**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff fully processed and implemented physician's orders for immediate care and ensure provision of necessary care and services and failed to complete a thorough investigation for possible neglect for 2 of 6 residents, reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to process and implement physician's orders for immediate care and to provide necessary care and services contributed to the destabilization of resident #1's acute and chronic medical conditions and placed all residents at risk for neglect and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F635 and F726. 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension, deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and re-admitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure, health care associated pneumonia, heart failure, pressure ulcers, and epilepsy. The Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with an ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a 5000-3008 AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of 35-40%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM, and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the on call APRN by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. In a telephone interview on [DATE] at 8:41 AM, the Weekend Supervisor said protocols for care and monitoring of a resident who was admitted from the hospital after respiratory failure included nurses' assessments of their lungs for abnormal sounds, oxygen saturation status, blood pressure, and heart rate at least every shift and most physicians requested it every 4 hours. She explained nurses needed to complete physical assessments and were to monitor residents for changes in condition so the physician was notified to determine if the treatment plan should be revised, or if a higher level of care was needed. She recalled she completed resident #1's assessments after she was admitted on [DATE]. Review of the admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 12:36 PM, LPN B recalled on [DATE] from 9:55 AM to 10:00 AM, nurses were unable to easily determine resident #1's code status because it was not included in her physician's orders in the medical record. She explained she was not able to locate a Do Not Resuscitate Order (DNRO), and nurses determined without one, the resident was a Full Code. She stated she had not expected difficulty with finding the resident's code status because it was usually located on their profile however resident #1's record did not show one. Review of the Order Summary Report revealed there were no physician's orders for resident #1's code status. The Comprehensive Care Plan did not include a focus for advanced directives nor Code Status. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 11:04 AM, the Nursing Home Administrator (NHA) explained on [DATE], the facility investigated resident #1's death in the facility and determined licensed nurses had not provided care and services. He explained regulatory non-compliance was reviewed with their Quality Assurance Performance Improvement (QAPI) program. He noted the last Ad-Hoc QAPI meeting was held on [DATE] when a nursing concern was addressed. He said the facility determined no willful intent occurred and the incident did not meet criteria for an adverse report of possible neglect. On [DATE] at 11:10 AM, the [NAME] President of Clinical Services said they determined resident #1's incident was, more of a nursing issue with compliance for poor nursing care. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died. He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. Review of the facility's Standards and Guidelines titled, Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) revised on [DATE] revealed Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) 800-160 MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim 800-160 MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, one stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. Review of the [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored and maintained the IV for three days. A Wound Care APRN progress note dated [DATE] documented the resident was assessed and treated for pressure ulcers that were present when he was admitted located on his coccyx, right hip, and two ulcers on his left foot. Review of the [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at noted to the left side of his bed. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the residents Heparin injectable medication. The Shipment Summary dated [DATE] at 5:51 PM indicated the facility received the residents IV Ertapenem medication and administration supplies, four days after the resident returned to the facility from the hospital. Review of the facility's automated dispensary machine showed a history report that noted one dose of oral Bactrim was removed on [DATE] for resident #6. The inventory reports showed the dispensary contained the IV medication Ertapenem, that resident #6 should have received, however it had not been dispensed. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, but the facility had not responded. On [DATE] at 11:45 AM, the DON said the pharmacy usually filled medication orders within hours and delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's MAR and confirmed there were multiple missed doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor and stated she needed to look into the matter further. She explained the facility's automated dispensary was used for pharmacy delays, and it contained most antibiotics including IV Ertapenem, but the facility did not keep the required equipment on hand to infuse the IV antibiotic. Review of a Nursing Progress Note dated [DATE] at 9:06 AM, read, resident #6, (called) 911 himself, stating he must go to the hospital due to the unbearable pain in legs and feet. Rating at 10/10 (10 out of 10), because the Tylenol 2 Tab 650 mg administered was not effective. 911 responded and called for (transportation provider) to transport. Patient went out via (transportation provider) for further evaluation and treatment. Additional Progress Notes showed on the same day at 3:15 PM, the resident had returned from the emergency room, and narcotic pain reliever medication was added to his treatment. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. During a telephone interview on[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician orders for immediate care were fully processed and implemented to ensure provision of necessary care and services for 2 of 6 residents reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to ensure the correct procedure was followed to implement physician orders for immediate care and failure to provide critical life sustaining medications including oxygen, contributed to the destabilization of resident #1's acute and chronic medical conditions and placed all residents at risk for major complications from worsening and unstable health conditions and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600 and F726. 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension (high blood pressure), deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and re-admitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure with a history of mechanical ventilation (breathing machine) dependence, health care associated pneumonia, heart failure, pressure ulcer, and epilepsy. Review of the Minimum Data Set (MDS) Death in facility tracking record with Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a 5000-3008 AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of 35-40%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the On Call Advanced Practice Registered Nurse (APRN) by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. Review of the admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 11:04 AM, the Nursing Home Administrator (NHA) explained on [DATE], the facility investigated resident #1's death in the facility. He acknowledged the resident did not receive care and services including critical medications by the nurses. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died. He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) 800-160 MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim 800-160 MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, one stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. Review of the [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored and maintained the IV for three days. A Wound Care APRN progress note dated [DATE] documented the resident was assessed and treated for pressure ulcers that were present when he was admitted located on his coccyx, right hip, and two ulcers on his left foot. Review of the [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at noted to the left side of his bed. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the residents Heparin injectable medication. The Shipment Summary dated [DATE] at 5:51 PM indicated the facility received the residents IV Ertapenem medication and administration supplies, four days after the resident returned to the facility from the hospital. Review of the facility's automated dispensary machine showed a history report that noted one dose of oral Bactrim was removed on [DATE] for resident #6. The inventory reports showed the dispensary contained the IV medication Ertapenem, that resident #6 should have received, however it had not been dispensed. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, but the facility had not responded. On [DATE] at 11:45 AM, the DON said the pharmacy usually filled medication orders within hours and delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's MAR and confirmed there were multiple missed doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor and stated she needed to look into the matter further. She explained the facility's automated dispensary was used for pharmacy delays, and it contained most antibiotics including IV Ertapenem, but the facility did not keep the required equipment on hand to infuse the IV antibiotic. Review of a Nursing Progress Note dated [DATE] at 9:06 AM, read, resident #6, (called) 911 himself, stating he must go to the hospital due to the unbearable pain in legs and feet. Rating at 10/10 (10 out of 10), because the Tylenol 2 Tab 650 mg administered was not effective. 911 responded and called for (transportation provider) to transport. Patient went out via (transportation provider) for further evaluation and treatment. Additional Progress Notes showed on the same day at 3:15 PM, the resident had returned from the emergency room, and narcotic pain reliever medication was added to his treatment. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. During a telephone interview on [DATE] at 12:45 PM, the Medical Director conveyed he was unaware and even more concerned that additionally, resident #6 missed multiple medications including four days of IV antibiotic infusions. He explained that antibiotics were especially important for continuance due to the risk for developing sepsis. He stated there were processes in place for checks and balances and omissions of admission orders and did not explain why they were not followed. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following: *On [DATE], the facility reviewed all current residents' records to ensure no other residents were affected. *On [DATE], the facility began daily reviews of admissions and readmission orders and had not found additional unconfirmed orders that placed any additional residents at further risk for neglect. *On [DATE], the facility educated 100% of their facility staff for identification of neglect, and the [NAME] President of Operations provided re-education to the Nursing Home Administrator/Risk Manager on identification of instances or situations of potential neglect. *On [DATE], the facility filed an Immediate Federal report related to the allegation of neglect for resident #1 and initiated a full investigation. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From [DATE] to [DATE], interviews were conducted with 20 staff members who represented all shifts. All staff, including 3 Personal Care Attendants (PCAs), 6 CNAs, 8 LPNs, 2 RNs, and a Physical Therapist verbalized understanding of the education provided. The resident sample was expanded to include 4 additional residents admitted on [DATE], and 1 additional resident who died at the facility. Observations, interviews, and record review revealed no concerns related to Neglect for residents #2, #3, #4, and #5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and competent with skill sets to fully process physician orders for immediate care of a post hospitalized resident with high risk health conditions for 2 of 6 vulnerable residents of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to ensure nurses were competent to follow procedures, implement physician's orders for immediate care, adequately monitor, and ensure the resident received critical life sustaining medications including continuous oxygen contributed to the destabilization of resident #1's acute and chronic health conditions and placed all residents at risk for major complications from worsening and unstable high risk medical conditions and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross reference F600 and F635. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension, deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and re-admitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure, health care associated pneumonia, heart failure, pressure ulcers, and epilepsy. Review of the Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a 5000-3008 AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of 35-40%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM, and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the on call APRN by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. In a telephone interview on [DATE] at 8:41 AM, the Weekend Supervisor said protocols for care and monitoring of a resident who was admitted from the hospital after respiratory failure included nurses' assessments of their lungs for abnormal sounds, oxygen saturation status, blood pressure, and heart rate at least every shift and most physicians requested it every 4 hours. She explained nurses needed to complete physical assessments and were to monitor residents for changes in condition so the physician was notified to determine if the treatment plan should be revised, or if a higher level of care was needed. She recalled she completed resident #1's assessments after she was admitted on [DATE]. Review of the admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a marked response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of the Assessments showed there was one Respiratory assessment completed by nurses with an effective date of [DATE] at 9:19 PM, that was done when the resident returned to the facility from the hospital. The medical record did not include additional nurse assessments to monitor vital signs or the resident's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 3:02 PM, the DON conveyed licensed nurses were expected to possess skills and competencies within their scope of practice to safely care for vulnerable residents. She explained licensed nurses were required to recognize the importance of monitoring high risk health conditions, the need to implement actions to ensure physician's orders for immediate care were carried out, and to be qualified with adequate clinical judgement skills to contact physicians for concerns, condition changes, clarifications, and orders. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died. He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. Review of the Facility Assessment updated [DATE] revealed the facility provided assessment and management of medical conditions with licensed nurses with competencies that included verification of physician's orders, new admission chart/review, oxygen physician's orders, availability of medications and medication administration including IV infusions, medication administration schedule, admission process, 24 hour chart check, medical error prevention, change in condition, and resident assessment and examinations. The document read, 3.7.1 We employ a team oriented approach when working with health care professionals. Our goal is to provide the best care for patients, so communication is essential. We ensure that we are meeting regulatory requirements while implementing any patient specific protocol that the healthcare professional requires to treat the patient. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) 800-160 MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at the left side of his bed. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim 800-160 MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, once stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 3:12 PM, in a telephone interview, LPN H said she had worked at the facility for about 2 months. She recalled she worked on [DATE] and had resident #6 on her assignment. She explained the resident's IV antibiotic medication had not arrived from the pharmacy and she didn't have access to the facility's medication dispensing system. She stated she thought LPN B had accessed the IV antibiotic from the dispensing system and had administered the IV to the resident. The [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored the IV for three days. On [DATE] at 11:45 AM, the DON said the pharmacy usually fulfilled medication orders within hours and they delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the resident's Heparin injectable medication. The Shipment Summary indicated the facility received the residents IV Ertapenem medication and administration supplies on [DATE] at 5:51 PM, four days after the resident returned from the hospital. On [DATE] at 3:45 PM, LPN B said she had access to the facility's medication dispensing system and recalled she had removed one dose of oral Bactrim for resident #6. She asserted she had never removed an IV antibiotic medication for the resident. During a joint observation on [DATE] at 3:49 PM, LPN B accessed the facility's dispensary and retrieved resident #6's complete history report. The report showed one dose of oral Bactrim was removed on [DATE]. The inventory report showed the machine contained the IV medication Ertapenem, however it had never been dispensed for the resident. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, and the facility had not responded. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's [DATE] MAR and confirmed there were several missing doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. On [DATE] at 4:30 PM, the NHA, DON, Facility Regional Nurse Consultant, Regional Nurse Consultant, and [NAME] President of Operations were informed the investigation revealed there was conflicting information provided from interviews with licensed nurses, and review of their pharmacy delivery and dispensing records. Review of the Wound Care Advanced Practice Registered Nurse's progress notes dated [DATE] noted the resident was assessed and treated for pressure ulcers on his coccyx, right hip, and two ulcers on his left foot. The [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. On [DATE] [TRUNCATED]