**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report a significant medication error for one of three sampled residents (R1), with actual harm occurred on 9/14/2024 when R1 was administered the wrong medications and was admitted to the Intensive Care Unit for higher level of care and monitoring. In addition, the facility failed to report allegations of sexual abuse to the State Survey Agency within the required time frame for two of three residents (R) (R7 and R8) when R8 was found in R7's room receiving oral gratification. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. The noncompliance related to the IJ was identified to have existed on 9/14/2024 when the facility failed to report an incident of significant medication error for R1, when Registered Nurse AA administered the wrong medications, which included allopurinol 100 milligram (mg), amlodipine 10 mg, Eliquis 2.5 mg, ferrous sulfate 325 mg, Lasix 40 mg, losartan 50 mg, metoprolol 100 mg, oxcarbazepine 300 mg (two tablets), potassium chloride extended release (ER) 10 milliequivalents (mEq), valsartan 80 mg, and vitamin D3 25 micrograms (mcg). R1 had a change in condition (bradycardia and hypotension) and was sent to the emergency room for evaluation and admitted to Intensive Care Unit (ICU) for higher level of care with diagnosis of poisoning by beta-adrenergic receptor antagonist - accidental (unintentional). The resident received intravenous (IV) fluids for hypotension, IV glucagon, IV Levophed, and IV Calcium. An Acceptable Removal Plan was received on 10/8/2024. The removal plan included in-service training for nursing staff on medication administration, including competency checks for licensed staff, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/5/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding reporting of incidents related to medication administration. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 1/11/2024, indicated Policy Statement: It is the policy of the facility and its affiliated entities (collectively, the Organization) to comply with all applicable federal and state requirements regarding the reporting of patient abuse. Procedure No 2: In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. 1. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnosis of cerebral infarction, aortic valve stenosis, hypertension (HTN) and hypercholesteremia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. Section D revealed the mood none. Section E revealed no behaviors exhibited during the assessment period. The resident required partial/moderate assistance with bathing, dressing and transfers, supervision with toileting and was independent for eating and oral hygiene. Review of the care plan dated 8/30/2024 revealed that R1 was at risk for decreased cardiac output related to hypertension (HTN). Approaches to care include medications as ordered, monitor for chest pain, observe for syncope, dizziness, palpitations, or feeling of weakness associated with an irregular heart rhythm. Resident will not receive nitroglycerin in any form due to severe aortic stenosis. Nitroglycerin is listed as an allergy due to strict contraindication. Review of Progress Note dated 9/14/2024 and written by Registered Nurse (RN) AA, revealed patient was set to be discharged home with her son and daughter-in-law when she announced she had been given the wrong meds and she was not feeling well. She stated that she had been given approximately 14 pills including two large blue pills that she does not normally take. I only gave her four or five pills and none of them were blue. The son and daughter-in-law were at bedside and were aware of the situation. The patient was sent to the emergency room (ER), and after evaluation, was placed in the Intensive Care Unit (ICU). Review of the Grievance/Complaint Form dated 9/14/2024 completed by Licensed Practical Nurse/Unit Manager (LPN/UM) BB, revealed the resident stated, that nurse gave me the wrong medicine. Further review of the grievance revealed the resident had given a Dietary Aide a medicine cup that had '206' written on it, and the resident resides in room [ROOM NUMBER]. The resident complained of dizziness and nausea. The resident was sent to the hospital for possible consumption of the wrong medications. Interview on 9/24/2024 at 11:25 am, LPN/UM BB stated she was working on the 400 Hall on Saturday 9/14/2024, when a dietary staff member told her that a resident on the 200 Hall was upset and wanting to speak to a person in charge. She stated that when she went to R1's room, she was very upset and nervous and informed her that she had been given the wrong pills earlier that morning. She stated R1stated there were about 12 pills in the cup, and she only takes three. She stated she started looking at the residents on the hall close to R1's room, and discovered that R1 could possibly have been given another resident medications, who was room [ROOM NUMBER], next door to R1's room (room [ROOM NUMBER]). Interview on 9/24/2024 at 12:20 pm, with the family member of R1, stated when he arrived at the facility on 9/14/2024, to take his mother home, she informed him she had been given the wrong medications earlier that day, that she had given 12 pills that weren't prescribed to her. R1's son stated that his mom told him she questioned the nurse about the pills, but the nurse told her they were her pills, and that she needed to take them. During further interview, he said that he spoke to the nurse on the hall, and she stated that she didn't give those pills to his mother, so he asked to speak to the 'head' nurse. He stated the head nurse came to his mother's room and he informed her of what his mother had said happened. The nurse returned to R1's room and told him his mother could have possibly been given the resident's meds in room [ROOM NUMBER] (R1 was in 208). He stated he wanted his mother to be sent to the emergency room to be checked out because she was complaining of nausea and her stomach was hurting. He stated that she was admitted to the hospital in ICU for four days, but was at home now with home health. He stated that she is still very weak. Phone interview on 9/24/2024 at 2:43 pm, RN AA confirmed that she was the nurse on duty on 9/14/2024. She stated that she remembers the resident alleged that she had received the wrong medications. She stated that there were four or five medications listed on R1's Medication Administration Record (MAR) and that she pulled the medications that were listed. During further interview, she stated that the resident did not question her about the medications that were in the cup. 2. Review of the EMR for R7 revealed she was admitted to the facility on [DATE] with diagnosis of dementia with mood disturbances. Review of R7's significant change MDS dated [DATE] revealed a BIMS was assessed as 4, which indicated severe cognitive impairment. Section D revealed the mood none. Section E revealed no behaviors exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 7/17/2024 revealed that R7 was admitted to the behavior management program due to sexually inappropriate behaviors with a male resident. The approach implemented included activities staff to visit resident and provide diversional activities and administer behavior medications as ordered by the physician. Review of the Witness Statement Form dated 7/6/2024 revealed Certified Nursing Assistant (CNA) FF documented on 7/6/2024 at 6:45 pm she entered R7's room and observed R8 with his pants down and underwear around his ankles. The resident (R7) head was up against R8's hip area. The CNA documented that she could only see R7's forehead and did not see anything in R7's mouth. The CNA documented immediately that the nurse was notified. Interview on 10/2/2024 at 11:07 am, LPN MM stated she was not working on the day the incident happened between R7 and R8. She stated the incident happened on third shift and she was told about the incident when she came to work. During further interview, she stated the off going nurse told her R8 went into R7's room. She stated she spoke with the daughter of R7 who was very upset and requested that R7 be moved off the unit. She stated the resident has a diagnosis of dementia and is confused. Interview on 10/9/2024 at 12:40 pm, the Interim DHS and Senior Nurse Consultant confirmed that the physician and/or Nurse Practitioner (NP) were not notified of R7's behavior and there was no skin assessment completed on the day of the incident. 3. Review of the EMR for R8 revealed he was admitted to the facility on [DATE] with diagnosis of depression and heart failure. Review of R8's discharge MDS dated [DATE] revealed a BIMS was assessed as 13, which indicated cognitively intact. Section D revealed the mood none. Section E revealed no behaviors exhibited. Review of the care plan initiated 7/17/2024 revealed that R8 admitted to the behavior management program due to sexually inappropriate behaviors with a female resident. The approach implemented included activities staff to visit resident and provide diversional activities and administer behavior medications as ordered. Review of the Witness Statement Form dated 7/6/2024 revealed the Registered Nurse (RN) EE documented around 6:45 pm, CNA FF approached and asked the RN to go to R7's room. The RN documented upon entering the room it appeared that R8 was receiving oral gratification from R7. The residents were separated, and management was notified. Review of the Facility Incident Report Form submitted to the SSA on 7/17/2024 revealed: date and time of incident: 7/6/2024 documented R7 was observed performing a sexual act on R8. Interview on 10/7/2024 at 12:37 pm, Social Worker (SW) XX stated the Social Service Department is responsible for social/psychosocial assessments and the behavioral management program. The behavioral management program with the list of residents that are at risk for behavior (wandering, yelling, inappropriate behavior with other residents sexual and conversation) is kept by the Social Service Department. She stated residents are placed on the behavior management program or seen by psych services if admitted with psych diagnosis or taking antipsychotic meds. She revealed there are currently 10-12 residents on the behavioral management program. SW XX stated R7 was followed by the behavior management program, and stated the family refused psych services for her. Phone interview on 10/8/2024 at 4:24 pm, Medical Director stated the Administrator notified him of the allegation of sexual abuse between R7 and R8. He stated I do not remember off the top of my head the exact date or time but was sure he was notified. He stated he would expect that a progress note should have been written indicating that the residents were seen by a provider following any type of incident. A post exit phone interview on 10/18/2024 at 3:00 pm with the Senior Nurse Consultant stated she was not aware that the incident between R7 and R8 happened on 7/6/2024 and was not reported until 7/16/2024. She stated facility reportable incident should be reported on the day of the incident. The Senior Nurse Consultant did state at the time of the incident, the facility had a different Administrator. Cross Refer to F760 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 10/2/2024, the facility Administrator reported the incident of significant medication error to the state agency. 2. On 10/2/2024, the facility Administrator and Director of Health Services was provided education by the Regional Senior Nurse Consultant via telephone regarding the reporting requirements using the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property outlining what to report, how to report and reporting allegations within 2 hours if the incident could result in serious bodily, injury. 3. On 10/4/24, the facility Administrator and Director of Health Services provided education to 184 out of 185 staff to total 99.45% of facility staff regarding abuse reporting including the who is abuse coordinator, what constitutes as abuse and the requirements for reporting abuse. The one remaining staff needing education is currently on leave and will be provided education upon return. 96 staff were provided education in person, and 88 staff were provided education via telephone by the Director of Health Services and Administration. The facility currently employs nine RNs, 29 LPNs, 61 CNAs, two Social Services, 21 Dietary, two Maintenance, 23 Housekeeping, 24 Rehab, and 13 Administrative. 4. The Administrator reviewed all grievances on 10/3/2024 that occurred in the last three months to review for any potential missed state reportable incidents. 28 out of 28 grievances reviewed did not require reporting to the state agency. 5. The facility Administrator held an Ad Hoc Quality Assurance Process Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) on 10/2/2024 to discuss the alleged incident and reporting of significant incidents to the state agency. The Administrator, DHS, Unit Manager, Treatment Nurses, Social Service Assistant, Maintenance, Housekeeping Supervisor, Human Resource and the Financial Counselor attended the Ad Hoc meeting. The Policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property was reviewed, and no changes or revisions were made to the policy. The Medical Director was in attendance via telephone. A root cause analysis was completed regarding abuse reporting and identified lack of understanding related to reporting of significant incidents. 6. The Medical Director, Administrator, DHS, Senior Nurse Consultant, were all involved in developing the removal plan, reviewed it, and agreed with the contents. The facility will be in compliance effective 10/5/2024. 7. The Administrator and DHS will monitor the implementation of the removal plan. The Administrator and DHS will utilize the Performance Improvement Plan (PIP) that is updated with the current interventions listed above. The Performance Improvement Plan (PIP) was started on 10/2/2024 and includes interviews with residents with BIMs above 9/15 and education with staff on the requirements of reporting. 8. The Facility's corrective actions were completed on 10/4/24 and the facility alleges immediacy of IJ removal on 10/5/24. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the Facility Incident Report Form dated 10/2/2024 (202445846) revealed the facility reported the incident of alleged significant medication error which occurred on 9/14/2024 to the State Survey Agency (SSA) with steps taken to educate nursing staff and the resident was transferred to the emergency department on 9/14/2024. 2. Review of the In-service Education Program Attendance Record Form dated 10/2/2024 revealed that the Administrator and the DHS were educated on reporting a significant medication error to the SA by the Regional Nurse Consultant. 3. Review of the Inservice Education Program Summary Record Form dated 10/4/2024 revealed the following topic was provided as education to all staff Reporting Resident Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property either in-person or via telephone with a total of 160 staff members and 24 rehab staff in-serviced via phone or in person. Interview on 10/9/2024 at 9:50 am, LPN RR stated she was educated about abuse and what, when and who to report to if you suspect abuse. Interview on 10/9/2024 at 9:55 am, LPN CC stated they had in-service training and they talked about abuse - what and when and who to report to. Interview on 10/9/2024 at 10:25 am, LPN DD stated that she is the Nurse Navigator for the facility and is aware of why surveyors are in the facility. She stated they discussed the abuse policy - that the Administrator is the Abuse Coordinator, and she is who they report suspected abuse to as soon as it is suspected. Interview on 10/9/2024 at 10:45 am, RN QQ, stated that he was educated on different types of abuse, who the Abuse Coordinator is and what and when to report. Interview on 10/9/2024 at 11:11 am, LPN LL stated she has worked at the facility for six years and she is aware of the reason the surveyors are here at the facility is due to a medication error and also sexual abuse allegations. She stated the staff talked about abuse, move the client out of the way of potential abuse and report it immediately. Interview on 10/9/2024 at 11:50 am, LPN/UM KK stated that she is the Unit Manager on the second floor which includes halls 500 - 800. She stated that she has been recently educated on the Abuse Policy but states she can't remember the exact date. 4. Review of the attestation signed and dated by the Administrator on 10/3/2024 revealed that all grievances (28) for the last 3 months were reviewed to ensure that there were no state reportables with no concerns identified. 5. Review of the Quality Assessment and Assurance/QAPI Committee Meeting Attendance Sheet dated 10/2/2024 revealed signatures from the following indicating attendance: The Administrator, the DHS, the Medical Director (via phone), Infection Preventionist (IP), Admissions, Business Office Manager, Clinical Competency Coordinator, Dietary Services, Environmental Services, Human Resources, Maintenance, Medical Records Clerk, Senior Care Partner, Wound/Treatment Nurse, Unit Managers. The following was discussed that all staff are to follow care plans and report abuse as soon as it occurs. The Administrator's cell phone is posted and must be called immediately regarding any allegation of abuse. The policies for Care Plan Implementation and Abuse Reporting were reviewed with no revisions necessary. Interview on 10/9/2024 at 10:43 am, OT/Therapy Outcome Coordinator (TOC 2013) stated if the therapist did not attend the in-service on abuse in person they were in-serviced via phone. She stated the therapy department was not in-serviced on the care plan policy or the administration of medication policy. She stated the therapist were in-serviced on the abuse policy only. The TOC reviewed the Therapy Employee Roster and verified the employees that had not signed the in-service sheet were educated via phone and a copy of the abuse policy was texted to the therapists. Interview on 10/8/2024 at 12:57 pm, with Certified Nursing Assistant (CNA) VV stated she has been educated on abuse. She stated she was educated to always make sure the resident is safe, report the incident immediately to the Abuse Coordinator (Administrator). She stated there are many types of abuse, one being misappropriation of funds. Interview on 10/9/2024 at 10:38 am, Environmental Services (EVS) WW stated the EVS manager did in-service the department that the surveyors were in the facility and be on your best behavior. He stated the facility did an in-service on abuse. He stated several types of abuse, including verbal and physical. He stated all abuse should be reported right away to the Administrator. 6. Review of the facility document dated 10/5/2024 revealed that the removal plan has been developed, reviewed by the Medical Director, Administrator, DHS, and Senior Nurse Consultant and we agree with the contents with signatures from all four listed above. 7. Review of the Performance Improvement Plan (PIP) for Medication Administration revealed that the target end date will be 10/16/2024 with interventions in progress. Problem category - medication administration; root cause summary - nurses are provided competency upon hire and annually. The nurse failed to follow the medication administration policy. Overall goal - residents will receive prescribed medications as ordered. Project Conclusions - in progress. 8. The Facility's corrective actions were completed on 10/4/24 and the facility alleges immediacy of IJ removal on 10/5/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Care Plans, the facility failed to follow the comprehensive person-centered care plan related to potential for decreased cardiac and aortic stenosis for one of 12 sampled residents (R) (R1). Actual harm occurred on 9/14/2024 when R1 was allegedly administered the wrong medications and was admitted to the Intensive Care Unit for higher level of care and monitoring. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. The noncompliance related to the IJ was identified to have existed on 9/14/2024 when the facility failed to report an incident of significant medication error for R1, when Registered Nurse AA administered the wrong medications, which included Allopurinol 100 milligram (mg), Amlodipine 10 mg, Eliquis 2.5 mg, Ferrous Sulfate 325 mg, Lasix 40 mg, Losartan 50 mg, Metoprolol 100 mg, Oxcarbazepine 300 mg (two tablets), Potassium Chloride ER 10 milliequivalents (meq), Valsartan 80 mg, and vitamin D3 25 micrograms (mcg). R1 had a change in condition (bradycardia and hypotension) and was sent to the emergency room for evaluation and admitted to ICU for higher level of care with diagnosis of poisoning by beta-adrenergic receptor antagonist - accidental (unintentional). The resident received IV glucagon, IV fluids for hypotension, and IV Calcium. An Acceptable Removal Plan was received on 10/8/2024. The removal plan included in-service training for nursing staff on medication administration, including competency checks for licensed staff, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/5/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding reporting of incidents related to medication administration. Findings include: Review of the policy titled Care Plans revised 7/11/2023, revealed the policy is the health care center for each resident to have a person-centered comprehensive care plan following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) according to the Resident Assessment Instrument (RAI). Person centered care focuses on the resident as the center of control, supporting each resident in making his/her own choices, understanding what the resident is communicating, and identifying what is important to each resident with regard to daily routines and preferred activities. Procedure: Number 3. The comprehensive person-centered care plan is developed to include measurable goals ad timeframes to meet a resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs, Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of other artery, malignant neoplasm of unspecified bronchus or lung, aortic valve stenosis, hypertension (HTN), and hypercholesteremia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. No mood or behavior concerns during the assessment period. The resident required partial/moderate assistance with bathing, dressing and transfers, supervision with toileting and was independent for eating/oral hygiene. Review of the care plan dated 8/30/2024 revealed that R1was at risk for decreased cardiac output related to hypertension (HTN). Approaches to care include medications as ordered, monitor for chest pain, observe for syncope, dizziness, palpitations, or feeling of weakness associated with an irregular heart rhythm. Resident will not receive nitroglycerin in any form due to severe aortic stenosis. Nitroglycerin is listed as an allergy due to strict contraindication. Review of Progress Note dated 9/14/2024 and written by Registered Nurse (RN) AA, revealed patient was set to be discharged home with her son and daughter-in-law when she announced she had been given the wrong meds and she was not feeling well. She stated that she had been given approximately 14 pills including two large blue pills that she does not normally take. I only gave her four or five pills and none of them were blue. The son and daughter-in-law were at bedside and were aware of the situation. The patient was sent to the emergency room (ER), and after evaluation, was placed in the Intensive Care Unit (ICU). Review of the Grievance/Complaint Form dated 9/14/24 completed by Licensed Practical Nurse/Unit Manager (LPN/UM) BB, revealed the resident stated, that nurse gave me the wrong medicine. Further review of the grievance revealed the resident had given a Dietary Aide a medicine cup that had '206' written on it, and the resident resides in room [ROOM NUMBER]. The resident complained of dizziness and nausea. The resident was sent to the hospital for possible consumption of the wrong medications. Interview on 10/9/2024 at 11:43 am Licensed Practical Nurse (LPN) JJ stated that she works in the MDS department and she completes the MDS assessments for the residents and develops the care plans, based on what the assessment reveals. She stated that she updated the care plans for the residents related to the deficiency. Interview on 10/9/2024 at 7:45 pm with LPN II via telephone, stated that the Unit Manager (UM) provided education on updating and following interventions on the resident care plans. Interview on 10/9/2024 at 11:39 am with RN NN stated she works in the MDS department and gathers data for the resident's MDS and implements the care plan. She stated that she participated in updating all of the residents' care plans regarding the care plan tag. She further stated that she does not work on the units as a charge nurse, so she doesn't give medications to the residents. Interview on 10/9/2024 at 10:25 am, LPN DD stated that she re-educated on care plans - following the care plans and updating the care plans when a change occurs for the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Assistant Director of Health Services began education with all licensed nurses beginning on 9/14/2024 on the topic of Medication Administration and the Rights of Medication Administration. At the time of the incident, the facility employed 11 RNs and 30 LPNs. 40 out of 41 nurses were educated by 9/23/2024 to total 97.56% of nursing staff education completed. 11 licensed nurses were provided education in person, and 30 licensed nurses were provided education via telephone by the Assistant Director of Health Services. The remaining one licensed nurse is on leave and will be provided education upon return. The facility does not utilize Medication Aides or Agency staff. 2. The Assistant Director of Nursing began competencies with licensed nurses beginning on 9/14/24, to review the Medication Administration. 40 out of 41 nurses were reviewed for competency by 9/23/2024 to total 97.56% of nursing staff education completed. The remaining one licensed nurse is on leave and will be provided education upon return. 40 out of 40 licensed nurses passed the medication administration competency. 3. The following medication administration observations were performed: Between 9/14/24 and 9/23/24, The Assistant Director of Health Services and Unit Managers completed a total 54 medication administration observations utilizing the tool titled Medication Administration. The observations were completed for one resident on each of the 6 medication carts each day to include both day shift and night shift between 9/14/24 and 9/23/24. The observations were focused to ensure medications were administered as ordered and that no medication error occurred, the observation was completed with 54 out of 54 observations with no findings. 4. On 10/4/2024, the Director of Health Services provided education to 100 out of 101 clinical staff including licensed nurses, certified nursing assistants, and social services to total 99.03%, on the topic of care plan implementation, reviewing interventions and the importance of following the residents plan of care. The facility currently employs 9 RNs, 29 LPNs, 61 CNAs, and 2 Social Services. 48 clinical staff were provided education in person, and 52 clinical staff were provided education via telephone by the Director of Nursing. The 1 remaining staff needing education is currently on leave and will be provided education upon return. 5. On 9/14/2024, the Medical Director was notified of the alleged medication error by the Administrator with no additional directive regarding the incident other than ensuring the resident was transferred to the hospital. 6. RN AA was provided with a written disciplinary action on 9/14/2024 by the Assistant Director of Nursing and the Administrator and re-educated regarding medication administration. RN AA was also observed with a medication administration competency by the Assistant Director of Nursing on 9/14/2024. RN AA was suspended pending investigation on 10/2/2024 and subsequently terminated of employment on 10/3/2204. 7. The facility Administrator held an Ad Hoc QAPI meeting with the Interdisciplinary Team (IDT) on 10/2/2024 to discuss the importance of following the interventions on the resident's care plan and the requirements for reporting abuse and significant incidents. The Administrator, Assistant Director of Nursing (ADHS), Unit Manager, Treatment Nurse, Maintenance, Housekeeping Supervisor, Human Resource and the Financial Counselor. The Care Planning Policy and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Funds was reviewed, and no changes or revisions were made to the policy. The medical director attended via phone. A root cause analysis was completed on 10/2/2024 by the Interdisciplinary Team and determined that the licensed nurse failed to follow the care plan policy. 8. The DHS and the ADHS will provide education to licensed nurses upon hire regarding medication. administration and the rights of medication administration during new hire orientation. Licensed nurses will also receive a competency for medication administration upon hire. 9. The Medical Director, Administrator, DHS, Senior Nurse Consultant, were all involved in developing the removal plan, reviewed it, and agreed with the contents. The facility will be in compliance effective 10/5/2024. 10. The Administrator and DHS will monitor the implementation of the removal plan. The Administrator and DHS will utilize the Performance Improvement Plan that was created on 10/2/24 and includes a 100% audit of care plan implementation, education with clinical staff on care plan revision and implementation, and ongoing audits of care plan implementation. 11. The Facility's corrective actions were completed on 10/4/2024 and the facility alleges immediacy of IJ removal on 10/5/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the Immediate Jeopardy Removal Plan (IJRP) revealed there were two In-service Program Attendance Record Forms dated 9/14/2024. The Program title was Medication Administration. The in-service record was signed or educated by phone: 10 Registered Nurses (RN) and 30 Licensed Practical Nurse (LPN). There were no other documentation under tab number one. An interview on 10/8/2024 at 10:45 am with the Administrator stated the staff were in-serviced on medication administration per the facility's policy and the five rights of medication administration. She stated the Director of Health Services (DHS) also completed a skills competency with all the nursing staff. The Administrator stated that the Assistant Director of Health Services (ADHS) no longer works at the facility. The Administrator was asked to provide the documents that were used in the in-service and proof that the Interim DHS has been in-serviced. Not provided. Refer to tab 6 for a copy of the medication administration policy. 2. Review of the IJRP revealed 41 skills check off on Medication Administration-Tablets, Pills, and Capsules. An interview on 10/8/2024 at 10:45 am, the Administrator stated the staff were in-serviced on medication administration per the facility's policy and the five rights of medication administration. She stated the DHS also completed a skills competency with all the nursing staff. 3. Review of the IJRP revealed a sheet titled Medication Administration Audit with the date, hall (100, 200, 300, 400, 500, and 600/700), medication administered accurately: yes/no, and initials. The Medication Administration Audit sheets were completed on 9/14/2024, 9/15/2024, 9/16/2024, 9/17/2024, 9/18/2024, 9/19/2024, 9/20/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/27/2024, 9/28/2024, 9/29/2024, 9/30/2024, 10/1/2024, 10/3/2024, 10/4/2024, 10/5/2024, and 10/6/2024. The facility answered yes to medication administered accurately. There was no other documentation. An interview on 10/8/2024 at 1:33 pm with LPN/ UM BB for 100, 200, 300, and 400 halls stated that she assisted in the medication audit. She stated on 9/14/2024 she observed six nurses on various halls administer medications. The UM stated she compared the medication from the auto fill to the medication administration record (MAR). She stated she came in on off shifts and observed a total of twenty-seven nurses administer medication. The UM stated she did not identify any issues during the medication observation 4. Review of the IJRP revealed a Inservice Education Program Summary Record Form dated 10/4/2024 Program Title: Care Plans. The Care Plan policy was attached with a revised date of 7/27/2023. Review of the in-service record was signed or educated by phone: RNs-10 out of 10; LPN's 24 out of 29; CNA's 62out of 63; Admin/General five out of eight; Activities two out of two; Dietary 11 out of 22; Housekeeping/Laundry 11 out of 24; Maintenance two out of two; Medical Records one out of one; Social Services two out of two; Therapy Department 17 out of 26. Further review of the IJRP revealed one employee would be in-serviced upon return to work. An interview on 10/9/2024 at 10:43 am, Occupational Therapy (OT) Therapy Outcome Coordinator (TOC 2013) stated if the therapist did not attend the in-service in person they were in-serviced via phone. She stated the therapy department was not in-serviced on the care plan policy or the administration of medication policy. She stated the therapist were in-serviced on the abuse policy only. The TOC reviewed the Therapy Employee Roster and verified the employees that had not signed the in-service sheet were educated via phone and a copy of the abuse policy was texted to the therapist. See the attached for employee interviews. 5. Review of the IJRP revealed on an 8x10 white sheet of paper. Typed, I notified the Medical Director of the Medication Error on 9/14/2024 with no additional directive. Signed by Administrator. A phone interview on 10/8/2024 at 4:24 pm, with the facility's Medical Director, stated he was aware of the incident with R1. He stated it was a medication error where the resident was given medication that was not on R1's medication profile. The Medical Director stated receiving the multiple medications caused R1's blood pressure to go down. He stated the resident was sent to the hospital. He stated he was part of the QAPI meeting on 10/2/2024. He stated the team was educated on reviewing the medications to ensure the medications are correct and administered to the right resident. He stated the education will continue. 6. Review of the IJRP revealed RN AA was in-serviced on medication administration policy on 9/14/2024. The document stated I understand the medication administration policy and understand this is a corrective action. Any violation of the policy, I will be subjected to further discipline including possible termination. The in-service was signed by RN AA and the previous Interim Director of Health Services (DHS). A copy of the Medication Administration policy was attached. In addition, a copy of RN AA's termination dated 10/4/2024. 7. Review of the IJRP revealed a document titled Quality Assessment and Assurance/QAPI Committee Meeting Attendance Sheet dated 10/2/2024 signed by 17 attendees. Administrator, Interim DHS, Medical Director, Infection Control Preventionist, Admissions, Business Office, Case Mix Director, Dietary Services, Environmental Services, Human Resource, Maintenance Director, Medical Records, Senior Care Partner, Treatments, Unit Managers KK, BB, and UU. There was an attached typed note stating All staff are to follow care plans and report abuse as soon as it occurs. Administrator's cell phone number is posted, and she must be called immediately. Policies for care planning and abuse reporting were reviewed with no revisions necessary. The Abuse and care plan policy attached. 8. Review of the IJRP revealed under tab 8 was a copy of the Performance Improvement Project (PIP) Care Planning dated 10/7/2024. The PIP identified the problem category care planning. The root cause summary licensed nursing failed to follow the residents plan of care. The overall goal is to follow each resident's individualized plan of care. The PIP remains in progress. Team members Project Director - Administrator, Project Manager - DHS, Team Member - LPN/UM KK and LPN/UM BB. There was no information under Tab 8 regarding medication. 9. Review of the IJRP revealed a document titled Quality Assessment and Assurance/QAPI Committee Meeting Attendance Sheet dated 10/2/2024 signed by seventeen attendees: Administrator, Interim DHS, Medical Director, Infection Control Preventionist, Admissions, Business Office, Case Mix Director, Dietary Services, Environmental Services, Human Resource, Maintenance Director, Medical Records, Senior Care Partner, Treatments, Unit Managers KK, BB, and UU. There was an attached typed note stating All staff are to follow care plans and report abuse as soon as it occurs. Administrator's cell phone number is posted, and she must be called immediately. Policies for care planning and abuse reporting were reviewed with no revisions necessary. Further review revealed 10/5/2024 The removal plan has been developed, reviewed by the medical Director, Administrator, DHS and Senior Nurse Consultant and we agree with the contents. Written in Medical Director by phone and the signature of the Senior Nurse Consultant, Interim DHS, and the Administrator. 10. There was no documentation in the IJRP book for Tab 10. At the beginning of F-Tag 656 IJRP was a copy of The Daily Census Report dated10/4/2024. At the top of the report handwritten care plan audit. An interview on 10/9/2024 at 1:25 pm, LPN JJ stated one hundred and twenty-seven resident care plans were reviewed. She stated the Interim DHS (prior), and unit managers went to each resident's room with a copy of the care plan. The care plan was reviewed to ensure accuracy. Any identified discrepancies were identified with a red pen. She stated the care plan were returned to the MDS department and updated. The residents care plan were signed off in pink to show that the corrections were made. LPN JJ supplied the surveyor with the 127 resident care plans. Thirty-seven care plans had to be corrected/updated. Three resident CP selected for review R4, R7, R12 for the identified concern that was corrected. 11. The Facility's corrective actions were completed on 10/4/2024 and the facility alleges immediacy of IJ removal on 10/5/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure that one resident (R) (R1) was free from a significant medication error which resulted in actual harm, requiring a transfer to the hospital and admitted to Intensive Care Unit on 9/14/2024. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. The noncompliance related to the IJ was identified to have existed on 9/14/2024 when the facility failed to report an incident of significant medication error for R1, when Registered Nurse AA administered the wrong medications, which included allopurinol 100 milligram (mg), amlodipine 10 mg, Eliquis 2.5 mg, ferrous sulfate 325 mg, Lasix 40 mg, losartan 50 mg, metoprolol 100 mg, oxcarbazepine 300 mg (two tablets), potassium chloride extended release (ER) 10 milliequivalents (mEq), valsartan 80 mg, and vitamin D3 25 micrograms (mcg). R1 had a change in condition (bradycardia and hypotension) and was sent to the emergency room for evaluation and admitted to Intensive Care Unit (ICU) for higher level of care with diagnosis of poisoning by beta-adrenergic receptor antagonist - accidental (unintentional). The resident received intravenous (IV) fluids for hypotension, IV glucagon, IV Levophed, and IV Calcium. An Acceptable Removal Plan was received on 10/8/2024. The removal plan included in-service training for nursing staff on medication administration, including competency checks for licensed staff, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/5/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding reporting of incidents related to medication administration. Findings include: Review of the policy titled Medication Administration: General Guidelines dated 7/22/2024 revealed the policy as medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Procedure Number 2. Medications are administered with written orders of the attending physician. Number 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time. Number 7. Patients/residents are identified before medication is administered. When in doubt: check photograph attached to medical record, call patient/resident by name, if necessary, verify patient/resident identification with other healthcare center personnel. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of other artery, malignant neoplasm of unspecified bronchus or lung, aortic valve stenosis, hypertension (HTN), and hypercholesteremia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. No mood or behavior concerns during the assessment period. The resident required partial/moderate assistance with bathing, dressing and transfers, supervision with toileting and was independent for eating/oral hygiene. Review of the Facility Reported Incident (FRI) revealed the report was undated, completed by the Administrator/Abuse Coordinator, revealed a report for type of incident as other - resident reported medication error. The report indicated the incident occurred on 9/14/2024 at morning med pass. Details revealed resident complained of dizziness and headache and was sent to emergency room and admitted . Review of the Situation, Background, Appearance, Review Communication Form (SBAR) dated 9/14/2024 revealed the resident reports ingestion of wrong meds. Background revealed medical history of cerebral infarction, malignant neoplasm, and aortic stenosis. The rest of the form was incomplete with no vital signs documented or signature noted. On 9/14/2024 a significant medication error occurred during the 9:00 am medication pass when RN AA allegedly administered medications to R1 that were not prescribed for her, including allopurinol (medication used to treat gout) 100 milligram (mg) one tablet at 9:00 am, amlodipine (medication used to treat high blood pressure and/or chest pain) 10 mg one tablet at 9:00 am, Eliquis (medication used to treat and prevent blood clots) 2.5 mg one tablet at 9:00 am, ferrous sulfate (medication used to treat iron deficiency anemia) 325 mg one tablet at 9:00 am, furosemide (medication used to treat fluid retention and swelling due to congestive heart failure) 40 mg one tablet at 9:00 am, losartan (medication used to treat high blood pressure) 50 mg one tablet at 9:00 am, metoprolol tartrate (medication used to high blood pressure and/or chest pain) 100 mg one tablet at 9:00 am, natural fiber laxative (medication used to prevent constipation) one tablet at 9:00 am, oxcarbazepine (medication to treat epileptic seizures) 300 mg two tablets at 9:00 am, potassium chloride extended release (ER) (medication used to treat low levels of potassium in the blood) 10 milliequivalents (mEq) two caps at 9:00 am, valsartan (medication used to treat high blood pressure and heart failure) 80 mg one tablet at 9:00 am, and vitamin D3 (medication used to treat and prevent bone disorders) 25 (micrograms) mcg two tablets at 9:00 am. Review of the Grievance/Complaint Form dated 9/14/2024 completed by Licensed Practical Nurse/Unit Manager (LPN/UM) BB, revealed the resident stated, that nurse gave me the wrong medicine. Further review of the grievance revealed the resident had given a Dietary Aide a medicine cup that had '206' written on it, and the resident resides in room [ROOM NUMBER]. The resident complained of dizziness and nausea. The resident was sent to the hospital for possible consumption of the wrong medications. Review of Progress Note dated 9/14/2024 at 6:18 pm written by Registered Nurse (RN) AA, revealed patient was set to be discharged home with her son and daughter-in-law when she announced she had been given the wrong meds and she was not feeling well. She stated that she had been given approximately 14 pills including two large blue pills that she does not normally take. I only gave her 4 or 5 pills and none of them were blue. The son and daughter-in-law were at bedside and were aware of the situation. The LPN/UM BB and Director of Health Services (DHS) were notified and the patient was sent to the emergency room (ER), and after evaluation, was placed in the Intensive Care Unit (ICU). Review of the September 2024 Physician Orders (PO) revealed no evidence that R1 was prescribed allopurinol, amlodipine, Eliquis, ferrous sulfate, furosemide, losartan, metoprolol tartrate, natural fiber laxative, oxcarbazepine, potassium chloride, valsartan, or vitamin D3, which were allegedly administered to her in error on the morning of 9/14/2024 during the 9:00 am medication pass. Review of the [name of hospital] Emergency Department (ED) provider note dated 9/14/2024 at 11:03 am documented resident presents via emergency medical services (EMS) for evaluation of accidental drug ingestion - patient reports she was given and took about 14 pills this morning at the [name of nursing facility] which were not her prescribed medications. She was admitted to the ICU and managed for shock, hypotension (blood pressure 87/47) and bradycardia (heart rate 53) after accidental ingestion of several medications including calcium channel blockers, beta-blockers, mood stabilizers, and anticoagulation{sic}. Review of faxed paperwork from the facility from today's date (9/14/2024), patient received oxcarbazepine 300 mg, potassium chloride 10 mEq, valsartan 80 mg, allopurinol 100 mg, amlodipine 10 mg, cyanocobalamin 1000 mcg/ml, Eliquis 2.5 mg, ferrous sulfate 325 mg, furosemide 40 mg, metoprolol tartrate 100 mg, and natural fiber laxative. Today's visit represents an acute illness or injury that poses a threat to life or bodily function. She was administered intravenous (IV) fluids, IV calcium, IV glucagon bolus times two doses and subsequently started on a glucagon drip, and Levophed drip. Interview on 9/24/2024 at 11:25 am. with LPN/UM BB stated she was working on the 400 Hall on Saturday 9/14/2024, when a dietary staff member told her that a resident on the 200 Hall was upset and wanting to speak to a person in charge. She stated that she went to R1's room, and she was very upset and nervous, and informed her that she had been given the wrong pills earlier that morning. She stated R1 said there were about 12 pills in the cup, and she only takes three pills in the morning. LPN/UM BB stated she started looking at the residents on the hall close to R1's room, and discovered that R1 could possibly have been given another residents medications, who was in room [ROOM NUMBER], next door to R1's room (room [ROOM NUMBER]). During further interview, she stated that she questioned RN AA if she had given R1 the wrong medication, and she replied, I did not. Interview on 9/24/2024 at 12:20 pm, a family member of R1, stated when he arrived at the facility on 9/14/2024, to take his mother home, she told him she had been given the wrong medications earlier that day, that she had been given 12 pills that weren't prescribed to her. R1's son stated that his mom told him she questioned the nurse about the extra pills, but the nurse told her they were her pills, and that she needed to take them. During further interview, he said that he spoke to R1's nurse, and she stated that she didn't give those pills to his mother, so he asked to speak to the 'head' nurse. He stated the 'head' nurse came to his mother's room and he explained to her what his mother had told him. The nurse returned to R1's room and told him his mother could have possibly been given the resident's meds in room [ROOM NUMBER] (R1 was in 208). He then stated he wanted his mother to be sent to the emergency room to be checked out because she was complaining of nausea and her stomach was hurting. He stated that she was admitted to the hospital in ICU for four days, but was at home now with home health. He stated that she is still very weak. Phone interview on 9/24/2024 at 2:43 pm, RN AA confirmed that she was the nurse on duty on 9/14/2024. She stated that she remembers the resident alleged that she had received the wrong medications that morning. RN AA stated that there were four or five medications listed on R1's Medication Administration Record (MAR) and that she administered only the medications that were listed. During further interview, she stated that the resident did not question her about the medications that were in the cup when she gave them to her. Interview on 10/2/2024 at 10:15 am, the Dietary Manager (DM) stated that on the morning of 9/14/2024 she was on her way back to the kitchen when R1 (who was in the hallway sitting in a wheelchair) stated that she took the wrong medication and wanted to talk to a nurse. The DM stated that she went to the 400 Hall and asked the UM to come check on the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 9/14/2024 the Assistant Director of Health Services (ADHS) interviewed 10 residents who are alert and oriented and residing on R1's floor/assignment. 10 of 10 residents stated that they had no concerns with their medication administration and received their medications as ordered. The other two residents on the hall were observed by the UM on 9/14/2024 with no change in condition observed for two out of two residents who were cognitively impaired. 2. On 9/14/2024 six out of six medication carts were audited by the UM with no evidence of improper medication labeling or storage to include the resident's name, medication, dose and frequency. 3. On 9/14/2024 a Situation, Background, Assessment and Recommendation (SBAR) form was completed for R1 related to the alleged medication error and the on-call Nurse Practitioner (NP) was notified. 4. The ADHS began education with all licensed nurses beginning on 9/14/2024, on the topic of Medication Administration and the five Rights of Medication Administration. At the time of the incident, the facility employed 11 RNs and 30 LPNs, 40 out of 41 nurses were educated by 9/23/2024 to total 97.56% of nursing staff education completed. 11 licensed nurses were provided education in person, and 29 licensed nurses were provided education via telephone by the ADHS. The remaining one licensed nurse is on leave ad will be provided education upon return. The facility does not utilize Medication Aides or Agency staff. 5. The ADHS began competencies with licensed nurses beginning on 9/14/2024, to review medication administration. 40 out of 41 nurses were reviewed for competency by 9/23/2024. The remaining one licensed nurse is on leave and will be provided education upon return. 40 out of 40 licensed nurses passed the medication administration competency. 6. The following medication administration observations were performed: a. Between 9/14/2024 and 9/23/2024, the ADHS and the UM completed a total of 54 medication administration observations utilizing the tool titled Medication Administration. The observations were completed for one resident on each of the 6 medication carts each day to include both day and night shifts. The observations were focused to ensure medications were administered as ordered and that no medication error occurred, the observations were completed with 54 out of 54 observations with no findings. 7. On 9/14/2024 the Medical Director was notified of the alleged medication error by the Administrator with no additional directive regarding the incident, other than ensuring that the resident was transferred to the hospital. 8. The facility Administrator held an Ad Hoc Quality Assurance Process Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) on 9/16/2024 to discuss the alleged incident and the plan to implement cart observations, education on medication administration, and medication administration observations. The Administrator, the ADHS, UM, Treatment Nurse, Social Services Director (SSD), Maintenance, Housekeeping Supervisor, Human Resources and the Financial Counselor were in attendance. The Medication Administration Policy was reviewed, and no changes or revisions were made to the policy. The Medical Director attended via telephone. A root cause analysis was completed during the AD Hoc QAPI meeting on 9/16/2024 by the IDT with the outcome that RN AA was provided competency upon hire by the ADHS on 9/9/2024 with a passing review; however, the nurse failed to follow the medication administration policies for R1 on 9/14/2024. 9. The DHS and the ADHS will provide education to the licensed nurses upon hire regarding medication administration and the rights of medication administration during new hire orientation. Licensed nurses will also receive a competency for medication administration upon hire. All findings will be brought to each QAPI meeting. 10. The Medical Director, Administrator, DHS, Senior Nurse Consultant were all involved in developing the removal plan, reviewed the plan, and agreed with the contents. The facility will be in compliance effective 10/5/2024. 11. The Administrator and DHS will monitor the implementation of the removal plan. The Administrator and DHS will utilize the Performance Improvement Plan that was created on 9/16/2024 and is updated with interventions including medication administration observations to ensure residents are free from medication errors and medication cart audits to ensure proper medication labeling and storage to include the resident's name, medication, dose, and frequency. 12. The facility's corrective actions were completed on 10/4/2024, and the facility alleges immediacy of IJ removal on 10/5/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the form dated 10/14/2024 revealed that 10 residents were interviewed regarding medications they received on the morning med pass of 9/14/2024 and all residents interviewed voiced no concerns and stated they received their medications as usual. Review of the form dated 9/14/2024 revealed that the two residents who were non-interviewable were observed regarding medications they received on the morning med pass of 9/14/2024, both residents are in wheelchairs sitting in hallway near the nurses' station and both residents were acting as per usual with no concerns noted with either resident. Review of the Medication Administration Audit tool dated 9/14/2024 revealed that all medications passed were administered correctly. Interview on 10/8/2024 at 1:33 pm with LPN/UM BB for 100, 200, 300, and 400 halls stated that she assisted in the medication audit. She stated on 9/14/2024 she observed six nurses on various halls administer medications. The UM stated she compared the medication from the auto fill to the medication administration record (MAR). She stated she came in on off shifts and observed a total of twenty-seven nurses administer medication. The UM stated she did not identify any issues during the medication observations. Interview on 10/9/2024 at 10:00 am with R15, stated that he doesn't remember anyone asking him about his medications, but stated that as far as he knows, he gets the correct medications at the right time. He also stated that the nurses will verify who he is before they give him his medication. Interview on 10/9/2024 at 10:05 am, R16 stated he remembers a nurse asking him about his medications and if he was getting what the doctor had ordered for him. He stated that he gets the medicines that he is supposed to have. He further stated that the nurse will ask him his name before giving him his medicines. Interview on 10/9/2024 at 10:15 am, R12 stated that she thinks she gets her medications as the doctor has prescribed. She stated that she would question the nurse if she had thought she was getting the wrong medication. 2. Review of the Medication Cart Audits dated 9/14/2024 revealed that all medication carts for all eight units were audited with no issues noted - medications were labeled with residents' names, medication, dose and frequency. The following halls share a medication cart on 300 and 400 Halls, and 700 and 800 Halls share a medication cart for a total of six medication carts. 3. Review of the Situation, Background, Appearance, Review (SBAR) form dated 9/14/2024 revealed the change in condition, symptoms, or signs observed and evaluated were resident reports ingestion of wrong medications. The remainder of the form is incomplete and is not signed by facility staff. 4. Review of the Inservice Education Program Summary Record Form dated 9/14/2024 titled Medication Administration by the ADHS revealed 'we do not pre-pour medications in a nursing home, we also don't leave meds at the bedside - this helps prevent serious errors and is essential for patient safety' with the policy titled Medication Administration: General Guidelines attached. Review of the Inservice Program Attendance Record Form dated 9/14/2024 revealed 11 signatures from licensed nurses indicating in-person attendance and 29 licensed nurses names listed as receiving education via telephone on 9/14/2024. Interview on 10/8/2024 at 1:30 pm, Regional Nurse Consultant (RNC) revealed that there were 29 licensed nurses who were educated via telephone and 11 nurses were educated in-person. One nurse on leave. Interview on 10/9/2024 at 9:50 am, LPN RR stated she was educated on med administration - verify the resident, check the name of the med, the dose, the frequency, etc. Interview on 10/9/2024 at 10:25 am, LPN DD stated that she is the Nurse Navigator for the facility and is aware of why surveyors are in the facility. She stated that the DHS re-educated her on medication administration, the five rights of the med pass, don't pre-pour meds and leave in the med cart, etc. Interview on 10/9/2024 at 10:45 am, RN QQ stated that he was educated on medication administration, the five rights of med administration, do not pre pour medications, do not label the med cup with the room number. Interview on 10/9/2024 at 11:20 am, LPN PP stated she has worked with the facility for six years on the 600 Hall - spoke about the incident regarding the medication incident where a resident received the wrong medications. She stated she was educated on the medication administration policy and meds that can be crushed or not crushed. Phone interview on 10/9/2024 at 7:45 pm, LPN OO stated she was educated on the medication administration policy where they discussed the five rights of med administration, not to pre-pour meds in the cups and do not label the cups with the room number. 5. Review of the competencies revealed that from 9/14/2024 until 9/23/2024 40 out of 40 licensed nurses were checked-off for medication administration. 6. Review of the Medication Administration Audit tool dated 9/14/2024 revealed that all medications passed were administered correctly. Interview on 10/8/2024 at 1:33 pm with LPN/UM BB for 100, 200, 300, and 400 halls stated that she assisted in the medication audit. She stated on 9/14/2024 she observed six nurses on various halls administer medications. The UM stated she compared the medication from the auto fill to the medication administration record (MAR). She stated she came in on off shifts and observed a total of twenty-seven nurses administer medication. The UM stated she did not identify any issues during the medication observation 7. Review of the facility document which revealed that the Administrator notified the Medical Director of the medication error on 9/14/2024 with no additional directive. 8. Review of the facility form titled AD Hoc Quality Assurance Process Improvement (QAPI) Meeting Attendance Sheet dated 9/16/2024 revealed the following were in attendance with signatures present: Administrator, Assistant Director of Health Services (ADHS), Medical Director via phone, Infection Preventionist (IP), Activities Director, Admissions Coordinator, Business Office Manager, Clinical Competency Coordinator, Dietary Director, Environmental Services Director, Human Resources, Maintenance, Medical Records, Restoration Nurse, Senior Care Partner, Social Services Director, Transportation Coordinator, Treatment Nurse, Unit Managers. The following was discussed at the QAPI meeting - discussed/reviewed medication error, the plan will be to re-educate nurses on the medication administration policy and all nurses will be competent to administer medication, the clinical team will complete medication cart audits and medication administration observations daily. Interview on 10/9/2024 at 11:43 am, LPN JJ stated that she works in the MDS department where she does the MDS for the residents and develops the care plans. She further stated that she received education on medication administration even though she does not work on the unit as a charge nurse. Interview on 10/9/2024 at 11:50 am, with LPN/UM KK, stated that she is the UM on the second floor which includes Halls 500 - 800. She stated that she was involved in the med administration observations with the Charge Nurses and med cart audits. 9. No new Licensed Nurse's hired. 10. Review of the facility document dated 10/5/2024 revealed that the removal plan has been developed, reviewed by the Medical Director, Administrator, DHS and Senior Nurse Consultant and we agree with the contents. Four signatures reviewed from above list indicating attendance. 11. Review of the Performance Improvement Plan (PIP) for medication administration revealed that the target end date will be 10/16/2024 with interventions in progress. Problem category - medication administration; root cause summary - nurses are provided competency upon hire and annually. The nurse failed to follow the medication administration policy. Overall goal - residents will receive prescribed medications as ordered. Project Conclusions - in progress. 12. The Facility's corrective actions were completed on 10/4/2024 and the facility alleges immediacy of IJ removal on 10/5/2024.

Based on record review, interviews, review of the Administrator Job Description and Director of Health Services Job Description, and review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility Administration failed to use its resources effectively and efficiently resulting in the failure to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to ensure resident (R) R1 was free from significant medication error resulting in actual harm on 9/14/2024, requiring transfer to hospital and admission to Intensive Care Unit (ICU). In addition, Administration failed to report the alleged medication error incident as well as an allegation of sexual abuse between R7 and R8 to the State Survey Agency (SSA) in a timely manner. On 10/2/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Interim Director of Health Services, and Licensed Practical Nurse Unit Manager were informed of the Immediate Jeopardy (IJ) on 10/2/2024 at 12:03 pm. The noncompliance related to the IJ was identified to have existed on 9/14/2024 when the facility failed to report an incident of significant medication error for R1, when Registered Nurse AA administered the wrong medications, which included allopurinol 100 milligram (mg), amlodipine 10 mg, Eliquis 2.5 mg, ferrous sulfate 325 mg, Lasix 40 mg, losartan 50 mg, metoprolol 100 mg, oxcarbazepine 300 mg (two tablets), potassium chloride extended release (ER) 10 milliequivalents (mEq), valsartan 80 mg, and vitamin D3 25 micrograms (mcg). R1 had a change in condition (bradycardia and hypotension) and was sent to the emergency room for evaluation and admitted to Intensive Care Unit (ICU) for higher level of care with diagnosis of poisoning by beta-adrenergic receptor antagonist - accidental (unintentional). The resident received intravenous (IV) fluids for hypotension, IV glucagon, IV Levophed, and IV Calcium. An Acceptable Removal Plan was received on 10/8/2024. The removal plan included in-service training for nursing staff on medication administration, including competency checks for licensed staff, and in-service training for administration staff on reporting and investigating alleged violations. Through observations, record review, and interviews, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on 10/5/2024. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures regarding reporting of incidents related to medication administration. Review of the document titled Position Description-Administrator revealed a hire date of 7/22/2024. The document revealed the 'Job Purpose' is to direct the day-to-day functions of the nursing center is in accordance with federal, state, and local regulations that govern long-term care centers. Key Responsibilities: Number 5. Ability to apply standards of professional practice to operations of nursing facility and to establish criteria to assure that care provided meets established standards of quality. Number 8. Demonstrates knowledge of and respect for the rights, dignity and individuality of each patient/resident in all interactions. Demonstrates competency in protection and promotion of resident rights. Number 10. Ability to communicate effectively with staff members, other professional staff, consultants and residents in interdisciplinary care setting and to government agencies. The bottom of the document had a statement that indicated the job description was reviewed with no changes needed at this time, dated 10/2024. Review of the document titled Position Description-Director of Health Services revealed a hire date of 9/23/2024. The document revealed the 'Job Purpose' is to plan, organize, develop and directs the overall operation of the Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director to provide appropriate care. Key Responsibilities: Number 34. Maintain knowledge of documentation procedures including appropriate use of forms, timelines, and Medicare documentation. Number 35. Maintain a working knowledge of current licensure standards and the survey process. The bottom of the document had a statement that indicated the job description was reviewed with no changes needed at this time, dated 10/2024. 1. The facility administration failed to ensure one resident was free of significant medication errors. R1 had a change in condition that jeopardized the residents health requiring her to be cared for in the ICU. 2. The facility administration failed to report an incident of significant medication error on 9/14/2024 that occurred during the 9:00 a.m. medication pass, by RN AA. The incident was not reported timely within the mandated two-hour time frame. 3. The facility Administration failed to report an allegation of sexual abuse on 7/6/2024 between R7 and R8, when R8 was found in R7's room receiving oral gratification, in a timely manner. Interview on 10/2/2024 at 1:00 pm, the Administrator stated that she would have never thought to report a medication error to the State because it wasn't abuse or neglect. During continued interview, she acknowledged that the medication error was an adverse incident that caused harm to the resident. Post survey interview on 10/18/2024 at 3:00 pm with Senior Nurse Consultant (SNC) GG stated any reportable sent to the SSA should be sent to herself or the Area [NAME] President (AVP). She stated she did not receive a reportable for the incident between R7 and R8. She also stated she was not aware that the incident happened on 7/6/2024 and was not reported until 7/16/2024. During further interview, the SNC revealed at that time the facility had a different Administrator that is no longer working at the facility. She confirmed the facility reportable incident should be reported on the day of the incident. Cross Refer F609, F760 The facility implemented the following actions to remove the Immediate Jeopardy: 1. Education has been provided to facility administration by Senior Nurse Consultant (SNC) to include the Administrator and Director of Health Services (DHS) on the medication administration policy and procedures and the reporting of significant incidents to the state agency on 10/2/24. 2. The Director of Partner Services reviewed the Job Descriptions on 10/2/2024 with no changes or revisions needed. The Area [NAME] President provided education to the Administrator regarding the job responsibilities and a new job description was signed by the Administrator on 10/2/2024 acknowledging the job responsibilities and duties for facility oversight. The Administrator provided education to the Director of Health Services on 10/2/2024 regarding the job responsibilities and a new job description was signed by the Director of Health Services. 3. The Assistant Director of Health Services began education with all licensed nurses beginning on 9/14/2024, on the topic of Medication Administration and the Rights of Medication Administration. At the time of the incident, the facility employed 11 RNs and 30 LPNs. 40 out of 41 nurses were educated by 9/23/2024 to total 97.56% of nursing staff education completed. 11 licensed nurses were provided education in person, and 29 licensed nurses were provided education via telephone by the Assistant Director of Health Services. The remaining one licensed nurse is on leave and will be provided education upon return. The facility does not utilize Medication Aides or Agency staff. 4. The Assistant Director of Health Services began competencies with licensed nurses beginning on 9/14/2024, to review the Medication Administration. 40 out of 41 nurses were reviewed for competency by 9/23/2024 to total 97.56% of nursing staff education completed. The remaining 1 licensed nurse is on leave and will be provided education upon return. 40 out of 40 licensed nurses passed the medication administration competency. 5. On 9/14/2024, the Medical Director was notified of the alleged medication error by the Administrator with no additional directive regarding the incident other than ensuring the resident was transferred to the hospital. 6. RN AA was provided with a written disciplinary action on 9/14/2024 by the Assistant Director of Health Services and the Administrator and re-educated regarding medication administration. RN AA was also observed with a medication administration competency by the Assistant Director of Health Services on 9/14/2024. RN AA was suspended pending investigation on 10/2/2024 and subsequently terminated employment on 10/3/2024. 7. The facility Administrator held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) on 9/16/2024 to discuss the alleged nedication incident and the plan to implement cart observations, education on medication administration. The Administrator, Assistant Director of Health Services (ADHS), Unit Managers, Treatment Nurses, Social Service Director, Maintenance, Housekeeping Supervisor, Human Resource and the Financial Counselor. The Medication Administration Policy was reviewed, and no changes or revisions were made to the policy. Medical Director attended via phone. A root cause analysis was completed during the Ad Hoc QAPI meeting related to administrative oversight where it was identified a lack of understanding regarding the parameter of the administrative role. 8. The DHS and the ADHS will provide education to licensed nurses upon hire regarding medication administration and the rights of medication administration during new hire orientation. Licensed nurses will also receive a competency for medication administration upon hire. 9. The Medical Director, Administrator, DHS, Senior Nurse Consultant, were all involved in developing the removal plan, reviewed it, and agreed with the contents. The facility will be in compliance effective 10/5/2024. 10. The Administrator and DHS will monitor the implementation of the removal plan. The Administrator and DHS will utilize the Performance Improvement Plan (PIP) was initiated on 10/2/2024 to include education with administration regarding their roles and responsibilities and monitoring by the Area [NAME] President (AVP). 11. The facility's corrective actions were completed on 10/4/2024 and the facility alleges immediacy of IJ removal on 10/5/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of the Inservice Education Program Attendance Record Form dated 10/2/2024 revealed the Administrator and the DHS were educated on the Medication Administration Policy, the Abuse Policy and reporting of significant medication errors. 2. Review of the facility document dated 10/2/2024 revealed that the Area [NAME] President (AVP) has reviewed and educated the Administrator on her duties and job description. The skilled nursing administrator job description for [facility name] was reviewed in detail and inservice completed. Signed by Area [NAME] President (AVP). Review of the facility document dated 10/2/2024 revealed the Administrator has reviewed and educated the Director of Health Services (DHS) on her duties and job description. The Director of Health Services job description for [facility name] was reviewed in detail and in-service completed. Signed by Administrator. 3. Review of the Inservice Education Program Summary Record Form dated 9/14/2024 titled Medication Administration by the ADHS revealed 'we do not pre-pour medications in a nursing home, we also don't leave meds at the bedside - this helps prevent serious errors and is essential for patient safety' with the Medication Administration: General Guidelines attached. Review of the In-Service Program Attendance Record Form dated 9/14/2024 revealed 11 signatures from licensed nurses indicating in-person attendance and 29 licensed nurses names listed as receiving education via telephone on 9/14/2024. - Discrepancies being clarified by the Regional Nurse Consultant (should be a total of 40 nurses with one nurse on leave). In an interview with the Regional Nurse Consultant on 10/8/2024 at 1:30 pm revealed that there were 29 licensed nurses who were educated via telephone and 11 nurses were educated in-person. In an interview with LPN/UM BB on 10/9/2024 at 9:50 am stated she was educated on med administration - verify the resident, check the name of the med, the dose, the frequency, etc. She further stated they discussed care plans - following the care plan and updating as needed. She stated they talked about abuse and what, when and who to report to is you suspect abuse. In an interview with LPN CC on 10/9/2024 at 9:55 am stated that the UM educated them on medications administration and watched them pass meds and checked their med carts. She stated they talked about the rights of medication administration, verify the resident, the med, the dose, the frequency, do not pre-pour meds or right the room number on the med cup. She stated they talked about abuse - what and when and who to report to. In an interview with LPN DD on 10/9/2024 at 10:25 am stated that she is the Nurse Navigator for the facility and is aware of why surveyors are in the facility. She stated that the DHS re-educated her on medication administration, the five rights of the med pass, don't pre-pour meds and leave in the med cart, etc. She stated that she was also re-educated on care plans - following the care plans and updating the care plans when a change occurs for the resident. She stated that they also discussed the abuse policy - that the Administrator is the Abuse Coordinator and she is who they report suspected abuse to as soon as it is suspected. In an interview with RN PP on 10/9/2024 at 10:45 am stated that he was educated on medication administration, the five rights of med administration, do not pre pour medications, do not label the med cup with the room number. He also stated that he was educated on abuse, who the Abuse Coordinator is and what and when to report. He further stated that he was also educated on care plans - following the care plan and update the care plan as needed. In an interview with LPN HH 10/9/2024 at 11:00 stated she was educated on medication pass, abuse, care plans, UM KK watched med pass, don't pre-pour the medication, if you suspect abuse to report to the Administrator immediately. Discussed updating the care plan when there is a change in condition. In an interview with RN EE via phone on 10/9/2024 at 7:50 pm stated that she normally works 7:00 pm to 7:00 am as a Charge Nurse. She stated that the UM KK educated them on the abuse policy, medication administration, and care plans. She also stated that they are to follow the medication rights, verify the resident, the medication, the dose, frequency, route, etc. She stated that the Abuse Coordinator is the Administrator. 4. Review of the competencies revealed that from 9/14/2024 until 9/23/2024 40 out of 40 licensed nurses were checked-off for medication administration In an interview with LPN HH on 10/9/2024 at 11:00 am, she stated she was educated on medication pass, abuse, care plans, the UM KK watched med pass, don't pre-pour the medication, if you suspect abuse to report to the Administrator immediately. Discussed updating the care plan when there is a change in condition. In an interview with LPN LL on 10/9/2024 at 11:11 am stated she has worked at the facility for six years. She stated she is aware of the reason the surveyors are here is due to medication administration. She stated the UM KK watched her pass medications, she checked the medication cart and verified all contents. She stated she uses an acronym CTDMR = right client, right time, right dose, right medication, right room. She stated the care plan is all you need to take care of the person, and she was aware of how to locate the care plan in the EMR. During further interview, she stated they discussed abuse, move the client out of the way and report it immediately. 5. Review of the facility document dated 9/14/2024 revealed that the Administrator notified the Medical Director of the medication error which occurred on 9/14/2024 with no additional directive. 6. Review of the facility document revealed that RN AA was educated on medication administration policy on 9/14/2024 and understands the policy and understands that this is a corrective action. Any violation of the policy will result in further discipline including possible termination. Signed by the ADHS and RN AA. Further review of the facility document titled 'Pending Transaction' revealed the RN AA was terminated and not eligible for rehire on 10/4/2024. 7. Review of the facility form titled AD Hoc QAPI Meeting Attendance Sheet dated 9/16/2024 revealed the following were in attendance with signatures present: The Administrator, The ADHS, Medical Director via phone, Infection Preventionist (IP), Activities Director, Admissions Coordinator, Business Office Manager, Clinical Competency Coordinator, Dietary Director, Environmental Services Director, Human Resources, Maintenance, Medical Records, Restoration Nurse, Senior Care Partner, Social Services Director, Transportation Coordinator, Treatment Nurse, Unit Managers. The following was discussed at the QAPI meeting - discussed/reviewed medication error, the plan will be to re-educate nurses on the medication administration policy and all nurses will be competent to administer medication, the clinical team will complete medication cart audits and medication administration observations daily. 8. No new Licensed Nurse's hired. 9. Review of the facility document dated 10/5/2024 revealed that the removal plan has been developed, reviewed by the Medical Director, the Administrator, DHS and Senior Nurse Consultant and we agree with the contents. Four signatures reviewed from above list indicating attendance. 10. Review of the Performance Improvement Plan (PIP) for Medication Administration revealed that the target end date will be 10/16/2024 with interventions in progress. Problem category - medication administration; root cause summary - nurses are provided competency upon hire and annually. The nurse failed to follow the medication administration policy. Overall goal - residents will receive prescribed medications as ordered. Project Conclusions - in progress. Review of the facility document dated 10/2/2024 revealed that the Area [NAME] President (AVP) has reviewed and educated the Administrator on her duties and job description. The skilled nursing administrator job description for [facility name] was reviewed in detail and inservice completed. Signed by AVP. Review of the facility document dated 10/2/2024 revealed the Administrator has reviewed and educated the DHS on her duties and job description. The Director of Health Services (DHS) job description for [facility name] was reviewed in detail and in-service completed. Signed by Administrator.