**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, # 5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed multiple doses of the intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on 07/15/2023 for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on [DATE] with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on [DATE] with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. 1. Medication Administration, Documentation and Translation of orders: a. In-Services were conducted with weekend staff to ensure all nurses were educated on Medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. 100% of nursing staff will be educated by 08/09/2023. b.100% of all residents' medical records were reviewed to ensure accuracy of physician orders. c. Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. Starting 08/04/2023 and all nursing staff will be observed by 08/09/2023. d.100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. e. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. f. All residents receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. g. Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RR Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. h. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. i. Nurses and Respiratory therapists were educated on communicating new Respiratory orders. j. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. 2. Identification of other residents having the potential to be affected was accomplished by: a. The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The following training began on 08/04/2023 and will be completed by 08/09/2023: a. Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. Competency checks began on 08/04/2023. All nursing staff to receive competency checks by 08/09/2023. b. New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. c. Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy. d. Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at facility. e. Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education was laminated and placed on all med carts. f. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. The following monitoring began on 08/04/2023 and will be completed by 09/22/2023: g. ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. Oversight by DON or designee of pharmacy process weekly. h. ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. Oversight by DON or designee of pharmacy process weekly. i. Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, AHT, Medication administration, documentation, and transcription to be completed by ADONs and DON. j. All new orders to be pulled and checked by ADON's or designee daily in the morning. k. Monitoring of medication administration, documentation, translation processes as well as physician order review and pharmacy communication as listed above by Regional Corporate Consulting Nurse weekly. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress meetings to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining resident identified by the facility as receiving all medications as ordered. Findings: 1.) Review of the facility's Medication Reconciliation policy revealed the following, in part: 2. Resident identifiers will be verified on all medication labels and documents containing medication information to verify the correct person. 5. b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. Review of the facility's Medication Reordering policy revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Resident #1 A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Traumatic Spinal Cord Dysfunction, Quadriplegia, Pressure Ulcer of Sacral Region Stage 4, and Cellulitis. A review of Resident #1's Physician Orders dated June 2023 revealed an order for Vancomycin 750mg vial administer Intravenous every twelve hours x 7 days with a start date of 06/13/2023. Further review revealed the physician ordered the last dose of Vancomycin to be given on 06/19/2023. A Review of Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Vancomycin 750 mg IV every 12 hours x7 days was not administered on 06/15/2023 at 9:00 p.m., and the 9:00 a.m. and 9:00 p.m. doses were not administered on 6/17/2023, 06/18/2023, or 06/19/2023. This was indicated on the MAR by either an empty box or circled initials. A review of Resident #1's Nurses' Notes dated June 2023 revealed the following: 06/17/2023 at 8:30 a.m., No Vancomycin available. Called and placed order to pharmacy. Pharmacist will call back regarding Vancomycin. No call back, supervisor aware. 06/19/2023 called and faxed order to pharmacy for IV Vancomycin. 06/20/2023 at 10:00 p.m. Vancomycin not available 06/21/2023 at 9:00 a.m. Vancomycin not available. NP Notified A review of Resident #1's Physician's Progress Notes dated June 2023 revealed the following: 06/13/2023, Ordered Vancomycin 750mg IV every 12 hours x 7 days. 06/23/2023, Wound noted to be deteriorating. IV Vancomycin noted with multiple missed dosing for unknown reason. Patient was referred to long term acute care hospital yesterday for wound needing IV antibiotic treatment, aggressive wound debridement, and Negative Pressure Wound Therapy. A review of Resident #1's clinical lab results revealed the following Vancomycin Trough levels: 06/15/2023- 5.9-low 06/19/2023- <3.5-abnorml 06/21/2023- <3.5-abnormal (Therapeutic values: Trough: 10-20 ug/ml) It is noted the above values are sub therapeutic. A review of Resident #1's Pharmacy Records dated June 2023 revealed the following: 06/19/2023 at 3:21 p.m., Fax received for initial order as follows: (start date 06/13/2023) Vancomycin 750 mg IV every 12 hours x 7 days. Vancomycin trough 30 minutes prior to 4th dose; hold Vancomycin until trough results. A review of the facility's Emergency Transfer Log dated June 2023 revealed Resident #1 was transferred to the hospital on [DATE]. A review of Resident #1's Hospital Records from 06/22/2023 revealed Resident #1 arrived at the Emergency Department with a chief complaint of a large sacral wound. Labs were drawn and revealed the following: RBC: 3.24 (low), Hemoglobin: 6.9 (low), Hematocrit 23.8 (low) and Albumin 2.2 (low). Resident #1's labs were significant for severe anemia likely secondary from the bleeding sacral wound. Resident #1 was admitted to the hospital for abnormal labs and received 1 unit of packed red blood cells. Resident #1 received iron while impatient due to iron deficiency anemia. On 06/26/2023, Resident #1 had a wound debridement for the Sacral Decubitus Ulcer, Stage IV. A review of Resident #1's Nurse's Note revealed the resident returned to the facility on [DATE] at 2:00 p.m. A review of Resident #1's re-admission Physician Orders dated 07/07/2023 revealed the following: Vancomycin 1.25gm/250ml - 0.9% Normal Saline to infuse intravenously every 12 hours for Stage 4 Sacral Wound for 21 days Start Date: 07/07/2023 End Date: 07/29/2023 Cefepime HCL 2 gram vial to infuse intravenously every 12 hours for Cellulitis for 21 days Start Date: 07/07/2023 End Date: 07/29/2023. A Review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed neither dose of Vancomycin 1.25gm/250ml IV was administered on 07/22/2023, 07/23/2023 and 07/25/2023. Further review revealed Resident #1 did not receive the 9:00 a.m. dose of Vancomycin on 07/24/2023 and 07/26/2023. This was indicated on the MAR by either an empty box or the box indicated not given. Further review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed Cefepime HCL 2 Grams IV was not administered at 9:00 p.m. on 07/22/2023, 07/23/2023, 07/25/2023 or 07/28/2023. This was indicated on the MAR by either an empty box or the box indicated not given. A review of Resident #1's Nurses' Notes dated July 2023 revealed the following: 07/23/2023 at 12:35 a.m., IV antibiotics not administered, waiting on pharmacy to bring refill, will resume when arrive. 07/24/2023 at 11:20 a.m., Morning IV antibiotics not administered. Awaiting delivery. ADON notified. 07/24/2023 at 11:36 a.m., At start of shift pharmacy called inquiring about IV Vancomycin. Requesting trough levels for 07/21/2023. New orders given to continue current dose and Vancomycin trough on 07/24/2023 and 07/28/2023. Lab results and order faxed to pharmacy. A review of Resident #1's Physician's Progress Notes dated July 2023 revealed the following: 07/27/2023, Discussed with nurse to give Vancomycin as ordered. Apparently Resident #1 has not been given Vancomycin as ordered. Discussed with nurse to follow orders and Vancomycin needs to be given. A review of Resident #1's clinical lab results dated July 2023 revealed the following Vancomycin Trough levels: 07/11/2023- 5.0 ug/mL 07/14/2023- <3.5 ug/mL 07/18/2023- <3.5 ug/mL 07/21/2023- <3.5 ug/mL 07/28/2023- 6.5 ug/mL Target Trough: 10-20 ug/ml It is noted all of the above trough levels were sub therapeutic. A review of Resident #1's Pharmacy Records dated July 2023 revealed the following: 07/07/2023 at 5:18 p.m., Fax received for re-admit physician orders as follows: (start date 07/07/2023 stop date: 07/29/2023) Vancomycin 1.25 gm/250 ml 0.9% NS infuse IV every 12 hours for Stage 4 Sacral Wound for 21 days. 07/07/2023 at 6:22 p.m., 6 doses of Vancomycin sent 07/10/2023 at 2:16 p.m., Nurse said she gave Vancomycin dose at 10:00 a.m. The facility has 5 doses left so that was the only dose given. I faxed the Vancomycin dosing form twice today but she doesn't see the form. Nurse stated labs came back at 3.5 ug/mL. I asked several times to speak with the NP and was told he was busy. Nurse stated they had enough Vancomycin until labs are ordered to be drawn on 07/11/2023. 07/10/2023, 5 remaining doses of Vancomycin in facility at 2:00 p.m. 07/11/2023 at 5:08 p.m., Called and no one answered. Need Vancomycin count. 07/12/2023, 4 remaining doses of Vancomycin in facility at 3:15 p.m., obviously not being given correctly 07/13/2023, 1 dose of Vancomycin sent, 2 doses remaining in facility at 2:44 p.m. 07/14/2023 at 11:43 a.m., Spoke with nurse. Told her we have not been able to get consistent labs or answers since we got this patient and doses are not being given correctly. Labs were not draw again today. I told her we will send enough to get through Monday but if labs aren't drawn on Monday then they will be cutting this patient off unless the doctor and DON are involved. 07/14/2023, 6 doses of Vancomycin sent, 1 dose remaining at 11:35 a.m. 07/17/2023- 0 doses of Vancomycin remains in facility at 1:15 p.m. 07/18/2023 at 12:53 p.m. spoke with S6ADON again about not being able to obtain any information on this patient. S6ADON stated trough was done that morning so I told her to call back with results. 07/18/2023 at 2:23 p.m., Per S6ADON lab results were 3.7 ug/mL, I'm willing to bet they have not been giving the Vancomycin. I have no idea where the Vancomycin is going. I will send 1 dose for tonight and 2 for tomorrow. I will contact the doctor because this patient is not being treated appropriately. 07/18/2023 at 2:37 p.m., 3 doses of Vancomycin, 0 remaining. 07/19/2023 at 7:41 a.m., Spoke with S3DON. I told her we had problems getting the correct information needed. I read her my notes to help her understand the problems we had been having and the lack of care/concerns. I told her we will no longer be dosing for this facility, we will require Dr. to dose form faxed to us. Pharmacy gave specific instructions on what was needed. 07/20/2023 at 11:06 a.m., Spoke with nurse who informed Pharmacy Resident #1 line came out so they were waiting for replacement. They have 1 Vancomycin on hand. Instructed her to follow up with labs. Will send out 1 dose of Vancomycin. Dr. to dose sheet faxed. 07/20/2023, 1 dose of Vancomycin sent 07/21/2023 at 7:27 a.m., Dr. to dose form faxed. 07/21/2023 at 11:15 a.m., Called phone rang off hook. 07/21/2023 at 4:10 pm., No labs yet 07/24/2023 at 8:36 a.m., Spoke with nurse who was looking for Vancomycin. I told her we never received labs or MD orders. I told her we need this. We cannot keep sending Vancomycin without any information. Faxed new dose form with all needed to comment section at 8:39 a.m. 07/24/2023 at 9:28 a.m., Spoke with S2NP and he wanted to find out what was needed and what was going on. I gave him all the information needed. 07/24/2023, 5 doses of Vancomycin sent 07/26/2023 at 2:38 p.m., Called, rang, no answer. 07/26/2023, 6 doses of Vancomycin sent, 1 dose remaining at 3:00 p.m., should have 2 for today On 08/01/2023 at 9:20 a.m., an interview was conducted with S10LPN. She stated when a medication was administered, it was documented on the MAR. She stated if the MAR was left blank then it meant the medication was not administered. On 08/01/2023 at 12:30 p.m., an interview was conducted with S3DON. She stated the nurses were expected to request a medication refill prior to the medication running out. She reviewed Resident #1's MARS of June and July 2023 and confirmed Vancomycin and Cefepime was not administered as ordered and should have been. On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. He confirmed he was familiar with Resident #1. He stated Vancomycin was ordered on 06/13/2023 for an infected pressure ulcer. He reported reviewing the Vancomycin trough labs and realized the resident was not receiving the medication because the labs were sub therapeutic and not rising. He stated he notified administration about Resident #1 not receiving the Vancomycin. S2NP stated he remembered in June being contacted by a nurse to clarify to give the last dose of Vancomycin since so many doses had been missed. At that time he gave an order to give the last dose. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for higher level of wound treatment. He stated he spoke to the nurses and educated them on the importance of receiving the medication and how they needed to follow the orders to give Vancomycin. He reported the resident retuned to the facility on [DATE] with orders for Vancomycin and Cefepime. He stated Resident #1 had multiple missed doses of Vancomycin in July 2023. He stated the pharmacy wanted the nurses to communicate trough levels via fax prior to the medication being sent. S2NP stated he educated the nursing staff and the administration on the pharmacy's new protocol. He stated the nursing staff did not communicate Resident #1 missed doses of either Vancomycin or Cefepime. On 08/01/2023 at 1:21 p.m., a phone interview was conducted with S8RN. He confirmed working the weekend of 06/18/2023-06/19/2023. He stated a nurse reported Resident #1's Vancomycin was not available for administration. He said he directed the nurse to contact the pharmacy and the provider if she could not reach the pharmacy. He stated he did not know if the nurse contacted the pharmacy or if the medication was received and given. He confirmed he did not follow up with the nurse after she reported the medication as unavailable. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She confirmed working on 07/22/2023 and 07/23/2023. She stated she did not administer Resident #1's Vancomycin on either day because the medication was not available. She stated she was not trained on the procedure if a resident was out of medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated knew Resident #1 did not receive ordered Vancomycin in June 2023. She stated she in-serviced the floor nurses in June on Antibiotic Administration. She stated the nurses did not know the process for obtaining medications from the pharmacy when a resident was out. She stated if the medication was not available the nurses would not administer it and move on. She stated the nurses would not communicate missing medications with herself or the NP. She stated the in service included education on communicating with the ADON, DON, NP and the process to follow if a medication was not available. She stated on 07/11/2023, she received a call from the pharmacy requesting a trough level for Vancomycin and an order from the provider on the plan of care. She stated she educated and instructed the ADON's to oversee the Vancomycin trough levels and the NP order form. She stated the ADON's were responsible to communicate with the pharmacy and the NP. On 08/02/2023 at 3:30 p.m., a telephone interview was conducted with contracted pharmacist. She stated the first time the pharmacy received an order for Resident #1 to start Vancomycin was on 06/19/2023. She confirmed the pharmacy did not receive an order for Resident #1 on 06/13/2023 and therefore did not send medication prior to 06/19/2023. She stated on 06/19/2023, the pharmacy sent 5 bags of Vancomycin to the facility. She stated on 06/21/2023, the facility requested 2 more bags of Vancomycin because they were out. The pharmacist said she sent 2 bags at that time, but the facility should not have been out of the medication. She stated the nurses reported they were giving the medication as ordered, but the Vancomycin trough levels suggested Resident #1 was not receiving the medication appropriately. She stated she called and communicated the suspected missing doses with S3DON in June 2023. She reported the facility had poor communication with pharmacy and would not provide needed information. She reported in July 2023, the pharmacy had the same issues with the facility and missing doses of medication so she spoke with 3DON again. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. If a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON and DON. He stated the nurses did not report Resident #1 was out of Vancomycin in June or July 2023. He stated the medications should have been administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated Resident #1 was not getting Vancomycin trough labs drawn so the Pharmacy would not send the Vancomycin in June 2023. She confirmed working on the morning of 06/18/2023. She stated she did not give Resident #1's Vancomycin as ordered because it was not available. She stated she notified S2NP and told him she did not have the medication. She stated she did not notify the Pharmacy. On 08/04/2023 at 10:45 a.m., an interview was conducted with S6ADON. S6ADON confirmed knowing Resident #1 had missed doses of Vancomycin in June 20203. She explained in July 2023, S3DON instructed her to oversee the trough levels and communication with the lab and pharmacy. She stated after receiving trough results from the lab, she would then fax the labs to the pharmacy. She confirmed it was unacceptable that Resident #1 missed intravenous Vancomycin and Cefepime. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. S3DON said if a resident's MAR was not initialed by the nurse, it meant the medication was not given. She also said if the MAR had circled initials, it also meant the medication not given. She reviewed Resident #1's clinical record and confirmed Resident #1 had an order for Vancomycin to start on 06/13/2023. She stated she did not know the resident missed doses of Vancomycin until 06/19/2023. She said the nurses did not know the process to follow if a resident was out of medications, so they did not give it. Resident #2 A review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, UTI, and Type 2 Diabetes Mellitus. A review of Resident #2's Physician's Orders dated July 2023 revealed an order dated 07/12/2023 for Meropenem 1 gram IV every 8 hours for 7 days. Diagnosis: UTI. Further review revealed an order for Humalog sliding scale: 0-120: 0 units; 121-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 9 units; 301-350: 12 units; 351-400: 15 units and call MD. A review of Resident #2's MAR dated July 2023 revealed Meropenem 1 gram IV every 8 hours was documented as not given on 07/14/2023 at 6:00 a.m. or 10:00 p.m., 07/15/2023 at 6:00 a.m. or 10:00 p.m., 07/16/2023 at 6:00 a.m., and 07/18/2023 at 10:00 p.m Further review of Resident #2's July 2023 MAR revealed: 07/14/2023 at 4:30 p.m., Accucheck result of 165 and no documentation of insulin administered. 07/19/2023 at 7:30 a.m., Accucheck result of 135 and no documentation of insulin administered. 07/27/2023 at 4:30 p.m., Accucheck result of 218 and documentation of incorrect insulin dose of 4 units administered. A review of Resident #2's nurses' notes revealed no documentation as to why the resident did not receive Meropenem, the incorrect insulin administrations or if the physician was notified. On 08/02/2023 at 11:18 a.m., an interview was conducted with S3DON. S3DON reviewed Resident #2's July 2023 MAR. She confirmed there were blank boxes on the MAR that correlated with the above dates. She verified the blank boxes on the MAR meant the medication was not given. On 08/02/2023 at 12:10 p.m., an interview was conducted with S2NP. He verified he was not notified that Resident #2 missed doses of intravenous Meropenem in July 2023. He also confirmed he was not aware the resident received incorrect insulin coverage in July 2023. On 08/02/2023 at 1:50 p.m., an interview was conducted with S12LPN. S12LPN reviewed Resident #2's July 2023 MAR. She verified the boxes for administration times on 07/14/2023, 07/15/2023, 7/16/2023 and 07/18/2023were blank. She stated if the boxes on the MAR were blank it meant the medication was not administered. Resident #3 A review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Anoxic Brain Damage, Tracheostomy, Osteomyelitis, Congestive Heart Failure, Pressure Ulcer to Left Buttock, Stage 4, Pressure Ulcer of Sacral Area, Stage 4, and Pressure Ulcer to Right Buttock, Stage 4, Gastrostomy Status, and Chronic Respiratory Failure A review of Resident #3's Physicians Orders for June 2023 revealed the following: 06/26/2023, Meropenem 1gm IV every 8 hours for 26 days; 06/26/2023, Albuterol 0.633 mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Budesonide 0.5 mg/2mL give 2 mL via neb BID x14 days; 06/26/2023, Duo-neb 0.5-3mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Lasix 40 mg administer one tablet per peg twice a day; and 06/26/2023, Levetiracetam 500 mg administer one tablet per peg twice a day. A review of Resident #3's Medication Administration Record (MAR) for June 2023 revealed Meropenem 1gm IV every 8 hours was not administered on 06/28/2023 at 2:00 p.m.; Lasix 40 mg 1 tablet per peg twice a day was not administered on 06/28/2023 at 6:00 a.m. and 6:00 p.m. and on 06/29/2023 at 6:00 a.m. and Keppra 500mg 1 tablet per peg tube twice a day was not administered on 06/28/2023 at 6:00 a.m. A review of the respiratory therapy documentation for Resident #3 revealed Budesonide 0.5 mg/2mL give 2 mL via nebulizer BID was not administered on 06/26/2023, 06/27/2023, or 06/28/2023. A review of the Transfer Log revealed Resident #3 was transferred to the emergency room on [DATE] due to a critical H&H. A review of Resident #3's Physicians Orders for July 2023 revealed the following: 07/01/2023, Albuterol-Ipratropium 2.5mg-2.5/3mL give 3mL by neb every six hours; 07/01/2023 and 07/19/2023, Levetiracetam 500mg/5mL administer 5mL per peg twice daily; 07/19/2023, Lasix 40 mg administer one tablet per peg daily; 07/19/2023, Enoxaparin 40 mg administer subcutaneous daily; and 07/19/2023, Duo-neb 2.5-0.5 mg/3 mL give 3mL via neb every six hours A review of Resident #3's Medication Administration Record (MAR) for July 2023 revealed the following: Lasix 40 mg 1 tablet per peg tube twice a day was not administered on 07/01/2023 at 6:00 p.m. or 07/28/2023 at 5:00 a.m.; Levetiracetam 500mg/5mL solution, 5 mL solution per peg tube twice a day was not administered on 07/03/2023 and 07/28/2023 at 6:00 a.m., 07/04/2023, 07/20/2023 and 07/21/2023 at 6:00 p.m. and Enoxaparin 40 mg/0.4mL (0.4 mL=40 mg) into the skin subcutaneous daily was not administered on 07/28/2023 at 6:00 a.m. A review of Resident #3's Nurse's notes dated 07/15/2023 revealed the respiratory therapist alerted the nurse Resident # 3 had oxygen saturations levels of 82%. Resident #3's respirations were very shallow and labored, and pulses were faint. The respiratory therapist began mask bag ventilation. A review of Respiratory flowsheet dated 07/15/2023 revealed at 12:20 p.m. Resident #3 respiratory rate was 23 and had an oxygen saturation level of 90%. The respiratory therapist had suctioned bloody plugs, changed the resident's inner trach cannula, and performed trach care. Resident #3's oxygen saturation decreased to 80% and had become apneic. Artificial manual breathing unit with oxygen was initiated and the resident was suctioned three times. Resident #3 had become apneic again and her oxygen saturation levels decreased to 70%. Resident#3 was bagged until Emergency Medical Services arrived. Resident had no respiratory effort and weak pulse. A review of the respiratory therapy documentation for Resident #3 revealed Albuterol-Ipratropium 2.5mg-2.5/3mL was not administ

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure licensed nurses and other nursing personnel had the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed multiple doses of the intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on 07/15/2023 for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on [DATE] with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on [DATE] with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. a. Medication Administration, Documentation and Translation of orders: b. In-services were conducted with weekend staff to ensure all nurses were educated on medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. c. 100% of all residents' medical records were reviewed to ensure accuracy of physician orders. d. Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. e. 100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. f. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. g. All residents' receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. h. Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RP. Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. i. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. j. Nurses and Respiratory therapists were educated on communicating new Respiratory orders. k. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. 2.) Identification of other residents having the potential to be affected was accomplished by: a. The facility has determined that all residents have the potential to be affected. 3.)Actions taken/systems put into place to reduce the risk of future occurrence include: The following training began on 08/04/2023 and will be completed by 08/09/2023: a. Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. b. New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. c. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. d. Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy e. Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at the facility. f. Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education will be laminated and placed on all med carts. The The following monitoring began on 08/04/2023 and will be completed by 09/22/2023: a. All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). b. For ongoing compliance, the DON or designee will conduct weekly medication cart, EMR and medication storage audits starting weekly x 4, then monthly ongoing for Quality Control and to ensure availability of medications for administration. c. The DON and or designees will also conduct medication administration observations at random, 1 on each shift, weekly then ongoing CQI. d. ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023. e. ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). Oversight by DON or designee of pharmacy process weekly. f. Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, AHT, Medication administration, documentation and transcription to be completed by ADONs and DON. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023. g. All new orders to be pulled and checked by ADON's or designee daily (Monday through Friday) in the morning. Oversight by DON or designee weekly. h. Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. i. The Regional Nurse or designee will conduct quarterly checks to determine compliance with the completion of the audits by the DON or designee and the identify trends and areas of continued non-compliance. 4.) 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining resident identified by the facility as receiving all medications as ordered. Findings: Review of the facility's Medication Reconciliation policy revealed the following, in part: 2. Resident identifiers will be verified on all medication labels and documents containing medication information to verify the correct person. 5. b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. Review of the facility's Medication Reordering policy revealed the following, in part: 2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Resident #1 A review of the clinical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included, Traumatic Spinal Cord Dysfunction, Quadriplegia, Pressure Ulcer of Sacral Region Stage 4, and Cellulitis. A review of Resident #1's Physician Orders dated June 2023 revealed an order for Vancomycin 750mg vial administer Intravenous every twelve hours x 7 days with a start date of 06/13/2023. Further review revealed the physician ordered the last dose of Vancomycin to be given on 06/19/2023. A Review of Resident #1's Medication Administration Record (MAR) dated June 2023 revealed Vancomycin 750 mg IV every 12 hours x7 days was not administered on 06/15/2023 at 9:00 p.m., and the 9:00 a.m. and 9:00 p.m. doses were not administered on 6/17/2023, 06/18/2023, or 06/19/2023. This was indicated on the MAR by either an empty box or circled initials. A review of Resident #1's Nurses' Notes dated June 2023 revealed the following: 06/17/2023 at 8:30 a.m., No Vancomycin available. Called and placed order to pharmacy. Pharmacist will call back regarding Vancomycin. No call back, supervisor aware. 06/19/2023 called and faxed order to pharmacy for IV Vancomycin. 06/20/2023 at 10:00 p.m. Vancomycin not available 06/21/2023 at 9:00 a.m. Vancomycin not available. NP Notified A review of Resident #1's Physician's Progress Notes dated June 2023 revealed the following: 06/13/2023, Ordered Vancomycin 750mg IV every 12 hours x 7 days. 06/23/2023, Wound noted to be deteriorating. IV Vancomycin noted with multiple missed dosing for unknown reason. Patient was referred to long term acute care hospital yesterday for wound needing IV antibiotic treatment, aggressive wound debridement, and Negative Pressure Wound Therapy. A review of Resident #1's clinical lab results revealed the following Vancomycin Trough levels: 06/15/2023- 5.9-low 06/19/2023- <3.5-abnorml 06/21/2023- <3.5-abnormal (Therapeutic values: Trough: 10-20 ug/ml) It is noted the above values are sub therapeutic. A review of Resident #1's Pharmacy Records dated June 2023 revealed the following: 06/19/2023 at 3:21 p.m., Fax received for initial order as follows: (start date 06/13/2023) Vancomycin 750 mg IV every 12 hours x 7 days. Vancomycin trough 30 minutes prior to 4th dose; hold Vancomycin until trough results. A review of the facility's Emergency Transfer Log dated June 2023 revealed Resident #1 was transferred to the hospital on [DATE]. A review of Resident #1's Hospital Records from 06/22/2023 revealed Resident #1 arrived at the Emergency Department with a chief complaint of a large sacral wound. Labs were drawn and revealed the following: RBC: 3.24 (low), Hemoglobin: 6.9 (low), Hematocrit 23.8 (low) and Albumin 2.2 (low). Resident #1's labs were significant for severe anemia likely secondary from the bleeding sacral wound. Resident #1 was admitted to the hospital for abnormal labs and received 1 unit of packed red blood cells. Resident #1 received iron while impatient due to iron deficiency anemia. On 06/26/2023, Resident #1 had a wound debridement for the Sacral Decubitus Ulcer, Stage IV. A review of Resident #1's Nurse's Note revealed the resident returned to the facility on [DATE] at 2:00 p.m. A review of Resident #1's re-admission Physician Orders dated 07/07/2023 revealed the following: Vancomycin 1.25gm/250ml - 0.9% Normal Saline to infuse intravenously every 12 hours for Stage 4 Sacral Wound for 21 days Start Date: 07/07/2023 End Date: 07/29/2023 Cefepime HCL 2 gram vial to infuse intravenously every 12 hours for Cellulitis for 21 days Start Date: 07/07/2023 End Date: 07/29/2023. A Review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed neither dose of Vancomycin 1.25gm/250ml IV was administered on 07/22/2023, 07/23/2023 and 07/25/2023. Further review revealed Resident #1 did not receive the 9:00 a.m. dose of Vancomycin on 07/24/2023 and 07/26/2023. This was indicated on the MAR by either an empty box or the box indicated not given. Further review of Resident #1's Medication Administration Record (MAR) dated July 2023 revealed Cefepime HCL 2 Grams IV was not administered at 9:00 p.m. on 07/22/2023, 07/23/2023, 07/25/2023 or 07/28/2023. This was indicated on the MAR by either an empty box or the box indicated not given. A review of Resident #1's Nurses' Notes dated July 2023 revealed the following: 07/23/2023 at 12:35 a.m., IV antibiotics not administered, waiting on pharmacy to bring refill, will resume when arrive. 07/24/2023 at 11:20 a.m., Morning IV antibiotics not administered. Awaiting delivery. ADON notified. 07/24/2023 at 11:36 a.m., At start of shift pharmacy called inquiring about IV Vancomycin. Requesting trough levels for 07/21/2023. New orders given to continue current dose and Vancomycin trough on 07/24/2023 and 07/28/2023. Lab results and order faxed to pharmacy. A review of Resident #1's Physician's Progress Notes dated July 2023 revealed the following: 07/27/2023, Discussed with nurse to give Vancomycin as ordered. Apparently Resident #1 has not been given Vancomycin as ordered. Discussed with nurse to follow orders and Vancomycin needs to be given. A review of Resident #1's clinical lab results dated July 2023 revealed the following Vancomycin Trough levels: 07/11/2023- 5.0 ug/mL 07/14/2023- <3.5 ug/mL 07/18/2023- <3.5 ug/mL 07/21/2023- <3.5 ug/mL 07/28/2023- 6.5 ug/mL Target Trough: 10-20 ug/ml It is noted all of the above trough levels were sub therapeutic. A review of Resident #1's Pharmacy Records dated July 2023 revealed the following: 07/07/2023 at 5:18 p.m., Fax received for re-admit physician orders as follows: (start date 07/07/2023 stop date: 07/29/2023) Vancomycin 1.25 gm/250 ml 0.9% NS infuse IV every 12 hours for Stage 4 Sacral Wound for 21 days. 07/07/2023 at 6:22 p.m., 6 doses of Vancomycin sent 07/10/2023 at 2:16 p.m., Nurse said she gave Vancomycin dose at 10:00 a.m. The facility has 5 doses left so that was the only dose given. I faxed the Vancomycin dosing form twice today but she doesn't see the form. Nurse stated labs came back at 3.5 ug/mL. I asked several times to speak with the NP and was told he was busy. Nurse stated they had enough Vancomycin until labs are ordered to be drawn on 07/11/2023. 07/10/2023, 5 remaining doses of Vancomycin in facility at 2:00 p.m. 07/11/2023 at 5:08 p.m., Called and no one answered. Need Vancomycin count. 07/12/2023, 4 remaining doses of Vancomycin in facility at 3:15 p.m., obviously not being given correctly 07/13/2023, 1 dose of Vancomycin sent, 2 doses remaining in facility at 2:44 p.m. 07/14/2023 at 11:43 a.m., Spoke with nurse. Told her we have not been able to get consistent labs or answers since we got this patient and doses are not being given correctly. Labs were not draw again today. I told her we will send enough to get through Monday but if labs aren't drawn on Monday then they will be cutting this patient off unless the doctor and DON are involved. 07/14/2023, 6 doses of Vancomycin sent, 1 dose remaining at 11:35 a.m. 07/17/2023- 0 doses of Vancomycin remains in facility at 1:15 p.m. 07/18/2023 at 12:53 p.m. spoke with S6ADON again about not being able to obtain any information on this patient. S6ADON stated trough was done that morning so I told her to call back with results. 07/18/2023 at 2:23 p.m., Per S6ADON lab results were 3.7 ug/mL, I'm willing to bet they have not been giving the Vancomycin. I have no idea where the Vancomycin is going. I will send 1 dose for tonight and 2 for tomorrow. I will contact the doctor because this patient is not being treated appropriately. 07/18/2023 at 2:37 p.m., 3 doses of Vancomycin, 0 remaining. 07/19/2023 at 7:41 a.m., Spoke with S3DON. I told her we had problems getting the correct information needed. I read her my notes to help her understand the problems we had been having and the lack of care/concerns. I told her we will no longer be dosing for this facility, we will require Dr. to dose form faxed to us. Pharmacy gave specific instructions on what was needed. 07/20/2023 at 11:06 a.m., Spoke with nurse who informed Pharmacy Resident #1 line came out so they were waiting for replacement. They have 1 Vancomycin on hand. Instructed her to follow up with labs. Will send out 1 dose of Vancomycin. Dr. to dose sheet faxed. 07/20/2023, 1 dose of Vancomycin sent 07/21/2023 at 7:27 a.m., Dr. to dose form faxed. 07/21/2023 at 11:15 a.m., Called phone rang off hook. 07/21/2023 at 4:10 pm., No labs yet 07/24/2023 at 8:36 a.m., Spoke with nurse who was looking for Vancomycin. I told her we never received labs or MD orders. I told her we need this. We cannot keep sending Vancomycin without any information. Faxed new dose form with all needed to comment section at 8:39 a.m. 07/24/2023 at 9:28 a.m., Spoke with S2NP and he wanted to find out what was needed and what was going on. I gave him all the information needed. 07/24/2023, 5 doses of Vancomycin sent 07/26/2023 at 2:38 p.m., Called, rang, no answer. 07/26/2023, 6 doses of Vancomycin sent, 1 dose remaining at 3:00 p.m., should have 2 for today On 08/01/2023 at 9:20 a.m., an interview was conducted with S10LPN. She stated when a medication was administered, it was documented on the MAR. She stated if the MAR was left blank then it meant the medication was not administered. On 08/01/2023 at 12:30 p.m., an interview was conducted with S3DON. She stated the nurses were expected to request a medication refill prior to the medication running out. She reviewed Resident #1's MARS of June and July 2023 and confirmed Vancomycin and Cefepime was not administered as ordered and should have been. On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. He confirmed he was familiar with Resident #1. He stated Vancomycin was ordered on 06/13/2023 for an infected pressure ulcer. He reported reviewing the Vancomycin trough labs and realized the resident was not receiving the medication because the labs were sub therapeutic and not rising. He stated he notified administration about Resident #1 not receiving the Vancomycin. S2NP stated he remembered in June being contacted by a nurse to clarify to give the last dose of Vancomycin since so many doses had been missed. At that time he gave an order to give the last dose. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for higher level of wound treatment. He stated he spoke to the nurses and educated them on the importance of receiving the medication and how they needed to follow the orders to give Vancomycin. He reported the resident retuned to the facility on [DATE] with orders for Vancomycin and Cefepime. He stated Resident #1 had multiple missed doses of Vancomycin in July 2023. He stated the pharmacy wanted the nurses to communicate trough levels via fax prior to the medication being sent. S2NP stated he educated the nursing staff and the administration on the pharmacy's new protocol. He stated the nursing staff did not communicate Resident #1 missed doses of either Vancomycin or Cefepime. On 08/01/2023 at 1:21 p.m., a phone interview was conducted with S8RN. He confirmed working the weekend of 06/18/2023-06/19/2023. He stated a nurse reported Resident #1's Vancomycin was not available for administration. He said he directed the nurse to contact the pharmacy and the provider if she could not reach the pharmacy. He stated he did not know if the nurse contacted the pharmacy or if the medication was received and given. He confirmed he did not follow up with the nurse after she reported the medication as unavailable. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She confirmed working on 07/22/2023 and 07/23/2023. She stated she did not administer Resident #1's Vancomycin on either day because the medication was not available. She stated she was not trained on the procedure if a resident was out of medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated knew Resident #1 did not receive ordered Vancomycin in June 2023. She stated she in-serviced the floor nurses in June on Antibiotic Administration. She stated the nurses did not know the process for obtaining medications from the pharmacy when a resident was out. She stated if the medication was not available the nurses would not administer it and move on. She stated the nurses would not communicate missing medications with herself or the NP. She stated the in service included education on communicating with the ADON, DON, NP and the process to follow if a medication was not available. She stated on 07/11/2023, she received a call from the pharmacy requesting a trough level for Vancomycin and an order from the provider on the plan of care. She stated she educated and instructed the ADON's to oversee the Vancomycin trough levels and the NP order form. She stated the ADON's were responsible to communicate with the pharmacy and the NP. On 08/02/2023 at 3:30 p.m., a telephone interview was conducted with contracted pharmacist. She stated the first time the pharmacy received an order for Resident #1 to start Vancomycin was on 06/19/2023. She confirmed the pharmacy did not receive an order for Resident #1 on 06/13/2023 and therefore did not send medication prior to 06/19/2023. She stated on 06/19/2023, the pharmacy sent 5 bags of Vancomycin to the facility. She stated on 06/21/2023, the facility requested 2 more bags of Vancomycin because they were out. The pharmacist said she sent 2 bags at that time, but the facility should not have been out of the medication. She stated the nurses reported they were giving the medication as ordered, but the Vancomycin trough levels suggested Resident #1 was not receiving the medication appropriately. She stated she called and communicated the suspected missing doses with S3DON in June 2023. She reported the facility had poor communication with pharmacy and would not provide needed information. She reported in July 2023, the pharmacy had the same issues with the facility and missing doses of medication so she spoke with 3DON again. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. If a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON and DON. He stated the nurses did not report Resident #1 was out of Vancomycin in June or July 2023. He stated the medications should have been administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated Resident #1 was not getting Vancomycin trough labs drawn so the Pharmacy would not send the Vancomycin in June 2023. She confirmed working on the morning of 06/18/2023. She stated she did not give Resident #1's Vancomycin as ordered because it was not available. She stated she notified S2NP and told him she did not have the medication. She stated she did not notify the Pharmacy. On 08/04/2023 at 10:45 a.m., an interview was conducted with S6ADON. S6ADON confirmed knowing Resident #1 had missed doses of Vancomycin in June 20203. She explained in July 2023, S3DON instructed her to oversee the trough levels and communication with the lab and pharmacy. She stated after receiving trough results from the lab, she would then fax the labs to the pharmacy. She confirmed it was unacceptable that Resident #1 missed intravenous Vancomycin and Cefepime. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. S3DON said if a resident's MAR was not initialed by the nurse, it meant the medication was not given. She also said if the MAR had circled initials, it also meant the medication not given. She reviewed Resident #1's clinical record and confirmed Resident #1 had an order for Vancomycin to start on 06/13/2023. She stated she did not know the resident missed doses of Vancomycin until 06/19/2023. She said the nurses did not know the process to follow if a resident was out of medications, so they did not give it. Resident #2 A review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, UTI, and Type 2 Diabetes Mellitus. A review of Resident #2's Physician's Orders dated July 2023 revealed an order dated 07/12/2023 for Meropenem 1 gram IV every 8 hours for 7 days. Diagnosis: UTI. Further review revealed an order for Humalog sliding scale: 0-120: 0 units; 121-150: 2 units; 151-200: 4 units; 201-250: 6 units; 251-300: 9 units; 301-350: 12 units; 351-400: 15 units and call MD. A review of Resident #2's MAR dated July 2023 revealed Meropenem 1 gram IV every 8 hours was documented as not given on 07/14/2023 at 6:00 a.m. or 10:00 p.m., 07/15/2023 at 6:00 a.m. or 10:00 p.m., 07/16/2023 at 6:00 a.m., and 07/18/2023 at 10:00 p.m Further review of Resident #2's July 2023 MAR revealed: 07/14/2023 at 4:30 p.m., Accucheck result of 165 and no documentation of insulin administered. 07/19/2023 at 7:30 a.m., Accucheck result of 135 and no documentation of insulin administered. 07/27/2023 at 4:30 p.m., Accucheck result of 218 and documentation of incorrect insulin dose of 4 units administered. A review of Resident #2's nurses' notes revealed no documentation as to why the resident did not receive Meropenem, the incorrect insulin administrations or if the physician was notified. On 08/02/2023 at 11:18 a.m., an interview was conducted with S3DON. S3DON reviewed Resident #2's July 2023 MAR. She confirmed there were blank boxes on the MAR that correlated with the above dates. She verified the blank boxes on the MAR meant the medication was not given. On 08/02/2023 at 12:10 p.m., an interview was conducted with S2NP. He verified he was not notified that Resident #2 missed doses of intravenous Meropenem in July 2023. He also confirmed he was not aware the resident received incorrect insulin coverage in July 2023. On 08/02/2023 at 1:50 p.m., an interview was conducted with S12LPN. S12LPN reviewed Resident #2's July 2023 MAR. She verified the boxes for administration times on 07/14/2023, 07/15/2023, 7/16/2023 and 07/18/2023were blank. She stated if the boxes on the MAR were blank it meant the medication was not administered. Resident #3 A review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses, which included Anoxic Brain Damage, Tracheostomy, Osteomyelitis, Congestive Heart Failure, Pressure Ulcer to Left Buttock, Stage 4, Pressure Ulcer of Sacral Area, Stage 4, and Pressure Ulcer to Right Buttock, Stage 4, Gastrostomy Status, and Chronic Respiratory Failure A review of Resident #3's Physicians Orders for June 2023 revealed the following: 06/26/2023, Meropenem 1gm IV every 8 hours for 26 days; 06/26/2023, Albuterol 0.633 mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Budesonide 0.5 mg/2mL give 2 mL via neb BID x14 days; 06/26/2023, Duo-neb 0.5-3mg/3mL give 3 mL via neb every six hours prn wheezing; 06/26/2023, Lasix 40 mg administer one tablet per peg twice a day; and 06/26/2023, Levetiracetam 500 mg administer one tablet per peg twice a day. A review of Resident #3's Medication Administration Record (MAR) for June 2023 revealed Meropenem 1gm IV every 8 hours was not administered on 06/28/2023 at 2:00 p.m.; Lasix 40 mg 1 tablet per peg twice a day was not administered on 06/28/2023 at 6:00 a.m. and 6:00 p.m. and on 06/29/2023 at 6:00 a.m. and Keppra 500mg 1 tablet per peg tube twice a day was not administered on 06/28/2023 at 6:00 a.m. A review of the respiratory therapy documentation for Resident #3 revealed Budesonide 0.5 mg/2mL give 2 mL via nebulizer BID was not administered on 06/26/2023, 06/27/2023, or 06/28/2023. A review of the Transfer Log revealed Resident #3 was transferred to the emergency room on [DATE] due to a critical H&H. A review of Resident #3's Physicians Orders for July 2023 revealed the following: 07/01/2023, Albuterol-Ipratropium 2.5mg-2.5/3mL give 3mL by neb every six hours; 07/01/2023 and 07/19/2023, Levetiracetam 500mg/5mL administer 5mL per peg twice daily; 07/19/2023, Lasix 40 mg administer one tablet per peg daily; 07/19/2023, Enoxaparin 40 mg administer subcutaneous daily; and 07/19/2023, Duo-neb 2.5-0.5 mg/3 mL give 3mL via neb every six hours A review of Resident #3's Medication Administration Record (MAR) for July 2023 revealed the following: Lasix 40 mg 1 tablet per peg tube twice a day was not administered on 07/01/2023 at 6:00 p.m. or 07/28/2023 at 5:00 a.m.; Levetiracetam 500mg/5mL solution, 5 mL solution per peg tube twice a day was not administered on 07/03/2023 and 07/28/2023 at 6:00 a.m., 07/04/2023, 07/20/2023 and 07/21/2023 at 6:00 p.m. and Enoxaparin 40 mg/0.4mL (0.4 mL=40 mg) into the skin subcutaneous daily was not administered on 0

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident. The facility failed to ensure a functional system was in place to acquire, receive, transcribe, and implement accurate physician orders for 7 ( #1,#2,#3,#4, #R1, #R2, #R3) out of 8 ( #1, #2, #3, #4, #5, #R1, #R2, #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. From 06/15/2023 through 06/19/2023, Resident #1 missed 7 of the 10 doses ordered of intravenous Vancomycin which resulted in further wound infection. On 06/22/2023, S2NP transferred Resident #1 to the emergency room after noting the sacral wound had a foul odor and purulent drainage. Resident #1 returned to the facility on [DATE] with a new Physician's Order to continue intravenous Vancomycin for the Sacral Wound Infection. Nursing staff continued to miss doses of the intravenous Vancomycin as ordered. This deficient practice resulted in an Immediate Jeopardy situation for Resident #3 on 06/26/2023 when respiratory staff failed to administer scheduled breathing treatments twice a day as ordered. Resident #3 had a tracheostomy and was oxygen dependent. On 07/01/2023 and 07/19/2023 nursing staff failed to communicate new orders to respiratory staff. During this time, nursing staff also failed to administer oral, subcutaneous, and IV medications. On 07/15/2023 Resident #3 was found with a faint pulse and with decreased oxygen levels. Resident #3's respirations were labored and shallow. Resident #3 required tracheostomy suctioning, became apneic and required manual breathing. This led to a hospitalization on 07/15/2023 for respiratory distress. This deficient practice resulted in an Immediate Jeopardy situation for Resident #R1 on 07/21/2023, a ventilator dependent resident, when respiratory staff failed to administer scheduled breathing treatments every 8 hours as ordered. Resident #R1 did not receive scheduled breathing treatments after 4:00 p.m. on 07/21/2023 through 07/25/2023, which resulted in the resident experiencing respiratory distress. Resident #R1 was admitted to the hospital on [DATE] with a diagnoses of Sepsis with Severe Septic Shock. Resident #R1 returned to the facility on [DATE] with a Physician's Order for intravenous Cefepime. On 08/02/2023 nursing staff failed to administer the 6:00 a.m. dose of Cefepime to Resident #R1. On 08/02/2023 at 1:00 p.m., an observation was made of Resident #R1 receiving intravenous Meropenem, which was not prescribed to Resident #R1. Resident #R1 was readmitted to the hospital on [DATE] with a diagnoses of Sepsis with Septic Shock, Pneumonia and Hypoxia. S1ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 7:01 p.m. The Immediate Jeopardy was removed on 08/08/2023 at 2:20 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of removal: The following actions were taken immediately upon notification on 08/04/2023 to correct noncompliant practices. 1.) Medication Administration, Documentation and Translation of orders: In-services were conducted with weekend staff to ensure all nurses were educated on medication administration, documentation, translation, antibiotic administration, medication availability, pharmacy communication process and communication between Nursing and Respiratory Staff. -100% of all residents' medical records were reviewed to ensure accuracy of physician orders. - Medication pass observations were done on every nurse on every shift during the entire weekend by one of either the DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. -100% of all medication carts were looked at and cleaned up by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. Pharmacy communication policy and guidelines were immediately put in place by DON, Regional Corporate Consulting Nurse, ADONs and RN Supervisor to ensure competency and compliance. -All residents' receiving antibiotics were identified and a surveillance spreadsheet was created for direct observation of nurses administering the medication. -Education was provided to nursing staff in the case that antibiotics were unavailable. Nurses were educated to contact MD, DON and RR Nurses were educated on documenting the unavailability of antibiotic and what steps were taken. All residents receiving Respiratory orders were identified and compared to the Respiratory Medication Administration Record. - Nurses and Respiratory therapists were educated on communicating new Respiratory orders. All shifts beginning on 08/04/2023 night shift through 08/07/2023 day shift were educated and observed on medication administration, documentation and translation; antibiotic administration, and communication between nursing and respiratory therapist on new and existing orders. -All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until QA board deems monitoring has been effective by September 22, 2023). Policies have been reviewed. No changes determined to be necessary. 2.) Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. Actions taken/systems put into place to reduce the risk of future occurrence include: -On 08/04/2023, Administrator and DON were educated by Regional Corporate Consulting Nurse regarding the job duties and responsibilities associated with administering medications as ordered (by mouth, intravenous, respiratory), the 5 Rights to medication administration and medication availability. Completed by 08/04/2023. The following training with nurses and respiratory therapists began on 08/04/2023 and will be completed by 08/09/2023: -Immediate complete competency checks on existing nursing staff related to medication administration (see new process attached), documentation, and transcription of orders. -New staff and contract staff will be educated on AHT, medication administration processes, documentation, transcription, medication refill process and pharmacy communication. All competencies will be completed before working independently with residents. -Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. -Nurses responsible to send medication refills when indicated. Stickers to be pulled from medication blister packs when indicated and faxed to pharmacy. -Nurse to initial, time and date fax sheet that was sent to pharmacy. Once faxed, sheet to be put in ADON boxes. Pharmacy delivery receipts to be placed in ADON boxes once medication arrives at facility. -Power point education to be handed out to entire nursing staff explaining order entering, skin assessments, admission processes, and skilled documentation. A copy of all education will be laminated and placed on all med carts. The Administrator will review the implementation of the following beginning on 08/04/2023 and will be completed by 09/22/2023: -All nurses will complete an initial medication pass observation, observed by DON or designee. Random medication passes will be performed throughout the quarter. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). - For ongoing compliance, the DON or designee will conduct weekly medication cart, EMR and medication storage audits starting weekly x 4, then monthly ongoing for Quality Control and to ensure availability of medications for administration. -The DON and or designees will also conduct medication administration observations at random, 1 on each shift, weekly x 4, then ongoing CQI. -The DON or designee will notify the administrator of the findings of the audit and medication administration observation. -ADONs to review pharmacy delivery receipts daily and compare with faxed medication sheets to ensure all medications have been delivered. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). -ADONs or designee to communicate with pharmacy (Monday-Friday) to ensure receipt of faxes. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). Oversight by DON or designee of pharmacy process weekly. -Weekly in-services targeted to reorient current nursing staff on Antibiotic availability and administration, Al-IT, Medication administration, documentation, and transcription to be completed by ADONs and DON. (To continue to be monitored until quarterly QA board deems monitoring has been effective by September 22, 2023). -All new orders to be pulled and checked by ADON's or designee daily (Monday through Friday) in the morning. Oversight by DON or designee weekly. -Communication between Nursing and Respiratory on any new and existing Respiratory orders by providing new admission or readmission order set to Respiratory Manager or designee. New orders to be copied and handed to Respiratory Manager or designee. Daily monitoring by Respiratory Manager or designee or new orders to be placed in Respiratory box. -The Regional Nurse or designee will conduct quarterly checks to determine compliance with the completion of the audits by the DON or designee and to identify trends and areas of continued noncompliance. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: This plan of correction will be monitored at the monthly Quality Assurance meeting. QA Board to deem effective systems in place by September 22, 2023 via DON report of findings, to assure consistent substantial compliance. This plan of correction will be monitored at the Quality Assurance meeting at least quarterly, optimal monthly at QA progress meetings to ensure consistent substantial compliance. This deficient practice continued at more than minimal harm for the remaining residents identified by the facility as receiving medications. Findings: Cross reference: F-726 Cross Reference F-684 On 08/01/2023 at 12:45 p.m., an interview was conducted with S2NP. S2NP stated in June 2023, he was aware Resident #1 was not receiving intravenous Vancomycin as ordered for an infected pressure ulcer. He stated he notified facility's DON about it. He stated Resident #1's wound abscessed and he sent Resident #1 to the hospital for a higher level of wound treatment. S2NP stated Resident #1 returned to the facility on [DATE] with orders for intravenous Vancomycin and Cefepime. He stated after re-admission, the nurses continued to fail to administer IV antibiotics as ordered. On 08/01/2023 at 1:21 p.m., a telephone interview was conducted with S8RN. He stated he was the RN Supervisor on weekends. He stated a nurse had informed him intravenous Vancomycin was not available on the weekend of June18th - June 19th. He stated he did not remember which resident. S8RN sated he instructed the nurse to follow up with the provider and pharmacy. He stated he did not follow up with the nurse to verify the medication was available and administered. On 08/01/2023 at 4:05 p.m., an interview was conducted with S15LPN. She stated she was not trained on the procedure to follow when a resident's medication was unavailable. On 08/02/2023 at 1:00 p.m., an observation of Resident #R1 was performed. S3DON observed the bag of IV medicine hanging and verified the bag of medicine was full and labeled for 6:00 a.m., therefore the resident missed that dose. The label on the bag of IV medicine infusing was observed and had a different resident's name. S3DON confirmed Meropenem was infusing and Resident #R1 was not prescribed Meropenem. She verified Resident #R1 was prescribed Cefepime 2 gm/100 ml IV every 8 hours and confirmed the resident received the wrong medication. On 08/02/2023 at 2:00 p.m., an interview was conducted with S3DON. She stated she was aware Resident #1 did not receive intravenous Vancomycin as ordered in June 2023. She stated the nurses did not know the process for obtaining medications from the pharmacy when medications were unavailable. She stated the nurses had not communicated missing medications to her or the NP. She stated she educated nursing staff in June 2023 on the process for acquiring medications if they were not available. She verified residents were not receiving medications as ordered following her educating staff. On 08/02/2023 at 3:30 p.m., an interview was conducted with the contracted pharmacist. She stated she called S3DON in June 2023 and again in July 2023 to report she suspected IV antibiotics were not being administered as ordered and nursing staff were not communicating the Vancomycin trough levels and NP orders to the pharmacy. On 08/03/2023 at 12:40 p.m., an interview was conducted with S22RT. She confirmed the respiratory department administered all nebulizer treatments. She stated the respiratory department does not have access to electronic medical records. She stated the process should be for the nurses to bring a copy of new orders to the respiratory department so they can be implemented. She confirmed the respiratory department did not receive new orders for Resident #3 on 07/02/2023 for Albuterol-Ipratropium 2.5mg-2.5/3mL or on 07/19/2023 for Duo-neb 2.5-0.5 mg/3mL. She verified if the respiratory department did not receive the orders then the medications were not administered. She confirmed Budesonide 0.5 mg/2mL via nebulizer was not administered to Resident #3 for the p.m. doses on 06/26/2023, 06/27/2023 and 06/28/2023 and could not verify why the doses were missed. On 08/03/2023 at 2:26 p.m., an interview was conducted with S21RTD. She verified Iprat-Albut 0.5-3(2.5) mg/3 ml was not documented as administered for Resident #R3 from 07/21/2023 through 07/25/2023 when the resident was transferred to the hospital. S2RTD reported there were no processes in place to ensure residents received respiratory medications and treatments as ordered. On 08/03/2023 at 3:11 p.m., an interview was conducted with S5ADON. He stated it was the nurse's responsibility to communicate new medication orders with the pharmacy. He stated if a medication was unavailable, the nurse should communicate with the pharmacy, NP/MD, ADON, and DON. He stated medications should have been available and administered as ordered. On 08/04/2023 at 10:10 a.m., an interview was conducted with S16LPN. She stated she did not give Resident #1's intravenous Vancomycin as ordered because it was not available. She stated she did not notify the Pharmacy.