the UMs (Unit Managers) were responsible for monitoring the 2-nurse sign sheets. She stated she had worked at the facility since November 2022 and had given an in-service regarding patch usage. On 05/18/23 at 9:15 a.m., the DON stated she had worked at the facility for 1 ½ years and to her knowledge, they had not had an in-service regarding patch administration. During an interview with Staff C, LPN, UM on 05/18/23 at 10:01 a.m. she stated, The 2-nurse signature form was put in place when Resident #3 went to the ER with, what was reported, two patches on. So, we looked into it and started a process, on how the patch was to be put on. Could not sign two nurses on PCC, so we had to put a paper form in place for two signatures. When it [the signature form] is full, I turn it into the DON. As far as a weekly or monthly auditing is concerned, it is not being done by me. When the form is filled, it is handed to me. During an interview on 05/19/2023 at 4:11 p.m. with the NHA and the DON. DON stated the NHA conducted education yesterday, 05/19/2023, to administrative staff and the RNC educated the NHA related to reporting. If adverse, must submit a 15-day report. Educated administrative team, including DON, ADON, UM's, Rehab Director, MDS, (Minimum Data Set), Marketing, Admissions, Payroll, Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and Medical Records. The NHA educated them that their responsibility was to ensure the NHA was informed right away, and a report was completed timely and assurance that resident remained safe. The DON stated she worked with NHA to ensure residents were safe. The DON and NHA stated they were not aware the resident received Narcan and did not know the resident had the 2 patches until they received the report. Usually, admissions call the next day to check up. The NHA said Admissions brought to her attention resident received Narcan. The NHA and DON stated they did not get EMS reports and they were not aware of the resident getting Narcan. The NHA stated it did not strike her as something she needed to investigate further but did want to bring it to the assigned nurse's attention. She said, The resident often acted lethargic, and her son wanted the resident to be heavily medicated, she saw her like that often. The Son demanded staff check on her often. The Son always knew if someone was in the resident's room. The NHA thought the resident's demeanor was normally not very alert. The DON stated they found out on 2/13/23 about the incident and started education to ensure the incident did not happen again. The NHA stated adverse was something out of the ordinary and something caused by the resident's experience in the facility. The NHA stated she realized this should have been an adverse report regardless of their feeling that she did not have true full patches on her, and they did not have the ability to determine if one was stronger than the other. Facility immediate actions to remove the Immediate Jeopardy included: Upon completion of a root cause analysis, it was identified that the process required to effectively train and communicate the facility's Adverse Incident Reporting / Abuse, Neglect, Exploitation, & Misappropriation policies were in place. The root cause analysis identified the administrative staff did not proceed with reporting as there was no information from the hospital that there were two patches on the resident at the time, she was admitted to the emergency room. The order reads to apply patch transdermal one time a day and remove per schedule. The MAR is signed by nurse as removed and applied on correct dates. The facility was not notified that the resident arrived at the hospital with two Fentanyl patches, therefore no reporting was completed. Resident #3 received Narcan while in the facility. There was not a nurse present in the room, per the EMS staff. The facility was aware of the two patches on 02/13/2023 and started education to the nurses. The Administrator completed education on 05/18/2023 at 6:00 p.m. to 100% of administrative staff on the following policies. Adverse Incident Reporting Abuse, Neglect, Exploitation, and Misappropriation-which includes reporting guidelines. The administrator during the interview stated the Consultant Nurse educated her on reporting. Interviewed DON and she stated she had been educated on reporting. An AD HOC QAPI meeting was held on 05/18/2023 at 6:30 p.m. with QAPI committee. The medical director (covering physician) was present virtually. Endings of survey and removal plans were discussed during this QAPI meeting. Reviewed QAPI sign in sheet for 05/18/2023. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 05/19/23 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records and facility polices, interviews with facility staff, and the Medical Doctor, the facility failed to provide supervision and services to prevent an unwitnessed exit from the facility for one (Resident # 2) of fifteen residents at high-risk for elopement. The facility failed to provide adequate supervision, to place an electronic monitoring device on a resident known to wander, and failed to provide appropriate safety measures for an exit door, resulting in the resident leaving the facility without staff intervention. Resident #2 was cognitively impaired, at risk for falls related to difficulty walking, and was known by the night shift staff to get up at night and walk around the facility. On 4/23/2023 at approximately 5:50 a.m., the resident ambulated and exited the facility through the front door of the lobby. Resident #2 had been assessed as at risk for elopement and was care planned to have an electronic monitoring device on. The resident did not have his monitoring device on as care planned and walked out the facility's front door without staff knowledge. Resident # 2 was at risk of walking out into a four-lane main road, putting him at risk of being struck by a vehicle and suffering serious injury or death. Staff N, the Maintenance Assistant, who found Resident #2, stated the resident was found outside around 5:55 a.m., at the front of the building, lying on the ground with his head in a flower bed. Resident # 2 suffered injuries on his face, and lips and was provided care by staff nurses. Due to the facility staff's failure to place a wander monitoring device on a resident assessed at risk for elopement and provide supervision, Resident # 2 and other residents with cognitive impairment and the ability to ambulate or self-propel were at risk for serious injury that could have resulted in death. Resident #2 ambulated with his walker approximately 532 feet from the building. The resident and other impaired residents had the likelihood to ambulate or self-propel through an ungated driveway leading to a four-lane main traffic road. These failures created a situation that resulted in injury with likelihood for serious injury and/or death to Resident # 2 and resulted in the determination of Immediate Jeopardy on 04/23/2023. It was determined the Immediate Jeopardy was removed on 05/19/2023 and the Scope and Severity for F689 was reduced to a D after verification of removal of Immediate Jeopardy. Finding Included: On May 16, 2023, at 11:18 a.m., an interview was conducted with Staff L, CNA (Certified Nursing Assistant). She reported she had worked at the facility for 1 year. She was assigned to Resident #2 on 4/23/2023, the day of the incident. She said the last time she saw the resident was at 5:00 a.m. when she went into his room to bring him some ice water. The resident was asleep at that time. She said, Resident #2 normally would get up at 2:30 a.m. or 3:30 a.m., come out of his room to talk with the staff, and have a snack. However, if the resident did not see anyone, he would usually start walking around the facility, which was a normal routine for him. She said they never had to worry about the resident going outside the front door because he always had an electronic monitoring device on. So even if he had wandered up to the front doors, the doors would have locked, but the resident did not have an electronic monitoring device on. She said at 6:05 a.m. she was in another resident's room providing care when she heard an announcement over the intercom for a nurse to report to the front lobby. She said the page went out at least 8 or 9 times before she heard the paging stop. When she came out of the other resident's room, she saw the nurse pushing Resident #2 in a wheelchair to the nurse's station. On May 15, 2023, at 2:09 pm., an interview was conducted with Staff N, the Maintenance Assistant, who found Resident # 2. He stated that at around 5:50 a.m., when he arrived at the facility, he drove past the front entrance heading to the back of the building to park his car. As he was driving, he reported that he noticed something white on the ground next to the flower bed in front of the building. He said at first, he thought that it was a bag. He said he was going to continue driving, but when he slowed down and got a little bit closer to the gate, he saw that there was a person lying down on the sidewalk with his head next to the flower bed. He said he got out of his car to assist the resident and tried to wake the resident up, but the resident was not responding to him. He proceeded to the front door to call for assistance. He reported when he reached the front door, he saw two women from therapy, and they came out to help assist the resident. He said the two women woke the resident up and assisted the resident into a wheelchair back into the facility. Staff N said after that, he went back to his assigned duties. On May 15, 2023 at 2:41 pm, an interview was conducted with Staff M, Central Supply/Certified Nursing Assistant (CNA). She reported she arrived at work at 6 a.m. or slightly earlier on the morning of the incident. When she got to the facility, she said she had to put the front door code in to enter the facility because the front door was locked. She said when she got inside, she saw the maintenance assistant yelling that he needed help outside because a resident was outside on the ground. She said when she went outside, she witnessed the resident lying outside on the ground on his side but halfway on his back. She said she noticed the resident had blood on his lip and scratches on his face. She immediately ran back into the facility and told another staff member to call for a nurse because a resident was outside on the ground. She said Staff K, a Registered Nurse (RN), one of the night shift nurses, headed towards the front door, Staff M said she grabbed a transport wheelchair to help assist the resident. She stated Staff J, RN, the resident's nurse, later arrived outside to help provide the resident with assistance. While the two nurses assessed the resident, Staff M said she heard the resident state he did not hit his head on the ground. While the two nurses assisted the resident off the ground, Staff M said she stood behind the wheelchair to provide assistance. After the resident was placed in the wheelchair, he was escorted back to his room by the nurse. A review of Resident #2's medical record showed he was originally admitted on [DATE] and re-admitted on [DATE]. Resident # 2 was re-admitted with diagnoses to include recurrent unspecified, Type 2 diabetes Mellitus without Complications, difficulty in walking, Unspecified Intellectual Disabilities, Altered Mental Status, Major Depressive disorder, Dehydration, Disorder of Kidney and Ureter, and Renal insufficiency. A review of the Nursing Admission/readmission Screening History dated 03/08/2023, showed that Resident # 2 was readmitted to the facility on [DATE], 1b. Alert, 2. Orientation to person, place, time and situation. 4. Motor Control - poor balance, 5. Cognition - confused. Note signed Staff R, LPN (Licensed Practical Nurse) A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed, Section C, Cognitive Patterns, Brief Interview for Mental Status, (BIMS) score of 08, which indicated mildly impaired cognition. Section G, Activity of Daily Living ( ADL) Assistance, showed the resident required limited assistance with bed mobility, transfer walking in the room, walking in corridor, and locomotion on and off the unit. MDS showed in section G0300, titled, Balance During Transitions and Walking showed the the resident is not steady, only able to stabilize with staff assistance, when walking A review of the nursing care plan dated 5/12/2023, showed on 10/26/2023, the resident was an elopement risk/ wanderer related to (r/t) Impaired safety awareness date initiated: 10/26/22. An intervention dated: 10/26/2022 showed, to assess Resident # 2 for fall risk, distract the resident from wandering and structured activities. Observe device for proper placement and function as ordered, [name of device] : electronic monitoring device (L) ankle. A new intervention created on 4/28/2023 showed, in the morning, set the resident up with coffee and a snack in the unit dining room/living room area. A review of the Physical Therapy (PT) Discharge Summary showed dates of services from 03/08/2023 to 03/28/2023, diagnosis (dx) , difficulty in walking, not elsewhere classified (Resident # 2) will safety ambulate on level surface 150 feet in his two-wheeled walker with independence with direction of movement, with use of righting reaction, with continuous steps and with normal cadence to facilitate increased participation in functional activity and to increase independence and safety in room. A review of Resident #2's Interdisciplinary team note, dated 05/02/2023, showed documentation of the elopement that occurred on 04/23/2023. Root Cause Analysis (RCA): Poor Safety Awareness due to periods of confusion. Care Plan: (Electronic monitoring device) placed on resident and frequent safety checks initiated. Labs and urinalysis (UA) with culture and sensitive to be sent related to increased confusion. A review of the Nursing Note dated: 4/24/2023, showed during the morning medication pass at approximately 6:05 a.m. there was an announcement that a nurse needed to come to the front lobby because a resident was on the floor in the front of the building. Resident was assessed, checked for injuries and vitals [vital signs] were taken. According to the note, the resident had cuts to his lip, the bridge of his nose, the center of his forehead, left eyebrow, and left upper cheek. Neurological checks were put in place and an electronic monitoring device was applied on the resident. The Medical Doctor (MD), risk manager and the resident's sister were notified. Note created by Staff J, Registered Nurse. On May 15, 2023, at 2:37 p.m., an interview was conducted with the Rehab Director (RD). He reported the resident ambulated well but at a slow pace, and he used a walker to help him get around the facility. The RD said the resident was not in therapy at the time of the elopement. Observation and reenactment revealed Resident #2 turned left out of the 200 unit and traveled down the hallway toward the 100 unit. Fire doors separate the 100 and 200 units. The distance from the resident's door to the fire doors was approximately 75 feet. Resident # 2 opened fire doors, which enter the 100 unit starting at room [ROOM NUMBER]. The hallway was from rooms 122 to 114 at the end of hallway. The distance from rooms 122 to 114 was approximately 68 feet. Resident # 2 turned right and continued down the 100-unit hallway starting at room [ROOM NUMBER] and ending at room [ROOM NUMBER], passing the nurse's station along the way. The distance from rooms 114 to room [ROOM NUMBER] was approximately 103 feet. Resident # 2 turned right at room [ROOM NUMBER] and traveled down the remainder of the hall on the 100 unit, to the hallway leading to the facility's lobby. From room [ROOM NUMBER] to the hallway which led to the lobby was approximately 68 feet. The resident turned left, passing the offices of the Director of Nursing (DON), the Assistant Director of Nursing, (ADON), the Social Service Director, (SSD), therapy, and administration offices to the front double doors of the facility. The distance from the start of the hallway to the front door was approximately 101 feet. The resident exited out of the front door to the front porch area of the facility. Resident # 2 turned left and traveled down the sidewalk in front of the facility. Resident #2 was found lying down on the sidewalk with his head resting in the flower bed. The distance from the front door of the facility to where the resident was found was approximately 117 feet. The total distance the resident traveled from his room to where he was discovered was approximately 532 feet. On 5/17/2023 at 5:00 p.m., an interview was conducted with Staff K, LPN. Staff K said as she was coming down the hall getting ready to leave, she crossed paths with Staff M. Staff M said she needed help with a resident on the ground outside. Staff K said when she arrived outside, she saw the maintenance assistant leaning down trying to help the resident off the ground. Staff K said she stepped in and started assessing the resident to make sure he was okay. She said after she saw that the resident was okay, she and Staff J, RN and the maintenance assistant lifted the resident off the ground, placed him in a wheelchair, and took him back to his room. Staff K said she stayed behind that morning to help the nurse ensure everything was taken care of. She said they notified Resident # 2's health provider and family and made sure the resident was okay. On May 15, 2023, at 11:03 a.m., an interview was conducted with Staff C, LPN/ Unit Manager for the 100 and 200 halls. She reported when Resident # 2 returned from the hospital on March 8th, 2023, the nurse continued Resident #2's old orders which included his previous wander monitoring device orders, but no wander monitoring device was ever put back on the resident. She reported, she and Staff I, Risk Manager/Staff Developer had a conversation when the resident went out to the hospital about the resident not needing to have the wander monitoring device put back on him because they felt like he was no longer a risk due to him not wandering or exit seeking. Staff C confirmed that neither she nor Staff I wrote a note in the resident's medical records showing he no longer needed to have a wander monitoring device when he returned to the facility. Staff C reported when Staff I performed an audit, she noticed the resident had orders for a wander monitoring device and at that time they were supposed to review and update his orders showing he no longer needed a wander monitoring device. Staff I conducted a second audit on the March 15th, 2023, and noticed that Resident # 2 still had wander monitoring device orders in the system and at that time, Staff I told Staff C that Resident # 2 still had orders for a wander monitoring device in the system. Staff C said even though she was aware that Resident # 2 was assessed on March 8th and was identified as an elopement risk, she discontinued his wander monitoring device without conducting another risk assessment on the resident as she felt he was no longer at risk for elopement. Staff C confirmed they never put a wander monitoring device back on the resident when he returned to the facility on March 8, 2023. After the event happened on April 24, 2023, new orders were obtained for a wander monitoring device and the resident now had a wander monitoring device on his left ankle. On May 16, 2023, at 10:06 a.m., an interview was conducted with Staff I. She said she had worked at the facility for one year. She said on the day of the incident, she arrived at the facility around 6:20 a.m. She said she entered the building at the employee entrance located around the side of the building, where she had to put a code in to enter the building. She said as she was entering the building she received a phone call from Staff J, the night shift nurse who was assigned to the resident. Staff J reported to her that Resident # 2 was found outside on the ground. Staff I said when she came in the building, she saw the resident back on the 200 hall in a wheelchair sitting at the nurse's station. She said she asked the resident where he was going when he went outside the door. She said he told her he was going outside to his tractor, or he may have been daydreaming. She said after the event, they conducted their investigation and asked staff that were on duty that night, when they had last seen the resident. She reported the floor tech was the last person to see the resident at 5:45 a.m. She said the resident was able to get out of the front door because he did not have an electronic monitoring device on and before they made changes to the front door, anyone that did not have an electronic monitoring device could walk up to the door and the door would open. She said since the event they had changed the doors so that staff must use a code to get in and out of the building when the receptionist was not working. She reported the resident did not have an electronic monitoring device when he was readmitted to the facility on [DATE]th, 2023. She and the unit manager decided the resident no longer needed the electronic monitoring device because he was not showing signs of exit seeking behaviors. She said when the floor nurse conducted the resident's admission assessment, she was not made aware of the discussion Staff I and the unit manager had regarding the resident's electronic monitoring device. She reported that 50% of staff, which included nurses, CNAs, maintenance, and housekeeping, were provided with elopement in service and their training was still on going to reach staff in other departments. In addition, nurses were provided with education regarding how to properly conduct elopement assessments, and if a nurse marked a resident was an elopement risk, then the nurse was responsible to put an electronic monitoring device on the resident when the assessment was completed. All staff were informed regarding the front door lock and unlock changes. On 05/16/2023, at 12:00 p.m., Resident # 2 was observed in his room sitting on his bed with his walker next to him. He was well-groomed, with no signs of distress. He had an electronic monitoring device on his left ankle. He said he was doing well and did not remember anything about the day he went outside. He said he remembered he went outside but he really did not know why. On 05/16/2023 at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). She said she came in after she was notified by the Risk Manager that Resident # 2 was found outside. The DON said Resident #2's assessment was inaccurately completed, his risk assessment should have reflected he was no longer an elopement risk, because he was not wandering around the facility. If the nurse found that the resident was an elopement risk, then she should have put an electronic monitoring device on him. The DON said she was aware that they did not do things accurately, because when she looked at the resident's medical record, she noticed her nurses did not document any of the resident's behaviors, stating they just went in the system and completed an elopement assessment. The DON said her process was when a resident was identified as an elopement risk on admission, the nurses were supposed to obtain an order for an electronic monitoring device. They were to place it on the resident and document the resident's behaviors. Then the Interdisciplinary team was to conduct a further review during the morning meeting to discuss whether a resident should or should not continue with an electronic monitoring device. The information should be documented in the resident's medical record, and this process was not done. The DON said elopement assessments were done on admission, then updated Quarterly and if the resident had a change in condition. When an elopement assessment was completed, the system did not allow the nurses to input a score, it just allowed the nurse to answer yes or no as to whether the resident was at risk for elopement. The DON said they did not file the report as an elopement because their corporate told them not to. She said they told her the resident did not elope because he never left the premises, so it was not considered an elopement. She said they told her the facility neglected to put the resident's electronic monitoring device back on him, that's the only thing they did wrong. On 05/16/2023 at 4:00 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She said she and the DON were notified Resident # 2 was found outside of the building. The NHA said that this incident happened because they decided Resident # 2 no longer needed an electronic monitoring device. He was able to go out the front exit door which could have happened with any resident that did not wear an electronic monitoring device. She said the facility was not designed to be a locked facility and the front exit doors were not locked. Staff had to use a code to enter the building in the morning. The NHA said the DON made sure that the nursing staff conducted a skin assessment to make sure the resident was okay. The NHA said the nurse who did the elopement assessment did what she felt was right because she used the information she knew about the resident at that time. On 05/17/2023 at 11:00 a.m. a telephone interview was conducted with Staff Q, LPN. Staff Q said she was not able to remember how she came to the determination that the resident was a still an elopement risk. She said without looking at his medical record, it was hard to say why she checked the answer yes which indicated the resident was still an elopement risk. She said she could have done it by accident. Staff Q said she had not had education regarding elopement because she had not worked after the incident happened. Staff Q said that she worked PRN (as needed). On May 18, 2023, at 12:12 pm, a tour of the facility was conducted with the Maintenance Director. The maintenance director stated the front door of the facility had a wander alert pad built in. If a resident with an electronic monitoring device approached the door, the pad would beep and would also alert the nurse's stations on the 100 and 300 halls. Also, the automatic doors would not open if a resident with an electronic monitoring device attempted to go through the doors. The door was currently equipped with a horn, which was armed at night and is synched with the door lock. The front main entrance door locked from 7:55 p.m. to 6:45 a.m. every night. The horn was now activated if any resident, even without a monitoring device, opened the 300 hall or the front main entrance door. Since the elopement, the 300 door and front main entrance door were locked at night from the inside and outside. He said he was not sure what hours the door was locked before the resident elopement, but thought it was from 8:05 p.m. to 4:45 a.m. He was not sure if the door was locked from the inside prior to the incident but knew it was locked from the outside. He was unable to state how he tested the horn alarm because it was on an automatic timer but stated an employee accidentally set it off recently, so he knew it worked. On 0518/2023 at 3:29 p.m., a telephone interview was conducted with Resident #2's primary care provider. He stated the resident's nurse made him aware of Resident # 2 being found outside. He said it was reported to him that the resident was okay. He said following the incident, he completed an assessment on the resident, but he had not sent it to the facility yet. He said he advised the resident's nurse to perform a UA (urinalysis) to check for a urinary tract infection (UTI), and the lab results were negative for a UTI. He told them to continue to monitor the resident. On May 18, 2023, at 1:53 pm., a telephone interview was conducted with the facility's medical director. He said the administrative staff notified him regarding any events that took place at the facility. He said he was notified about the situation regarding Resident #2, but he did not have any recommendations for the facility. He said the DON called him on 05/ 17/2023 and they discussed the situation. He said this was something they had to investigate to ensure a similar issue never happened again. On 05/19/02023 at 2:00 p.m., an interview was conducted with the Social Service Director, SSD. The SSD said she was made aware of the resident behaviors of wandering in the facility when he was first admitted to the facility. The SSD said Resident # 2 attempted to go out the front doors when he was first admitted to the facility looking for his sister. She said, that's why the [electronic monitoring device] was originally put on the resident, however the nurse never documented the event in the resident medical record. She said she was responsible for coding the behavior section on the MDS and she had always put code a 0 on Section E, showing that Resident # 2 did not exhibit wandering behaviors because nursing had never provided documentation showing that he had those behaviors. Review of the facility Missing Resident and Elopement policy with no date. Revealed: Policy Statement: The purpose of this policy is to clearly define resident elopement and to provide guidance in the management of all reports of missing residents. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. If any resident should leave the premises at any time without following the facility procedure for voluntary leave, the missing resident/elopement procedure should begin immediately. If a resident attempts to leave the facility or a safe area and a staff member is aware of the occurrence and immediately accompanies the resident and /or returns the resident to the facility, it will not be considered an elopement. The resident in this case was always under staff supervision. Procedure: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Charge Nurse as soon as possible. 2. Upon return of the resident to the facility, the Director of Nursing or Charge Nurse should: D. Make appropriate notations in the resident's Medical Record 5. Upon return of the resident to the facility, the Director of Nursing or Charge Nurse should: E. Make appropriate entries into the resident's Medical Record F. Update Plan of Care as indicated. Facility immediate actions to remove the Immediate Jeopardy included: 05/23/2023: Identification of Residents Affected or Likely to be Affected: A review of Resident # 2, and other residents affected or likely to be Affected elopement assessments, orders, and review of [electronic monitoring device] placement was conducted on 5/18/2023, showing no identified concerns. Risk Manager and NHA Completion of investigation and submission of Federal Immediate Reporting Action to Prevent Occurrence/Recurrence: Current residents had a new elopement risk evaluation completed on 5/18/2023 to ensure accuracy of potential risk. Care plan were reviewed /updated as necessary for those current residents identified as an elopement risk based on the evaluation to reduce elopement risk (completion date 5/18/2023) Resident identified as at risk for elopement have a Resident identification Sheet completed and a copy of recent photograph of the resident is attached. These sheets are kept in an elopement risk notebook on all four ( 4 ) units and the reception desk. The Risk Manager, will be responsible for maintaining and updating the elopement risk notebooks Current residents at risk for elopement have been reviewed and all have personal elopement risk transmitters. To adequately supervise residents to prevent elopement based on their elopement risk evaluation, several physical plant interventions were implement on 5/18/2023 The Front door has an automated keypad system and a separate [name] device for security, The [name] device is always active for those residents wearing an personal elopement risk transmitter. The automated keypad system now locks the doors at 8:00 pm as receptionist comes off duty as of 5/18/2023; prior to change doors unlocked at 8:00 am and locked at 8:00 pm. As of 5/18/2023 at 8:00 pm all interior double doors are closed on units and common areas to encourage residents to remain on their supervised units. Exit doors and front door Horn alarm will be checked daily to ensure proper function. An elopement drill was conducted on 5/18/2023 at 10:00 p.m. with staff present in facility. Immediate plan of action reviewed and approved during AD HOC QAPI meeting held 5/18/2023 at approximately 6:30 pm with IDT (interdisciplinary team) team and Medical Director. Attendees include Administrator , Director of Nursing, Minimum Data Set Coordinator, Medical Director designee (virtually), Risk Manager, Social Services director, Assistant Social Service Director, Maintenance Directors, Nursing Supervisors, Therapy Director (via phone), Dietary Supervisor, Assistant Business Office Manager, Activity Director, Customer Service Liaison, and Staffing Coordinator. The Removal plan has been implemented and will be updated as necessary. On 05/19/2023 at 3:41 p.m. Conducted interviews with Staff L LPN UM (unit manager) for the (300 and 400) unit, the Assistant Director of Nursing (ADON), and Staff C LPN UM for the (100 and 200) unit, and the RM. Education was conducted in a group setting. Alert sent out, and each UM did section of employees. Staff were called on the phone if not here for physical education. Education was conducted again last night (05/18/2023) related to elopement and doors functionality. The nurses were educated on elopement definition, which is when a resident is somewhere unsupervised. Conducted elopement drill last night (05/18/2023) on 3-11. If staff see a resident somewhere they should not be, staff are to assist them to get to where they should be. CNAs are required to check residents Q2H (every two hours). Staff were educated in elopement assessments. If the resident deemed a risk, the resident should have an electronic monitoring device applied and orders should be in place. Starting today (05/19/2023), the restorative aids will be responsible for checking the electronic monitoring device functionality daily. In the process of changing orders to ensure restorative aids are checking the functioning of the electronic monitoring device. The facility ordered a 2nd machine to check the functioning of an electronic monitoring device. Nurses should provide supporting documentation if a resident has a change in status and if they are or are not an elopement risk. The nurse management team will review elopement assessments during the morning meeting. Nurse management will be notified if a resident is at risk for elopement. If a progress note related elopement assessment is not found, will call the nurse that conducted the assessment for further review. Residents are reassessed quarterly or if they have a change in condition. The front door now locks at 8 p.m. and opens at 8 a.m. Fire doors also shut to provide a visual cue to residents to not open the doors. admission nurse to check if electronic monitoring device is working by using electronic checker. On 05/19/2023, survey staff validated all education, training and sign-sheets were reviewed showing that all staff were provided with the elopement training specified in the removal plan. Documentation showed that the DON and NHA were provided with reeducation by the regional nurse consultant regarding elopements, reporting of elopement and documentation. Documentation showed all staff (Nurses, CNA,'s Dietary Maintenance, Therapy and Housekeeping) were to adequately supervise residents to prevent elopements and ensure the safety of residents. On 5/19/2023 at approximately 1:00 p.m. the DON was provided with additional education regarding documentation during an incident. Nurses were provided with education on elopement assessment, and whenever they identified a resident to be at risk, they are responsible for putting a monitoring device on the resident identified to be at risk, and to document the resident behaviors in a progress note. Interviews were conducted with 70 staff members, 13 licensed nurses, 23 CNAs and 34 other staff. The staff members were able to state that they had been trained and were knowledgeable about the facility process. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 05/19/2023 and the non-compliance was reduced to a scope and severity of D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with the Nursing Home Administrator, the Director of Nursing, Assistant Director of Nursing, Nursing staff, certified Nurse Assistants, the resident's family member, the attending physician, Medical Director and consultant pharmacist, and review of the facility's policies and the resident's medical record, the facility failed to prevent the administration of an unnecessary medication to one (Resident #3) of three sampled residents. The facility failed to prevent the administration of unnecessary medications to Resident #3 who had dementia and cognitive communication dysfunction, who had an order to remove and replace Fentanyl (narcotic to treat severe pain) patches every 3 days. On 02/10/23, Staff A. Licensed Practical Nurse (LPN) neglected to ensure the prior narcotic patch was removed at 8:59 a.m. prior to placing a new patch on at 9:00 a.m. Resident #3 went into an unresponsive state at approximately 5:45 p.m., in the dining room. Her vitals were taken, and her blood pressure was 67/43, pulse 60 and respirations 14. Her family was called and wanted her transferred to the hospital. EMS (Emergency Medical Services) arrived at approximately 6:00 p.m. They were told by the family she had a drug overdose prior. The EMS assessed her body and found 2 Fentanyl patches, one on each shoulder. They provided 2.0 milligram (mg) or a total of 4 doses of Narcan (treats narcotic overdose in an emergency situation) and with each dose, her respirations improved per review of the EMS record. The failure created a situation that resulted in a worsened condition and admission to the hospital for Resident #3 resulting in the determination of Immediate Jeopardy beginning 02/10/2023. The findings of Immediate Jeopardy was determined to be removed on 05/19/2023 and the scope and severity reduced to a D. Findings included: Record review of the progress notes of Resident #3 showed on 02/10/23 at 10:19 p.m., at approximately 5:45 p.m. it was reported to me, [Staff D, Registered Nurse (RN)] that Resident #3 was unresponsive. She was in the dining room in her chair and had been through the shift. I performed a sternal rub in which she was slightly grimacing. Her vitals were taken, blood pressure 67/43, pulse 60, oxygen saturation, 94%, respirations 14. Her family was with her, and she called Resident #3's son in which he stated that he wished for her to be sent to the hospital. Attending physician was notified at 5:50 p.m. At 5:52 p.m. orders were received to send her out by Emergency Medical Services (EMS). EMS arrived at approximately 6:00 p.m. She was escorted to the hospital by EMS via stretcher at approximately 6:10 p.m. I called the hospital and gave a report. Staff D, RN A review of the Emergency Medical Services (EMS) report showed they were at the scene on 02/10 at 5:57 p.m. They were at the Resident at 6:00 p.m. EMS departed at 6:09 p.m. EMS was called to the facility for a resident with altered mental status. At resident contact there was no nursing staff in the room with the resident. Only another staff member who immediately walked out upon EMS arrival, and a friend visiting the resident. The resident was sitting in a wheelchair, completely comatose. No one was present to provide an accurate report of what was going on with the resident. Resident was moved to stretcher to be able to adequately assess her. She was moved from the wheelchair to the stretcher using the sheet pull method. While initial vital signs were obtained, EMS questioned nursing staff at the nursing station when the last time the resident was seen normal. They stated she was normal 20 minutes ago, prior to her visitor. Nursing staff had to be asked for paperwork on the resident and offered no other report as far as past medical history or events leading up to the current complaint. Staff handed EMS a packet of resident history and walked away. Resident's visitor stated the resident was unresponsive upon her arrival and was usually completely alert and oriented. The resident's visitor made a phone call to the family who stated the resident was overdosed on her pain medication in the past and requested that EMS administer Narcan prior to any assessment. EMS advised that after a thorough assessment we will treat the resident appropriately. Resident was moved to EMS stretcher for further assessment and treatment after initial assessment of vital signs. Resident was treated under the following protocols: type adult only: drug overdose. Vital signs indicated that the resident was hypotensive, bradycardic, with shallow respirations. Blood glucose was 156 (within normal limits). Nasal capnography (non-invasive measurement during inspiration and expiration to measure the respiratory rate and the amount of carbon dioxide exhaled in each breath) confirms shallow respirations; with each dose of Narcan, resident's respirations improved. Intravenous access was established. Immediately fluid bolus was initiated, resident was given her initial dose of Narcan 0.5 mg (6:04 p.m.), repeat dose was administered for the first 2.0 mg (6:04 p.m., 6:06 p.m., 6:08 p.m. 6:10 p.m.) of Narcan. At this point it was clear this was a significant overdose, and the resident's dosage was increased to 1.0 mg, each time Narcan was administered with better improvement in resident condition. At this point EMS was able to take a moment to review resident's medications and it was noted that the resident was administered Fentanyl via medication patches. Resident was checked once on scene for medication patches, but none was obvious. Resident was wearing a long sleeve sweater blocking EMSs view of her upper arm. Resident's shirt was cut away. Two Fentanyl patches were noted. One patch was on each shoulder. One looked freshly placed. The other looked very worn and dirty. No other patches were found. Both patches were removed by EMS. The resident received 1.0 mg of Narcan at 6:12 p.m., 6:14 p.m. and 6:16 p.m. Hospital Emergency Records dated 02/10/2023 at 10:46 p.m., showed transient hypotension, medication overdose. Per EMS resident was initially hypotensive on scene with blood pressure in the 90s. The resident was known to have accidental overdose with Fentanyl patches so was given 4 mg of Narcan IV(Intravenous) by EMS along with 400 cc (cubic centimeter) of normal saline. Resident presented with no Fentanyl patches on. The resident was not alert and oriented with no new complaints. The resident was given another 2 mg of Narcan while in the Emergency Department upon arrival as initial blood pressure was 80 systolic. This improved the mental status even further and brought the blood pressure up to the mid-90s systolic. Based on the hospital records Resident #3 was an [AGE] year-old female, nursing home resident with a history of paraplegia and advanced dementia, hypertension, bedbound. Presented to the ER today from nursing home with decreased responsiveness, apparently upon EMS arrival they found the patient to have 2 Fentanyl patches on bilateral upper extremities. Unfortunately, she is not able to provide meaningful information. Symptoms improved after the patient was given Narcan. Progress Note from hospital physician showed on 02/12/23 that the Fentanyl overdose was improving. Record review of the physician orders revealed the following: Fentanyl patch every 72 hours 12 mcg (microgram)/hour, apply 1 patch transdermal one time a day every 3 days related to pain and remove per schedule as of 04/26/22; Oxycodone-Acetaminophen 5-325 mg every 6 hours as need for pain as of 12/22/2022. Review of the February Medication Administration Record (MAR) showed on 02/10/23 Staff A, Licensed Practical Nurse (LPN) removed the Fentanyl patch at 8:59 a.m. and replaced the patch at 9:00 a.m. based on documentation. During an interview on 05/15/23 at 3:30 p.m. Staff A, LPN stated he had worked at the facility for about 3 months. He stated his process regarding Fentanyl patches was to look over the body to find the prior (patch) and remove it. He would replace it with a new one. Another nurse would witness the removal and place in the waste. The other nurse would sign the paper (2-nurse signature form). The paper to be signed was in the narcotic book. He stated in the interview, he took off her patch and replaced it with another on 02/10. During an interview on 05/16/23 at 9:11 a.m. with the Director of Nursing (DON), the Nursing Home Administrator (NHA) and the (Assistant Director of Nursing) ADON stated that Resident #3, had altered mental status which had typically been a Urinary Tract Infection (UTI). On 02/10/2023 the family wanted her sent out after he was called. The NHA stated, We expected her to come back with a UTI. The hospital reported to us that she had two Fentanyl patches on her bilateral upper extremities. The family called Staff C, LPN Unit Manager (UM) and told her that the resident had two patches on. We put education into place. We did not want it to happen again. We instituted the two-nurse sign off when the patch was removed and destroyed. The DON reviewed Resident #3's February MAR, for the staff member who applied the patch on the day in question. The Consultant Nurse, RN entered at 9:28 a.m. Staff A, LPN was the staff member to apply for the patch. The DON did not individually speak with Staff A, LPN about the incident. The DON stated, he was in on the education when it was performed, Staff I, RN, Risk Manager and staff Development (SD) would have talked to him. The DON stated, they did no reporting. A Medication error form or investigation was not performed. The DON did not speak with the nurse. Staff I, RN, RM, SD educated the nurses individually and would have told him he made the mistake. They stated that an Internal investigation was performed but was not reported. Record review of the face sheet showed Resident #3 was admitted on [DATE] and readmitted on [DATE] and discharged on 2/10/23. Review of her face sheet revealed the following diagnoses included but were not limited to mild protein-calorie malnutrition, quadriplegia Cervical-5 to Cervical-7 (bones in the neck region), muscle weakness, depression, anxiety, pain, stage 4 sacral pressure ulcer, fusion of spine, hypertension, cervicalgia, neuromuscular dysfunction of bladder, dementia, anemia, thoracic disc disorder, muscle spasm, and cognitive communication. Review of the 5-day, Minimum Data Set (MDS) dated [DATE], Section C, showed a Brief Mental Status (BIMS) score of 15 (cognitively intact). Review of section G showed the resident was totally dependent on two for bed mobility, transfers, and toileting. She required extensive assistance for eating. Review section N showed the medication section showed she was on diuretics and opioids. Record review of the Individual Resident's Controlled Substance Record was compared to the Medication Administration Record for January and February of 2023. The January MAR showed Fentanyl was given on 2, 5, 8, 11, 14, 17, 20, 23, 26, and 29. The February MAR showed Fentanyl was given on 1, 4, 7, and 10. The only Individual Resident's Controlled Substance Records provided for January 2, 5, 11, 14, 17, 20, and 23. There was no corresponding Controlled Substance Record for January 8, 26, and 20. The only Controlled Substance Record for February was for February 2 which was not a date on the MAR as given. The missing ones were for 02/01/23, 02/04/23, 02/07/23, and 02/10/23. During an interview on 05/16/23 at 12:23 p.m. DON stated she could not find any more Controlled Substance Records. Record review of the care plans showed Resident #3 was at risk for alteration related to pain/discomfort related to occipital condyle/maxillary fracture, intervertebral disc disease, compromised cardiac status, urinary catheter, and glaucoma. Interventions included but not limited to administering analgesia as per orders. Monitor for effectiveness/adverse effects initiated as of 05/16/2022. Review of the Situation, Background, Assessment, Recommendation (SBAR) dated 02/10/23 showed a change in condition of unresponsiveness. The resident appears to be in a stupor state. Suggest transferring to hospital. Family called on 02/12/23 at 6:05 p.m. The physician called on 02/10/23 at 5:50 p.m. During an interview on 05/18/23 at 12:45 p.m. with Staff D, RN, stated she worked the 3-11 shift. She was doing her 5 p.m. medication pass and Resident #3 does gets 5 p.m. medications. She gave the meds to her in the dining room. Staff D stated, We talked; she was alert. Passing meds was usually between 4-5:30 p.m. The patches are usually given 7-3 shift not hers. Resident #3 was sitting in the dining room with other residents in her day chair. The CNAs were doing vital signs. She could see her from the nursing station. She finished passing meds. The lady that was visiting her in the dining room stated she was unresponsive. We did vital signs and took the resident to her room. She texted the doctor that it was a priority. She called the son, and he wanted her to go to the hospital. She had to get an order to send her out. She called the doctor and got an order to send her via EMS. The visitor and the aide were in her room. She stated she was going in and out to the phone and things. She checked the residents blood sugar. The visitor called the family member also. The texts go to the doctor, the DON, the UMs and the ADON. She was not sure if they were still in the building at the time of the text. They responded to the texts. It was just her handling the situation. No other nursing staff. She did not see the patches on the resident because the resident was dressed and wore a jacket. EMS came and took her. She did not see EMS looking or finding the patches. During an interview with the attending physician on 05/17/23 at 1:15 p.m. he stated the facility told him about the resident having to go to the hospital due to two Fentanyl patches. He stated they should have documented the patch was applied and where. The next nurse removing needs to look at that site for the patch. If it is not there to look over the resident. They need to verify that the patch was removed and documented. During an interview with the consultant pharmacist on 05/18/23 at 12:25 p.m. revealed that the process for transdermal patches was to review the Electronic Medication Administration Report (EMAR) for orders, pull from the narcotic box and sign the narcotic sheet, go to resident's room, remove the old patch, apply the new patch with a date and initials. They are to dispose of old patch according to facility policy. Sign on the EMAR that it was given. Some facility folds them on themselves and put in trash some use a drug buster on their cart. She had not heard of any medication error for Resident #3. Related to narcotic sheets matching the EMAR for narcotics given, she stated they should match. The narcotic sheets will only go back to the pharmacy if the medication was refused at the time of delivery. She stated she audits the carts for expiration dates and opened dates. They have a nurse consultant do an audit related to EMAR to cart. The consultant visits every 4-6 weeks. The consultant pharmacist reviewed the consultant nurses report she had and in February the consultant nurse did a medication pass audit, she watched the nurses pass medications. She was not there in January. During an interview with the Medical Director on 05/18/23 at 1:58 p.m. stated he was aware of the two Fentanyl patches on Resident #3. The administrative staff and DON told him. He basically told them that especially with opioids to document and be extra careful with meds. During an interview with Staff E, Certified Nursing Assistant (CNA) on 5/18/23 at 3:08 p.m. revealed she gave the resident coffee and juice in her chair. The visitor came and went straight to her room, but the resident was out in the dining room. Staff E said hi to the resident and she was talking to her and drinking her juice. The visitor sat with her in the dining room. The visitor came to the nursing station and said the resident was unresponsive. We took the resident to her room. Vital signs were done, and they called EMS to come get her out. Staff E, stated, We did her sugar and vitals. She stated she was in the room with the resident. Interview with Staff F, CNA on 5/18/23 at 3:30 p.m. stated she came in (the facility) and checked in. She spoke to the resident. Asked her if she wanted a drink. She gave her a couple of sips of cranberry juice. The resident wanted to stay in the dining room that day. Staff F went about her regular routine. It was time for dinner, the cart was in. Resident #3 was her resident. She took her tray over and asked if she was hungry. The resident acted really sleepy; it came up on her quickly. The resident was hardly talking. Staff F tried to feed her, but she would not respond. Staff F thought she was falling asleep. We checked her vitals, and they were weak. She called the nurse over and one called 911 and one was with the resident. They took her to the room, while waiting on EMS to get there. The trays come at about 5:30 p.m. Record review of the facility's Root Cause Analysis which was not dated showed. The Immediate Intervention: Resident never returned to facility. Interview of Staff A, LPN, stated, When I placed the new patch there was no other patch on her. I put the new patch on her right arm. Root Cause Analysis (RCA): 1. Describe event or incident: ON 02/20/2023 at approximately 5:45 p.m. it was reported to me that Resident #3 was unresponsive. She was in the dining room in her chair and had been throughout the shift. I performed a sternal rub in which she slightly grimaced. Her vitals were taken BP 67/43, pulse 60, O2 94% RA temp 97.7, respirations 14. Her family member was with her and called Resident #3 son in which he stated that he wished for her to be sent to the hospital. Attending physician was notified at 5:50 p.m. At 5:52 p.m. orders were received to send her out by EMS. EMS arrived at approximately 6:00 p.m. She was escorted to the hospital by EMS via stretcher at approximately 6:10 p.m. I called the hospital and spoke with her nurse and was able to give a report. 2. After thorough investigation: was blank. #3 Determine Root Cause of Incidents: educated staff on Patch Administration and Removing with second nurse verification. Record review of the Education sign sheet for transdermal patches showed the facility began education related to applying and removing of transdermal patches (Fentanyl, Nitro, Nicotine, Scopolamine, Diclofenac, etc.) on 02/13/23 through 02/17/23. 1. Check order. 2. Prior to administering a new patch, PLEASE REMOVE THE OLD PATCH (if no patch is found in prior placement area, do a brief skin sweep to verify no patch can be removed). A second nurse must verify removal of patch (both nurse signatures in Narc Book and in PCC). Dispose of patch properly in Drug Buster on cart. Both nurses will be held responsible if a resident is found with more than one patch applied. 3. Please DO NOT apply patch to previous placement area. Please review and sign the educational moment stating understanding!! Staff I was the presenter. 20 nurses out of 45 had signed the in-service sheet. The sign in sheets that were provided showed the education was given on 02/13 to 02/17/23. During an interview with Staff I, RN, RM, SD on 05/18/23 at 9:14 a.m. revealed the 2-nurse signature process was educated between 2/13 and 2/17 and was supposed to start then. She provided the only sign in sheet she had which showed 20 nurses names. She stated she had not educated anyone else. She stated the Unit Managers (U.M.s) were responsible for monitoring the 2-nurse sign sheets. She stated she had been here since November 2022 and had given an in-service regarding patch usage. The DON on 05/18/23 at 9:15 a.m. stated she had been for 1 ½ years and to her knowledge they have not had an in-service regarding patch administration. During an interview with Staff C, LPN, UM on 05/18/23 at 10:01 a.m. she stated the 2-nurse signature form was put in place when Resident #3 went to the ER with, what was reported, two patches on. So, we looked into it and started a process, on how the patch was to be put on. Could not sign two nurses on PCC, so we had to put a paper form in place for two signatures. Who is supposed to be monitoring this form? When it is full, I turn it into the DON. As far as a weekly or monthly auditing is concerned, it is not being done by me. When the form is filled, it is handed to me. She stated that she had not monitored. She verified that some dates and signatures were missing from the two residents' forms. We went to the DON, and the DON stated that she did not have any 2 nurse signature sheets for the patches in her office except for another resident. The DON stated that when she receives them, she sends them to medical records. We went to medical records to verify the facility did not have any more 2-nurse sheets and there were none in their paper charts. Requested the [name of encrypted texting app] (the system the facility uses to communicate with the physicians) for 02/10/23 and the DON and the ADON stated the texts only keep for 2 weeks. During an interview on 05/19/2023 at 4:11 p.m. with the NHA and the DON. DON stated NHA conducted education yesterday to admin staff and RNC educated NHA related to reporting. Discussed what to do in case of an elopement, different steps required, including self-report within 24 hours and within 5 days completing the report and determining adverse. If adverse, must submit a 15-day report. Educated admin team, including DON, ADON, UM's, Rehab Director, MDS, (Minimum Data Set) Marketing, Admissions, Payroll, Business Office Manager (BOM), Assistant Business Office Manager (ABOM), and Medical Records. NHA educated them that their responsibility was to ensure the NHA was informed right away, and report was completed timely and assurance that resident remains safe. DON stated she works with NHA to ensure residents are safe. DON and NHA stated they were not aware the resident received Narcan and did not know the resident had the 2 patches until they received the report. Usually, admissions call the next day to check up. NHA stated admissions has a shared platform that nursing homes are able to get information on the residents for when they place them. Admissions brought it to her attention that resident received Narcan. DON stated the nurse was probably getting paperwork ready at the time. NHA and DON stated they do not get EMS report and they were not aware of resident getting Narcan. DON stated typically then resident was transferred and EMS here, nurse exits room to let EMS take over and gives report to the hospital. NHA stated she found out the next day about resident receiving Narcan. Stated at same time, son was not sending the resident back to the facility. NHA stated it did not strike her as something she needed to investigate further but did want to bring it to the assigned nurses attention. Stated resident often acted lethargic, and son wanted resident to be heavily medicated, she saw her like that often. Son demanded staff check on her often. Son always knew if someone was in the resident's room. NHA thought resident demeanor was normally not very alert. When they talked about it, DON educated her about the process being wrong to have 2 patches on the arm and that the other patch had little to no medicinal value and that it probably didn't contribute to the state she was in. NHA stated she was in that state often because she took several narcotics. DON stated they found out on 2/13/23 about the incident and started education to ensure the incident didn't happen again. NHA stated adverse is something out of the ordinary and something caused by the resident's experience in the facility. NHA stated she realizes this should have been an adverse report regardless of their feeling that she did not have true full patches on her, and they did not have the ability to determine if one was stronger than the other. NHA stated resident did not respond when she was getting Narcan the prior time. NHA stated she was not aware of the resident's reaction this time to the Narcan. Just found out the resident's Vital signs this week. DON stated normally Altered Mental Status (AMS) would be result of UTI and was a chronic thing with her and she would present with same symptoms. Record review of the Facility 's policy, Transdermal Drug Delivery System (Patch) Application, dated March 2019 showed propose to administer medication through the skin through proper placement of the patch and care of the application sites (s). Procedures: a. wash hands or use facility-approved sanitizer. B. Identify the location of the body for patch placement. Always rotate application sites to prevent irritation. C. remove old patch from body. Fold in half with adhesive sides together. Discard according to facility policy. (See IE5: MEDICATION DESTRUCTION FOR NON-CONTROLLED MEDICATIONS). G. Label patch with date and nurse's initials. Document placement site on MAR . Record review of the Facility's policy, Medication Disposal/Destruction, revised July 2016 showed the facility adheres to all federal, state, and local regulations regarding drug destruction when discarding any medication and medical waste. Record Review of the Facility's policy, Controlled Substance Disposal, March 2019 showed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. A. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Facility immediate actions to remove the Immediate Jeopardy included: Resident #3 no longer resides in facility as of 02/10/2023. This was verified that Resident #3 was discharged on 02/10/2023, she did not return to facility. There are two current residents identified having a physician's order for a transdermal narcotic patch. Those residents have an order to remove and apply on their medication administration record (MAR). in addition to the MAR, the facility established protocol is that two nurses witness and sign on a form that a transdermal narcotic patch is placed and the previous one removed and properly disposed of. This was verified to be the process by interviewing 13 out of 46 nurses on 05/19/2023. 100% or 46 of licensed nursing staff were educated to follow the protocol of two nurse signatures for witnessing that a transdermal narcotic patch is placed and the previous one removed with proper disposal. The education was completed on 05/18/23 at 9:00 p.m. Review of the in-service sheets showed 100% of the nurses were educated on application and disposal of transdermal drug delivery service by 05/18/23. Interviewed 13 nurses out of 45, who could explain the process for two-nurse signature sheets for narcotic patches. The DON / designee will be present to monitor the process during the removal and disposal of the old patch and the application of the new patch for each resident receiving transdermal pain medication delivery system for the next 30 days. The monitoring will then be done weekly thereafter for 30 days and then at an interval as determined by the QAPI Committee, based on results of prior monitoring. Based on verification of the facility's Immediate Jeopardy removal plan the Immediate Jeopardy was determined to be removed on 05/19/2023 and the non-compliance was reduced to a scope and severity of D.