**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews for two Residents (#94 and #38) out of a total sample of 29 residents, the facility failed to notify the Physician/Nurse Practitioner (NP) of the need to significantly alter treatment (need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Specifically, 1. For Resident #94, the facility failed to notify the Physician/NP of the Resident's uncontrolled pain during indwelling urinary catheter care and 34 missed doses of Lidocaine (pain medication) Gel, out of 46 ordered doses, to be applied topically for the Resident's genital pain resulting in ineffective pain management. 2. For Resident #38, the facility failed to notify the Physician/NP when the Resident's Atovaquone Oral Suspension medication (antiviral medication), Mycophenolate Mofetil Oral Suspension medication (immunosuppressant medication) and Xylimelts Mouth/Throat Disk medication (artificial saliva medication) were not received from the pharmacy resulting in symptoms of persistent dry mouth and double vision. Findings include: Review of the facility's policy titled Change in a Resident's Condition or Status, dated 2001, indicated: -The nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly. -Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring the resident's medical condition or status. -The nurse will record in the resident's medical records relative to changes. 1. Resident #94 was admitted to the facility in September 2022 with diagnoses including Urinary Tract Infection (UTI), retention of urine, and Urethral Erosion (tearing of the urethra in individuals who have had indwelling urinary catheters for a prolonged period of time). Review of Resident #94's Pain Care Plan, initiated 9/27/22, indicated: -The Resident had generalized pain. -Administer pain medication per Physician orders. -Notify Physician if pain frequency/intensity is worsening or of [sic] current analgesia regimen has become ineffective. -Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying . Review of Resident #94's Skin Breakdown Care Plan, initiated 2/3/25, indicated: -The Resident had skin breakdown related to slit on his/her genitals. -Administer treatment per Physician orders. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #94: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -has an indwelling urinary catheter. -was dependent on staff for bathing. -reported pain, almost constantly, at a level of eight out of 10 (severe). Review of the Nurse Practitioner (NP) Note dated 3/24/25, indicated Resident #94: -was assessed for worsening genital slit from chronic indwelling urinary catheter. -stated having occasional pain to his/her genital area when the indwelling urinary catheter was moved. -will have Lidocaine gel (topical medication used to treat pain) ordered to be applied BID (twice daily) PRN (as needed) for pain. Review of Resident #94's April 2025 Physician orders indicated: -Provide catheter care every shift, start 10/2/24. -Lidocaine external gel 0.5% (percent), apply to genital slit topically two times a day for pain, start 3/24/25. Review of Resident #94's April 2025 Medication Administration Record (MAR) indicated: -ordered Lidocaine Gel (to be applied to the Resident's genital slit) was coded as not administered due to absence of condition/not applicable. -ordered Lidocaine Gel was not administered for 30 out of 46 scheduled doses between 4/1/25 and 4/23/25. Review of Resident #94's April 2025 Treatment Administration Record (TAR) indicated: -Catheter care was provided every shift (three times daily) between 4/1/25 and 4/23/25. -The Resident reported pain to his/her genital area on 19 out of 23 days reviewed. Review of Resident #94's Non-Pressure Skin Condition Record dated 4/23/25, indicated the Resident's genital slit measured 3.0 centimeters (cm) x (by) 3.0 cm x 0.1 cm. On 4/23/25 at 10:31 A.M., surveyor #2 with Nurse #10 observed the following pertaining to Resident #94's indwelling urinary catheter: -Nurse #10 requested permission from Resident #94 for Nurse #10 and surveyor #2 to observe the indwelling urinary catheter. -Resident #94 furrowed his/her brow and clenched his/her teeth. -Nurse #10 said she knew the Resident's genital area was tender and that she just needed to see the catheter. -The Resident allowed the observation. -The surveyor observed the Resident's genital area to have a large slit. -Nurse #10 lifted the Resident's indwelling urinary catheter tubing and the Resident furrowed his/her brow, clenched his/her teeth, raised his/her hands in the air and clenched his/her fists. -When the observation was complete, Nurse #10 exited the room. During an interview on 4/23/25 at 2:15 P.M., Resident #94 said he/she had no pain in the genital area when staying still and that he/she always had pain whenever staff provided urinary catheter care and/or moved the catheter. Resident #94 said he/she was not aware of any topical medication being provided for genital pain at the catheter site. Resident #94 said staff just tell him/her they know the urinary catheter care hurts and is sore, and that they just need to keep him/her clean. Resident #94 said once staff stop manipulating the urinary catheter, the pain stops. During an interview on 4/23/25 at 5:00 P.M., Nurse #10 said Resident #94 always has pain when his/her urinary catheter was manipulated and that the pain would stop when procedures for the catheter were complete. Nurse #10 said that Resident #94 had Lidocaine Gel ordered to be applied to the Resident's genital area at the catheter site BID and that the Lidocaine Gel had not been applied that day. Nurse #10 also said the Lidocaine Gel had been unavailable for quite some time. The surveyor and Nurse #10 reviewed Resident #94's April 2025 MAR and Nurse #10 said the Lidocaine Gel was last administered to the Resident on 4/6/25 (17 days prior). Nurse #10 said the NP was in the facility daily and that staff would notify the NP of residents' changes in condition and need to alter treatment. Nurse #10 said she did not know when the NP was notified of the Lidocaine Gel being unavailable. Nurse #10 also said she was not sure if the NP was notified of the missed Lidocaine Gel doses and the Resident's pain during indwelling catheter care procedures. During an interview on 4/24/25 at 12:27 P.M., the NP said she worked in the facility five days per week and that Resident #94 was one of the Resident's she provided services for. The NP said staff had not communicated to her that Resident #94 always had pain when staff provided procedures to the Resident's urinary catheter site. The NP also said she did not know the Resident's Lidocaine Gel was not being administered and was not available. The NP said if staff had made her aware of the Resident always having pain during urinary catheter procedures, she would have reassessed the Resident's pain and provided orders for effective pain management. The NP said if she had known the Lidocaine Gel was not available for Resident #94, she would have provided alternate instructions for pain management. 2. Resident #38 was admitted to the facility in February 2025, with diagnoses including Myasthenia Gravis, Thrombophilia, Malignant Melanoma of Skin, Atherosclerotic Heart Disease, Drug-Induced Myopathy, Acute and Chronic Respiratory Failure with hypercapnia and recurrent enterocolitis due to Clostridium Difficile (C-DIFF). Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #38 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 15 out of 15. During an interview on 4/17/25 at 8:37 A.M., Resident #38 said that he/she had not received a few of his/her medications and every time he/she would ask, the facility staff would inform him/her that the medications were on back order. Resident #38 said the medications were very important as one of the medications was his/her immunosuppressive medication related to receiving chemotherapy for Melanoma diagnosis, one medication was to combat extreme dry mouth related to the side effects of the chemotherapy medication, and another medication helped to decrease double vision symptoms. Review of Resident #38's April 2025 Physician's orders indicated: -Atovaquone Oral Suspension 750 milligrams (mg)/5 milliliter (ml), Give 10 ml by mouth one time a day for antiviral, ordered 2/14/25. -Mycophenolate Mofetil Oral Suspension 200 mg/ml, Give 5 ml every 12 hours for supplement, ordered 2/14/25. -XyliMelts Mouth/Throat Disk 550 mg, Give 2 wafers by mouth at bedtime for dry mouth, ordered 3/17/25. Review of Resident #38's Medication Administration Records (MARs) indicated: >February 2025: -Atovaquone Oral Suspension medication was documented as 9 (Not Available), from 2/16/25 to 2/28/25. -Mycophenolate Mofetil Oral Suspension medication was documented as 9 (Not Available), 17 times from 2/14/25 to 2/23/25. >March 2025: -XyliMelts Mouth/Throat Disk 550 mg medication was documented as 9 (Not Available) and 13 (Does not Apply) from 3/17/25 to 3/30/25 daily. -Mycophenolate Mofetil Oral Suspension medication was documented as 9 (Not Available) from 3/16/25 to 3/31/25. -Atovaquone Oral Suspension medication was documented as 9 (Not Available) six times in the month of March. >April 2025: -XyliMelts Mouth/Throat Disk 550 mg medication was documented as 9 (Not Available) and 13 (Does not Apply) from 4/1/25 to 4/25/25 daily. -Mycophenolate Mofetil Oral Suspension medication was documented as 9 (Not Available) and 13 (Does not Apply) from 4/1/25 to 4/25/25 daily. -Atovaquone Oral Suspension medication was documented as 9 (Not Available) and 13 (Does not Apply) from 4/1/25 to 4/17/25. On 4/24/25 at 11:02 A.M., the surveyor and Unit Manager(UM) #2 reviewed Resident #38's April 2025 MAR. UM #2 said Resident #38's XyliMelts, Mycophenolate Mofetil, and Atovaquone medications were documented as Not Available. During an interview on 4/24/25 at 12:16 P.M., the Nurse Practitioner (NP) said she was made aware of Resident #38's medication not being available one time when the Resident was first admitted but had not been made aware that the medications were consistently not available. During a follow-up interview on 4/24/25 at 1:20 P.M., the DON said UM #2 had left a message for Oncology about Resident #38's medications not being available, but UM #2 did not receive a return call from Oncology. The DON said that the facility had not made any effort to follow-up with Oncology. The DON said that UM #2 forgot to write a note in the Resident's clinical record when she had left the message for Oncology. The DON provided the survey team a late entry note that indicated UM #2 left a voicemail for Oncology on 4/8/25. During a follow-up interview on 4/25/25 at 12:27 P.M., the NP said she was made aware of the medications not being available on 4/24/25, after the surveyor started making inquiries about the Not Administered medications. The NP said she would have hoped the facility staff would have notified her that the Resident's medications had not been administered before it went this long. The NP said since the medications were ordered by the Resident's Oncologist, she would have referred the Resident back to the Oncologist but she had not. Please refer to F690, F697, F755, and F865.

Based on observations, interviews, and record reviews, the facility failed to ensure that effective pain management that was consistent with professional standards of practice and the Resident's comprehensive person-centered care plan was provided for one Resident (#94) out of a total sample of 29 residents. Specifically, for Resident #94, the facility failed to: -adequately assess the Resident's pain during personal care of an indwelling urinary catheter when facility staff were aware the Resident had a genital wound and experienced pain during urinary catheter care, resulting in the Resident experiencing pain during indwelling urinary catheter related procedures. -provide interventions for pain management during personal care of an indwelling urinary catheter which resulted in the Resident anticipating and experiencing pain relative to indwelling urinary catheter care. -offer alternate pain interventions when prescribed pain medication specifically ordered for genital pain related to the Resident's genital wound was unavailable which resulted in the Resident experiencing pain. Findings include: Review of the facility's policy and procedure titled Pain Assessment and Management, dated 2001 and revised October 2022, indicated the following: >The purpose of the procedure was to help staff -identify pain in the resident. -develop interventions consistent with the resident's goals and needs. -address the underlying causes of pain. >Pain management is defined as the process of alleviating the resident's pain based on his/her clinical condition and established treatment goals. >Pain management includes the following: -Assessing the potential for pain. -Recognizing the presence of pain. -Identifying the characteristics of pain. -Addressing the underlying cause of pain. -Developing and implementing approaches to pain management. -Identifying and using specific strategies for different levels and sources of pain. -Modifying approaches as necessary. -Observe the resident (during rest and movement) for psychologic and behavioral (non-verbal) signs of pain. >Possible behavioral signs of pain include: -Negative verbalizations and vocalizations such as groaning, crying, screaming. -Facial expressions such as grimacing, frowning, clenching of the jaw, etc. -Behavior such as resisting care. -Assess the resident . to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment. -If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Resident #94 was admitted to the facility in September 2022 with diagnoses including Urinary Tract Infection (UTI), retention of urine, adjustment disorder with anxiety, and urethral erosion (tearing of the urethra in individuals who have had indwelling urinary catheters for a prolonged period of time). Review of the Pain Care Plan, initiated 9/27/22, indicated Resident #94: -had generalized pain. -has a goal to express that pain management was within acceptable limits. -had adjusted times of activities of daily living (ADLs) and treatment activities so that they occur after analgesia benefits have been achieved. -pain medication administration per Physician orders. -if pain frequency/intensity is worsening or of [sic] current analgesia regimen has become ineffective, notify Physician. -report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, . Review of Resident #94's SBAR (Situation, Background, Appearance, Review and Notify) Note, dated 2/3/25, indicated: -The Resident experienced a change in condition relative to a slit on his/her genital area. -The Nurse Practitioner (NP) was notified of the Resident's change in condition. Review of Resident #94's Skin Breakdown Care Plan, initiated 2/3/25, indicated: -has skin breakdown related to slit on his/her genitals. -Administer treatment per Physician orders. Review of Resident #94's NP Note, dated 2/3/25, indicated: -has an indwelling urinary catheter in place. -presented with a wound on his/her genital area. -was in no apparent distress. -plan for application of Bacitracin (antibacterial ointment) to the wound site. -continue pain medication regimen. Review of the Minimum Data Set (MDS) Assessment, dated 2/27/25, indicated Resident #94: -was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13 out of 15 total possible points. -has an indwelling urinary catheter. -was dependent on staff for bathing. -reported pain, almost constantly, at a level of 8 out of 10 (severe). Review of Resident #94's Telehealth Note, dated 3/23/25, indicated: -The Resident was being seen for edematous (swollen) genital area that was split open. -okay to apply Bacitracin to keep skin moist and prevent bacterial transmission. -diagnoses included laceration without foreign body of [genital site]. Review of Resident #94's NP note, dated 3/24/25, indicated: -was assessed for worsening genital slit from chronic indwelling urinary catheter. -Resident stated having occasional pain to his/her genital area when the indwelling urinary catheter was moved. -will order Lidocaine Gel (topical medication used to treat pain) to be applied BID (twice daily) PRN (as needed) for pain. Review of Resident #94's NP Note, dated 4/17/25, indicated: -was assessed for blood noted to his/her indwelling urinary catheter site. -At the time of the NP visit, the Resident presented with a scant amount of blood in his/her incontinence brief. -The Resident denied pain. -Continue Lidocaine Gel to be applied BID for pain/discomfort. Review of Resident #94's April 2025 Physician orders indicated: -Pain score every shift (0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-10 = severe pain), start date 9/27/22. -Provide catheter care every shift, start date 10/2/24. -Acetaminophen oral tablet 500 milligrams (mg), give 1000 mg by mouth every eight hours for pain, start date 10/9/24. -Skin documentation - Slit/genital area. Every shift for pain and infection, dated 2/3/25. -Tramadol HCL (opioid pain medication) oral tablet 50 mg, give 25 mg by mouth every 24 hours as needed for pain, start date 3/20/25. -Lidocaine External Gel 0.5% (percent), apply to genital slit topically two times a day for pain, start date 3/24/25. Review of Resident #94's April 2025 Medication Administration Record (MAR) indicated: -Acetaminophen was administered as ordered. -Tramadol HCL was administered for lower extremity pain on 4/11/25, 4/14/25, 4/15/25, 4/21/25, and 4/22/25. -Tramadol HCL was administered for pain of an unspecified site on 4/19/25. -Lidocaine Gel ordered to be applied to the Resident's genital slit was coded as not administered due to absence of condition/not applicable for: 30 out of 46 scheduled doses between 4/1/25 and 4/23/25. Review of Resident #94's April 2025 Treatment Administration Record (TAR) indicated: -Catheter care was provided every shift (three times daily) between 4/1/25 and 4/23/25. -under skin documentation [genital area slit], the codes for pain = P, for no pain = NP. -The Resident reported pain (P) to his/her genital area on 19 out of 23 days reviewed. Review of Resident #94's Non-Pressure Skin Condition Record, dated 4/23/25, indicated the Resident's genital slit measured 3.0 centimeters (cm) x (by) 3.0 cm x 0.1 cm. On 4/23/25 at 10:31 A.M., surveyor #2 with Nurse #10 observed the following in Resident #94's room: -Nurse #10 requested permission from Resident #94 for Nurse #10 and surveyor #2 to observe the indwelling urinary catheter. -Resident #94 furrowed his/her brow and clenched his/her teeth. -Nurse #10 said to Resident #94 she knew the Resident's genital area was tender and that she just needed to see the catheter. -The Resident allowed the observation. -The surveyor observed the Resident's genital area to have a large slit. -Nurse #10 lifted the Resident's indwelling urinary catheter tubing and the Resident furrowed his/her brow, clenched his/her teeth, raised his/her hands in the air and clenched his/her fists. -When the observation was complete, Nurse #10 exited the room. -The surveyor observed that Nurse #10 failed to assess Resident #94 for pain during the observation of the indwelling urinary catheter. During an interview on 4/23/25 at 1:55 P.M., Certified Nurses Aide (CNA) #8 said she had been working at the facility since November 2024 and frequently provided care for Resident #94. CNA #8 said Resident #94 required total staff assistance for Activities of Daily Living (ADLs) and care of the indwelling urinary catheter. CNA #8 said she provided urinary catheter care as well as she could for Resident #94 because care of the urinary catheter hurt the Resident. CNA #8 said she would just try to talk the Resident through urinary catheter care and explain that it was important to keep the catheter area clean to prevent infection. CNA #8 also said urinary catheter care was more painful for the Resident when the Resident had a bowel movement as the Resident was incontinent and feces would need to be cleaned from the genital slit. CNA #8 said she would tell the Resident that she knew it was sore, and that the catheter care just needed to be done. CNA #8 said she would alert the Nurse if the Resident experienced pain once the catheter care was complete. During an interview on 4/23/25 at 2:15 P.M., Resident #94 said he/she had no pain in the genital area when staying still and that he/she always had pain whenever staff provided urinary catheter care and/or moved the urinary catheter. Resident #94 said staff frequently asked him/her about lower extremity pain and did not ask him/her about genital pain during urinary catheter care or when they moved the urinary catheter. Resident #94 also said staff just tell him/her they know the urinary catheter care hurts and is sore, and that they just need to keep him/her clean. Resident #94 said once staff stop manipulating the urinary catheter, the pain stops. During an interview on 4/23/25 at 5:00 P.M., Nurse #10 said Resident #94 always has pain when his/her urinary catheter was manipulated and that the pain would stop when procedures for the urinary catheter were complete. Nurse #10 said she did not ask the Resident about pain during the observation on 4/23/25 at 10:31 A.M. with surveyor #2 because she did not think the Resident's pain was excruciating. Nurse #10 also said that the ordered Lidocaine Gel to be applied twice daily to Resident #94's genital slit had not been applied on 4/23/25 and that the Lidocaine Gel had been unavailable for quite some time. Nurse #10 said she did not know when the facility's last request was made to the pharmacy to deliver the Lidocaine Gel for the Resident. Nurse #10 said no alternate interventions for pain management had been offered to Resident #94 relative to genital pain this day. During an interview on 4/24/25 at 12:27 P.M., the NP said she worked in the facility five days per week and provided services for Resident #94. The NP said staff had not communicated to her that Resident #94 always had pain when they provided procedures to the Resident's urinary catheter site. The NP also said she did not know the Resident's Lidocaine Gel was not being administered and was not available. The NP said if staff had made her aware that the Resident was always having pain during urinary catheter procedures, she would have reassessed the Resident's pain and provided orders for effective pain management. The NP further said if she had known the Lidocaine Gel was not available for Resident #94, she would have provided alternate instructions for pain management. During an interview on 4/25/25 at 8:26 A.M., Nurse #11 said she had worked at the facility for five years and had provided care to Resident #94 for a long time. Nurse #11 said Resident #94 was not always comfortable due to his/her genital wound. Nurse #11 said the Resident always anticipated pain and would scream, even before initiating procedures for care of the urinary catheter. During an interview on 4/25/25 at 11:01 A.M., the Director of Nursing (DON) said facility staff were required to monitor and assess residents for verbal and nonverbal signs of pain and to provide effective interventions for pain management. The DON said if interventions for pain were unsuccessful, residents would be reassessed, and effective interventions would be implemented. The DON said she was not aware the ordered Lidocaine Gel was not being administered to Resident #94 and was not aware the Lidocaine Gel had been unavailable to the Resident. The DON said staff should have assessed Resident #94 for pain when the Resident demonstrated verbal and nonverbal signs of pain for urinary catheter procedures, and developed and implemented effective interventions for pain management. Please refer to F755 and F865.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose diagnoses included atrial fibrillation (irregular heartbeat) with a Physician's order for an anticoagulant (blood thinner) medication to manage the condition, the Facility failed to ensure he/she was free from significant medication errors, when due to a transcription error by nursing, Resident #1 was administered two different anticoagulant medications for five days and on 1/24/24 he/she was found to have blood in his/her stool, blood laboratory work indicated he/she had a critical low hemoglobin (helps red blood cells carry oxygen to muscles and tissues) level, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and required admission for further treatment. Findings Include: Review of the Facility Policy titled, Physician Orders: Obtaining and Transcribing, dated as revised 09/29/2015, indicated the following: -directive known as Physician Orders will be obtained to manage the medical condition and plan of care for each resident -physician orders can be obtained in person, verbally via telephone or written (in person, via fax, or via referral, consult, or other source) -the professional nurse (RN, LPN) per scope of practice defined by State law/practice acts) is responsible for the transcription of orders such as telephone orders -physician orders (recapitulations/renewals, telephone/verbal) or faxed orders are to be noted by a licensed nurse by writing: noted, date & time, and signature and title -high risk medications: medications that have an increased potential for causing harm if used in error and the consequences of those errors can be devasting; medications identified as high risk in this setting are: insulin, warfarin/coumadin, and heparin -validate (a physician order): review of a physician order that has been received or verified by another nurse to ensure it is a complete order that reflects the order(s) of the consult, referral, etc. or documented changes to those orders; that transcription of the orders is complete and correct; and that follow-through has been implemented -when a physician changes a physician order that is currently in place, the original order must be discontinued first, and a new order written that reflects the change -new or changed orders for high alert medications will be validated and noted by a second nurse Resident #1 was admitted to the Facility in September 2023, diagnoses included atrial fibrillation, hypertension, gastrointestinal hemorrhage, melena (black stool), anemia, and atherosclerotic heart disease. Review of Resident #1's Facility Medication Error Report, dated 1/24/24, indicated that Nurse #1 had not transcribed part of a medication order that she received from Resident #1's Physician on 1/17/24. The Report indicated Nurse #1 had not discontinued Resident #1's order for Xarelto (anticoagulant) after she entered the new order for Pradaxa (anticoagulant), which resulted in Resident #1 receiving both anticoagulant medications. Review of the Facility Investigation Report, dated 1/24/24, indicated that Resident #1's Xarelto was to be discontinued and he/she was to start Pradaxa, per Physician's order. The Report indicated Nurse #1 transcribed the Physician's order incorrectly and had not discontinued Resident #1's Xarelto and he/she received both anticoagulants from 1/20/24 through 1/24/24. The Report indicated Resident #1 developed rectal bleeding, was examined by the Physician and during review of his/her medical record, the Physician discovered that Resident #1 had been receiving two anticoagulant medications for several days. The Report further indicated that Resident #1 had a stat (immediate priority) hemoglobin (Hgb) blood level drawn, results showed a low level of 5.3 grams per deciliter (g/dl) (normal range 12.0-16.0 g/dl) and he/she was transferred to the Hospital Emergency Department for treatment. During an interview on 4/03/24 at 1:04 P.M., the Nurse Practitioner (NP) said she saw Resident #1 on 1/17/24 because he/she was having nausea, dizziness, diarrhea and his/her blood pressure was low. The NP said she assessed Resident #1, observed that he/she had black stool (sign of a problem in the upper digestive system, often indicates bleeding in the stomach) and ordered nursing to hold his/her Xarelto times one day (hold the 1/18/24, 9:00 A.M. dose). The NP said she also ordered laboratory blood work be obtained which included a complete blood count (CBC) drawn on 1/18/24 and an x-ray of his/her kidney, ureter, and bladder (KUB). The NP said Resident #1's laboratory results showed that his/her hematocrit (Hct) level was low at 22.0 % (normal range 36.0 % - 46 %) and his/her hemoglobin (Hgb) level was also low at 7.2 g/dl. The NP said that although Resident #1's hematocrit and hemoglobin (H&H) levels were low, they were not far off from his/her previous H&H that was done on 12/13/23 and said she ordered another CBC to be drawn in one week, on 1/25/24. Review of Resident #1's Medication Administration Record (MAR) indicated that his/her Xarelto was not held on 1/18/24, as ordered by the NP, but instead was administered at 9:00 A.M., by nursing. Review of Resident #1's Physician (MD) Communication Form, dated 1/17/24, (written by Nurse #1), indicated that Nurse #1 received a phone call from the Oncology NP with a recommendation to switch Resident #1 from Xarelto to Pradaxa 150 mg two times a day before he/she started chemotherapy in February 2024. The Physician Communication Form indicated that Resident #1's Physician approved the medication change and signed and dated the form on 1/17/24. Further Review of Resident #1's MAR indicated that although there was a new order on 1/18/24 for Pradaxa 150 mg two times a day in place, his/her order for Xarelto had not been discontinued, per the Physician's orders. Review of Resident #1's MAR, dated 1/18/24 through 1/24/24, indicated he/she received the medications Xarelto 20 mg and Pradaxa 150 mg, on following dates and times: - 1/18/24 Xarelto at 9:00 A.M., (despite NP order to hold the medication) - 1/19/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/20/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/20/24 Pradaxa at 9:00 A.M., - 1/20/24 Pradaxa at 5:00 P.M., - 1/21/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/21/24 Pradaxa at 9:00 A.M., - 1/21/24 Pradaxa at 5:00 P.M., - 1/22/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/22/24 Pradaxa at 9:00 A.M., - 1/22/24 Pradaxa at 5:00 P.M., - 1/23/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/23/24 Pradaxa at 9:00 A.M., - 1/23/24 Pradaxa at 5:00 P.M., - 1/24/24 Xarelto at 9:00 A.M., (despite MD order to discontinue medication) - 1/24/24 Pradaxa at 9:00 A.M., Although, Resident #1 was being administered two anticoagulants daily at 9:00 A.M. by nursing, there was no documentation during the above time period to support that any of the nurses questioned the need or the risks to Resident #1 of being administered both anticoagulant medications. During an interview on 4/08/24 at 1:27 P.M., with Nurse #1 (which included review of her written witness statement, dated 1/25/24), Nurse #1 said she worked 7:00 A.M. to 11:00 P.M. on 1/17/24 and was assigned to care for Resident #1. Nurse #1 said she received a phone call from the Oncology NP stating they wanted to change Resident #1's Xarelto to Pradaxa before he/she started chemotherapy in February. Nurse #1 said she documented the information on a MD communication form and asked Resident #1's Physician (who was in the Facility at the time) to review the form and that the Physician agreed to change Resident #1's medication and provided an order to discontinue his/her Xarelto and wrote a new order to start the Pradaxa. Nurse #1 said she entered the new order for Pradaxa into Resident #1's Electronic Medication Administration Record (EMAR) and had asked Nurse #2 to confirm and co-sign the order. Nurse #1 said she could not remember if she entered the order to hold Resident #1's Xarelto on 1/18/24 into his/her EMAR. Nurse #1 said Resident #1 ended up being administered both anticoagulant medications because she had not entered the order into the EMAR to discontinue his/her Xarelto on 1/17/24, and that she should have done so. During an interview on 4/08/24 at 2:24 P.M., Nurse #2 said she worked the 11:00 P.M. to 7:00 A.M. shift on 1/17/24, and could not remember who the 3:00 P.M. to 11:00 P.M. nurse was that night. Nurse #2 said she could not recall the details about Resident #1's medication error and said she did not want to say anything more about it. During an interview on 4/08/24 at 4:19 P.M., Nurse #4 said she worked the 7:00 A.M. to 3:00 P.M. shift on 1/18/24 and was assigned to care for Resident #1. Nurse #4 said Resident #1 had a new order for Pradaxa, but the medication was unavailable to administer to him/her because it had not been delivered from the pharmacy, so she administered Xarelto to Resident #1 as ordered. Nurse #4 said she notified the NP that the Pradaxa was not available and received an order to hold Resident #1's Pradaxa for three days until it was received from the pharmacy. Review of Resident #1's Physician Progress Note, dated 1/24/24, indicated that Resident was receiving Xarelto and Pradaxa and his/her stool was black, was guaiac tested (checks for occult, hidden blood in the stool) and the result was positive (presence of blood). The Note indicated there was a concern that Resident #1 had an active upper gastrointestinal (GI) bleed, to closely monitoring him/her, check complete blood count (CBC) with differential (measures the number of each type of white blood cells) and basic metabolic panel (BMP) stat and if his/her hemoglobin (Hgb) is less than 7.0 g/dl, he/she would need a blood transfusion. The Note further indicated Resident #1 was recently seen by Oncology for melanoma (skin cancer) with a recommendation to switch his/her Xarelto to Pradaxa, however he/she was receiving both medications over several days. The Note indicated the Physician spoke with the nursing staff about the medication error, and ordered to discontinue the Xarelto, hold Pradaxa times one week, give one dose of Protonix (treats conditions that cause to much stomach acid) 40 mg stat, then increase to Protonix to 80 mg twice a day and monitor vital signs every shift and follow up (with physician) when laboratory results become available. During an interview on 4/03/24 at 1:27 P.M., the Physician said on 1/17/24 Nurse #1 informed her of the recommendations received from Oncology to switch Resident #1's Xarelto to Pradaxa. The Physician said she reviewed the MD communication form with Nurse #1, agreed to the medication change and signed the form as an order. The Physician said she saw Resident #1 on 1/24/24 for nausea and vomiting, that the resident told her that his/her stool was black. The Physician said Resident #1's face looked pale, and that nursing staff had done a guaiac test with positive results for the presence of blood. The Physician said she reviewed Resident #1's medications and discovered that he/she was receiving two anticoagulants, and that the Xarelto should have been discontinued by nursing on 1/17/24 as ordered, with Resident #1 only receiving Pradaxa. The Physician said on 1/24/24 she wrote new orders to stop Resident #1's Xarelto, hold the Pradaxa times one week, check CBC and BMP stat and informed Nurse #1 that if Resident #1's Hgb is below 7.0 g/dl he/she needed to be sent to the Hospital ED for a blood transfusion. The Physician said she informed the Unit manager that she had found the medication error. During an interview on 4/08/24 at 5:09 P.M., Certified Nurse Aide (CNA) #1 said she worked on 1/23/24 and 1/24/23 from 7:00 A.M. to 2:00 P.M. and was assigned to care for Resident #1 on both days. CNA #1 said on 1/24/24 she was providing incontinent care to Resident #1, his/her stool looked bloody, and she reported what she saw to the Nurse (could not recall exact name, later identified as Nurse #1). CNA #1 said that Resident #1 did not have blood in his/her stool the day before on 1/23/24. Review of Resident #1's Laboratory Results (obtained at the Facility), dated 01/24/24, indicated his/her hemoglobin (Hgb) level was critically low at 5.3 g/dl, (normal range 12.0-16.0 g/dl). Review of Resident #1's Situation, Background, Assessment, Recommendation (SBAR) Note (written by Nurse #1), dated 1/24/24, indicated Resident #1's hemoglobin and red blood cell counts were low, lab results reported to on-call NP and an order was obtained to transfer him/her to the Hospital ED. Review of Resident #1's Hospital ED to Hospital admission Report, dated 1/24/24, indicated that Resident #1 presented to the ED after the Facility noticed blood in his/her stool, related to a concern for GI bleeding in the context of possible over-anticoagulation with Xarelto and Pradaxa. The Report indicated Resident #1 had a low hematocrit level of 16.7 % and his/her hemoglobin level was 5.2 g/dl, was also low. The Report further indicated that Resident #1 received anticoagulation reversal with the medication Kcentra (a blood coagulation used to quickly reverse the effects of a blood-thinning medicine during a bleeding episode), he/she was transfused with two units of packed red blood cells and admitted for further treatment. During an interview on 4/03/24 at 3:24 P.M., the Director of Nurses (DON) said on 1/24/24 she was made aware of Resident #1's medication error and started an investigation. The DON said that after reviewing Resident #1's medical record she determined that he/she had been receiving two anticoagulant medications (Xarelto and Pradaxa). The DON said that on 1/17/24 Nurse #1 had received a call from Resident #1's Oncology office asking to switch his/her Xarelto to Pradaxa before starting chemotherapy and Nurse #1 obtained orders from the Physician. The DON said Nurse #1 transcribed the new order for the Pradaxa into Resident #1's EMAR but had not discontinued the order for Xarelto. The DON said that Nurse #1 also had received an order from the NP earlier on 1/17/24 to hold Resident #1's Xarelto for one day on 1/18/24 and that Nurse #1 had not transcribed that order into Resident #1's EMAR as well. The DON said that anticoagulants are high risk medications and per facility policy, required two nurse's signatures in the EMAR system for the Physician's order to go through. The DON said Nurse #2 co-signed Resident #1's Pradaxa order on 1/17/24, but she (Nurse #2) had not checked and verified the written order before signing as the second nurse. The DON said Resident #1 received both Xarelto and Pradaxa for five days and on 1/24/24 he/she had blood in his/her stool, a stat Hgb level was drawn that showed a low level at 5.3 g/dl and Resident #1 was transferred to the Hospital ED for evaluation. The DON said Nurse #1 had not followed the Facility policy for transcribing Physician orders and her actions were not consistent with the standards of nursing practice. The DON said she expected all nurses to follow the Facility's policy and procedure for transcribing Physician medication orders. On 04/03/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 1/25/24, the Director of Nurses, Assistant Director of Nurses and Unit Mangers conducted an audit on all residents receiving anticoagulant therapy, resident's Physicians were reviewed, and updated if needed to ensure correct doses were in place. B. On 1/26/24 through 1/30/24, the Staff Development Coordinator provided education to all Licensed Nursing Staff on Transcribing Physician Orders, High Risk Medications (Anticoagulants), and obtaining, transcribing, clarifying and noting Physician Orders C. On 1/29/24, Resident #1 returned to the Facility with interventions that included: medication reconciliation completed upon re-admission, monitor for signs/symptoms of anticoagulation complications, vital signs monitored every shift for seven days, and the Physician assessed, verified and reviewed medications upon return. D. All residents on anticoagulants are discussed at the weekly risk meeting and residents with new orders for anticoagulants will be reviewed at morning meeting to ensure proper administration. E. The Director of Nurses and/or designee will review all newly admitted residents records and Physician orders. F. The DON and/or designee will conduct up to ten random audits on residents receiving anticoagulants one time per week for three weeks and then two times monthly for two months. G. Findings of the audits will be reviewed at the quarterly QAPI meeting for three meetings. H. The Director of Nurses and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure transportation was arranged for hemodialysis (HD) treatments for one Resident (#174) resulting in two missed dialysis treatments and a subsequent hospitalization, in a total sample of 25 residents. Findings include: Resident #174 was admitted to the facility in July 2022, and readmitted to the facility in August 2022, with a diagnosis of End Stage Renal Disease (ESRD). Review of the admission progress note dated 7/29/22, indicated the Resident was starting HD treatments on a Tuesday/Thursday/Saturday schedule. Review of laboratory results, collected on 7/29/22, indicated the following: -Elevated Blood Urea Nitrogen (BUN) - 62 (indicates how well kidneys are functioning with a normal range being 10-24) -Elevated Creatinine 5.4 (waste product filtered by the kidneys with a normal range of 0.7 to 1.5) -Potassium (an electrolyte filtered out of the body by the kidney) was normal at 4.6 with a normal range of 3.3 to 5.1. Review of a Nursing progress note dated 7/29/22, indicated the Resident was being transferred to the hospital after a fall. Review of a Nursing progress note dated 7/30/22 (Saturday), indicated the Resident had returned to the facility at 5:40 A.M. after being evaluated for a fall in the emergency department. There was no documentation to indicate the Resident had gone to HD, that alternate arrangements had been made, or that the Physician had been notified of the missed HD appointment that was scheduled for 7/30/22. Review of a Physician's progress note dated 8/1/22, indicated the Resident did not have a dialysis treatment since last Thursday (7/28/22), had increased confusion and orthostatic hypotension (sudden blood pressure drop on standing) since yesterday and no urinary output for the past five days. The Physician documented the Resident was supposed to have HD on 7/30/22, however there was no transportation available in the facility. The Physician also documented that he spoke with the nursing staff and secretary, stating the Resident needed dialysis today (8/1/22) and transportation had to be arranged as soon as possible. The Physician said he would follow up on the Resident's mental status tomorrow (8/2/22) after HD. Review of a Nursing progress note dated 8/2/22 (Tuesday), indicated the Resident was scheduled for HD that morning at 5:00 A.M. The facility called the transportation vendor to check on his/her ride. The transportation vendor said the Resident was not booked with them that day, and they had no open slots that morning. Review of the dialysis communication book did not indicate the Resident had HD on 8/2/22. Review of a Nurse Practitioner's (NP) note dated 8/2/22, indicated that a Physical Therapist reported to her that the Resident had increased confusion since yesterday (8/1/22), orthostatic hypotension and felt dizzy. The Resident had reported to the NP that he/she had no urination over the past five days and did not have a dialysis treatment since last Thursday (7/28/22). The NP note said no transportation had been arranged for the Resident's HD treatment that day in the facility. Review of a Nursing progress note dated 8/2/22, indicated the Resident had been admitted to the hospital with a diagnosis of abnormal labs. Review of the hospital Discharge summary dated [DATE], indicated the Resident was initially seen in the Emergency Department (on 8/2/22), where he/she sustained an additional fall. The Resident had not had dialysis treatments for five days. The discharge summary indicated that the Resident's potassium level was mildly elevated at 5.4, BUN was elevated at 93, and creatinine was elevated at 9.24. On 8/12/22 at 12:53 P.M. during an interview with Unit Manager (UM) #1 and the Director of Nurses (DON), the DON said that on 7/29/22 the Resident sustained a fall, and returned to the facility on 7/30/22 at 5:40 A.M. The Resident was scheduled for dialysis but did not go that day. The DON said the transportation vendor was called today, 8/12/22, by the facility to investigate. The transportation vendor said they did not dispatch anyone on 7/30/22 and did not update the facility because the insurance information they had was incorrect. Regarding the missed dialysis appointment on 8/2/22 scheduled for a 6:00 A.M. pickup, the DON said they were still not aware of the insurance issue at that time, so transportation did not show up as planned. The Physician was notified of the missed dialysis appointment mid-morning that same day when he came into the facility. The DON said they realized the issue with the insurance company at that time and arranged alternate transportation. The Physician saw the Resident and had him/her sent to the emergency department, where he/she was admitted for HD treatment and abnormal labs.