**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #86: On 08/16/22 at 10:30 AM Resident #86 was observed in her room sitting in a chair. Resident was pleasant and had time to talk. When asked if she had any concerns with her care she answered, not at all. Her discharge date was coming up and resident was excited to return home. She stated she had an antibiotic IV therapy (after her back surgery) while she was in a facility. PICC (peripherally inserted central catheter) line dressing was observed on resident's left upper arm. Clear film dressing was reinforced by tape around the edges. Corners of the taped dressing were loose. Resident stated nurses were trying to keep it intact and put some tape to hold it down. On 08/18/22 at 03:20 PM during the 1 [NAME] Unit tour with ADON Resident #86 was observed in her chair in her room. She was excited to share that she is leaving tomorrow. Resident stated she was done with antibiotic therapy as of today, on 8/18/22. ADON asked resident to look at Resident #86's PICC line dressing. It was covered with clear tape around the edges and small pieces of it were peeling off. Two Sodium Chloride prefilled syringes were observed on a side table next to the resident. When asked about it, ADON stated it was not an accepted practice to leave an unattended medication in a resident's room. Resident #86 said that nurses sometimes leave it on a side table for the next antibiotic administration. According to admission face sheet, Resident #86 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included: Discitis (condition where the spaces between the spinal bones (vertebrae) becomes irritated and inflamed), Intervertebral disk degeneration (lumbar region), Type 2 Diabetes Mellitus, Right foot drop, muscle weakness, abnormalities of gait and mobility. According to Minimum Data Set (MDS) dated [DATE], Resident #86 was scored BIMS of 15/15 on the Cognition Assessment, indicating no cognition impairment or memory problem. According to the MDS, Resident #86 required one staff assistance with bed mobility, transfers, care, and toileting. Record review for Resident #86 revealed following orders: 1) Unasyn Injection Solution Reconstituted 3 (2-1) gm (Ampicillin & Sulbactam Sodium). Use 3 gram intravenously every 6 hours for infection for 42 days. Order date 7/7/22 at 00:06 AM. 2) Sodium Chloride Flush Intravenous solution 0.9%; use 10 ml intravenously every 6 hours for flush before and after Antibiotic therapy. Order date 07/25/22. Review of Medication and Treatment administration records (MAR and TAR) for Resident #86 for July and August 2022 indicated that resident was not given 10 of 168 prescribed IV antibiotic doses. Doses that were missing in July 2022 not given on: 07/08 at 18:00 (6PM) 07/12 at 06:00 AM 07/16 at 18:00 (6PM) 07/21 at 06:00 AM 07/26 at 18:00 (6PM) Doses that were missing in August 2022 not given on: 08/04 at 12:00 PM 08/05 at 00:00 AM 08/08 at 06:00 AM 08/14 at 00:00 AM 08/15 at 06:00 AM Resident was discharged on 08/19/22 and did not receive the full prescribed IV antibiotic therapy. Sodium Chloride flushes were ordered only on 7/25/22 to administer flushes before and after each antibiotic IV administration, which resulted in 158 total missed doses of Sodium Chloride flushes. Further review on 08/22/22 of Resident #86's provider's orders revealed no PICC line dressing changes ordered. Review of Medication and Treatment administration records (MAR and TAR) for Resident #86 for July and August 2022 indicated no PICC line dressing changes completed for 45 days since resident's admission to facility on 07/06/22. Resident #86's Care Plan had the following documented: Focus: Resident is on IV (intravenous) Antibiotics medications for Discitis (initiated 7/21/22- 14 days after resident's admission to facility and start of the IV antibiotic therapy) Goal: Resident will be free of any discomfort or adverse side effects of antibiotic therapy through next review (initiated 7/21/22) Interventions: - IV flushes and Dressing Changes per orders (initiated 7/21/22) - Administer antibiotic medications as ordered by physician (initiated 7/21/22) - Monitor/document side effects and effectiveness every shift (initiated 7/21/22) - Report pertinent laboratory results to MD (initiated 7/21/22) No documented interventions were noted for PICC line site assessment or monitoring for infection. Resident #138: On 08/16/22 at 10:20 AM Resident #138 was observed resting in bed with eyes closed. IV pole was noted on a side of the resident's bed with a small IV medication bag (not infusing) on the pole with tubing attached and capped to itself in a loop. Small amount of medication was noted still in a bag. On 08/17/22 at 10:00 AM Resident #138 was observed in her room in bed. Resident expressed high satisfaction with her care in a facility. IV pole was observed next to the resident's bed. There was a small IV medication bag still hanging on it with little amount of medication present in a bag, tubing not capped. Resident was asked if she receives antibiotic therapy and she responded yes. She stated her pressure injures were infected and she was receiving therapy for that. Resident #138 was asked to see her central line IV site and dressing. She showed her left arm. Clear dressing was noted covering PICC line site insertion. It was not adhering to the resident's skin in a bottom part of it. It was bunched up due to a gauze folded under it, which obstructed the view of the insertion site. Dressing was secured with multiple tapes around its perimeter and across the top portion of the dressing. Some of the tapes were not holding dressing in place anymore. The sterility of the dressing was visibly compromised. Third observation was made on 08/18/22 at 07:40 AM during Resident #138's wound care procedure. Resident's central line dressing was still bunched up at the bottom and plastic outer portion of the dressing was not adhering to the skin. Dressing was taped to secure at the top with paper tape. According to admission face sheet, Resident #138 was a [AGE] year-old female, originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included: Osteomyelitis (an infection in the bone caused by bacteria or fungi) of vertebra, sacral and sacrococcygeal region, and left ankle and foot, encephalopathy (brain disease), Sepsis (infection of the blood stream), Anemia, Hypertension, Pulmonary embolism (blood clot in a lung), Neuropathy (disease resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet), Nutritional deficiency, Atherosclerosis of native arteries of extremities with gangrene (left leg), muscle weakness. According to Minimum Data Set (MDS) dated [DATE], Resident #138 was scored BIMS of 15/15 on the Cognition Assessment, indicating no cognition impairment. According to the MDS, Resident #138 required one staff assistance with bed mobility, transfers, care, and toileting. Review of Resident #138 electronic medical records revealed the following orders: 1) Daptomycin intravenous solution, reconstituted 350 mg. Use 350 mg intravenously one time a day for Osteomyelitis of foot until 09/09/22 23:59. Order date 08/02/22 at 0038 AM. 2) Meropenem 1 gm/100 ml NS, MB+; use 1 gram intravenously every 8 hours for osteomyelitis for 9 weeks. Order date 08/02/22 at 09:47 AM, discontinued date 08/15/22 at 22:09. 3) Meropenem 1 gm/100 ml NS, MB+; use 1 gram intravenously every 8 hours for osteomyelitis until 09/09/22 23:59. Order date 08/15/22 at 22:09. 4) Sodium Chloride Solution 0.9%. Use 10 ml intravenously every 8 hours for Antibiotics flush before and after IV administration. Order date 08/16/22 at 11:27 AM. IV Sodium Chloride flush was ordered on 8/16/22, 13 days after the start of antibiotic therapy. No IV Sodium Chloride flush was ordered for flushes before and after Daptomycin IV administration. Resident #138 missed total of 112 IV Sodium Chloride flushes with her antibiotic therapy. Record review on 08/18/22 revealed no orders for Resident #138's PICC line dressing changes. Review of Resident #138's Medication and Treatment administration records (MAR and TAR) for August 2022 indicated no PICC line dressing changes completed for 17 days since resident's admission to facility on 08/01/22. Resident #138's Care Plan had the following documented: Focus: Resident is receiving IV (intravenous) Antibiotics medications related to her diagnosis of Osteomyelitis (initiated 8/10/22) Goal: Resident will have no complications related to IV therapy through the review date (initiated 8/10/22) Interventions: - IV flushes and Dressing Changes per orders (initiated 8/10/22) - Administer antibiotic medications as per MD order (initiated 8/10/22) - Follow facility policy and procedures for reporting infections (initiated 8/10/22) - Maintain universal precautions when providing resident care (initiated 8/10/22) No documented resident centered interventions were noted for monitoring IV antibiotic effectiveness/side effects/tolerance. No interventions were noted for PICC line site assessment and monitoring. On 08/18/22 at 03:20 PM during the 1 [NAME] Unit tour with ADON Resident #138 was observed resting in her bed. ADON asked resident to show her PICC line site. ADON observed dressing that was not intact and a bag of medication hanging on the pole, which was not infusing at that moment. ADON was asked if the PICC line dressing site looked appropriate. She responded that it was not. Further, she was asked if that was considered a safe practice for a resident with history of sepsis and current infection in her bones, ADON responded that it was not. When queried if bag of antibiotic medication was appropriately left in a room with the resident, ADON said it was not. Review of the facility provided Intravenous Administration of Fluids and Electrolytes Policy (dated April 2017, no revision date) had the following: Staff will be knowledgeable regarding the safe and aseptic administration of intravenous fluids and electrolytes for hydration. General Guidelines 1. A physician's order is necessary to give intravenous fluids and electrolytes. 2. Assess resident's lung and heart status and vital signs before and during therapy to assess for fluid overload. No guidelines specific to intermittent IV antibiotic therapy was found in a provided Policy. According to Infusion Nursing Standards of Practice published by The Infusion Nurses Society (INS) in 2021 Central Venous Access Device (CVAD) Dressing Changes: Dressing change frequency to central lines is dependent upon what type dressing that is in use. For the Transparent Semi-permeable Membrane (TSM), the dressing change frequency is every 5-7 days, and for gauze dressings the frequency is every 48 hours. There is no evidence to support one type of dressing is superior to the other, but gauze is preferable if the patient is diaphoretic. Remember, CVAD site care consists of removing the old dressing, cleansing the catheter skin junction with appropriate antiseptic(s), replacement of stabilization device, and application of a sterile dressing. Standard 59: Infusion Medication and Solution Administration. Another issue is delivering IV medications via a mini-bag and a primary administration set (i.e., gravity infusion) often used with IV antibiotics. There can be a significant potential loss of medication in the administration set, especially with small volume mini-bags (e.g., 50 mL). In the context of antimicrobial stewardship, it is important that patients receive their antibiotics with minimal loss of drug. An additional primary solution to clear the IV tubing is a consideration (p. S182). For example, 25 mL of saline solution after the antibiotic container is empty. (https://www.ins1.org/publications/infusion-therapy-standards-of-practice/) According to Oncology Nurse Advisor article published in 2019 Guidelines related to the required amount of normal saline solution (NSS) to flush a line between medications vary and appear to be institution-based. The only consistency in the literature is that all lines should utilize a 10-mL syringe to preserve the patency and functionality of the catheter in adult patients and 3 mL for pediatric patients. The California Department of Health Care Services recommends flushing the IV line between medications based on the type of line (i.e., PICC vs [NAME]). These guidelines suggest flushing the line with as little as 3-10 mL NSS after antibiotics. Review of the Institute for Safe Medication Practices provides very little standards for the amount for flushing but does endorse the use of a 10-mL syringe. (https://www.oncologynurseadvisor.com/home/cancer-types/general-oncology/guidelines-for-flushing-iv-lines-between-medications/) According to CDC website, Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. CDC is providing guidelines and tools to the healthcare community to help end CLABSIs. A central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line. Healthcare providers must follow a strict protocol when inserting the line to make sure the line remains sterile and a CLABSI does not occur. In addition to inserting the central line properly, healthcare providers must use stringent infection control practices each time they check the line or change the dressing (https://www.cdc.gov/hai/bsi/clabsi-resources.html) Abatement/Removal Plan: The facility staff did the following to remove the Immediate Jeopardy: 8/22/2022: The facility reviewed Resident's #'s 24, 86 and 138. R #86 was no longer at the facility; R #24 was no longer receiving fluids; R#138 had orders updated to include saline flushes, PICC line dressing changes and maintenance. 8/23/2022: All residents in the facility with vascular devices or subcutaneous fluids were reviewed by the facility to ensure there were physician orders for dressing changes, flushes, maintenance, and documentation of vascular devices. One additional resident was found to need orders for: Dressing changes, monitoring, and saline flushes. Residents with dialysis catheters were screened by the facility and received updated orders for monitoring on 8/23/22. 8/22/2022: The facility reviewed their policies: Guidelines for Preventing Intravenous Catheter-Related Infections; Intravenous adminstraton of fluids and electrolytes, hypodermoclysis therapy care plan; Infusion therapy medication administration. Nursing education began 8/18/2022 related to: orders are in place for the route of administration, IV flushes, care, maintenance and assessment of resident response to treatment of vascular devices. Including: dating of the dress, medication, tubing, and appropriate documentation. 8/22/2022: The facility started ongoing reviews of residents receiving IV therapy or subcutaneous fluids: 3 times per week for 4 weeks, then weekly with results to the QAPI committee. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy due to the facility's failure to provide quality of care in accordance with professional standards of practice for 3 resident's (Resident #24, Resident #86, and Resident #138), with Intravenous catheters (IV's) and subcutaneous fluid administration (Hypodermoclysis) by ensuring that the residents had 1) Current physicians' orders for use, maintenance and monitoring of the sites, administration of fluids/medications, line flushes, dressing changes and discontinuation of the catheter and 2) Documentation of care, to aid in preventing serious complications/harm, including, inflammation, pain, blood clots, infections, Central Line Associated Blood Stream Infections (CLABSI), hospitalizations and/or death. Resident #24: The facility was administering subcutaneous fluids to Resident #24 with a discontinued order. The dressing, bag of fluids and tubing were all undated. There were no notes or assessments of the insertion or maintenance of the needle site, dressing, amount of fluids given or the resident's response to the fluid administration. The resident received subcutaneous fluids for 3 days with no provider's order or monitoring. Resident #86 received 69 doses of IV antibiotics with 138 missed doses of IV flushes. There were no orders for Central Line IV dressing changes or maintenance. There was no documentation that the care was provided. Resident #138: The facility administered 2 different IV antibiotics to Resident #138 without obtaining a provider's order for a saline flush before and after administration of the antibiotic. There were no orders for Central Line dressing changes or IV maintenance to aid in preventing the potential for a central-line-associated blood stream infection, per standards of practice, which could lead to sepsis. 53 doses of the antibiotics were given without providing the necessary saline flush before and after administration of the medication, meaning 106 IV flushes were not provided. The APIC Text: Long-Term Care, copyright 2022 by the Association for Professionals in Infection Control and Epidemiology (APIC), revealed, .The long-term care facility provides a home for elderly, physically disabled, and cognitively impaired residents, presenting unique challenges for the infection prevention and control program . Most commonly, residents who occupy LTCFs are over [AGE] years of age, with the mean age of 80 The aging population faces challenges to combating infection as their immunological systems become compromised as a result of changes related to aging, malnutrition, comorbidities, and medications that may alter their immune status . Prevention of HAIs (Healthcare Associated Infections) should be of high importance . Residents in LTCFs may be chronically dependent on ventilators, have indwelling urinary catheters, or have long-term indwelling central venous catheters. Longevity of stay within LTCF, for many residents, places them at greater risk for HAIs . Hypodermoclysis for Frail Patients and Patients in Long Term Care: A Review of Clinical Effectiveness, Cost Effectiveness, and Guidelines, Ottawa (ON): 2020 [DATE], revealed .Hypodermoclysis (HDC) is a method of administering fluids or medication subcutaneously (under the skin), as opposed to intravenously (IV; into a vein) or intramuscularly (into a muscle). As the number of intravascular devices in LTCFs has increased, so too has the number of complications. CDC guidelines for prevention of intravascular catheter-related infection recommend aseptic insertion, daily inspection, and quality control of intravenous fluids and administration set . Immediate Jeopardy: The Immediate Jeopardy began 8/13/2022. The Immediate Jeopardy was identified on 08/22/2022. The Administrator was notified of the Immediate Jeopardy (IJ) on 08/22/2022 at 1:20 PM. A plan to remove immediacy was requested. The Immediate Jeopardy was removed 08/23/2022 based on the facility's implementation of the removal plan as. verified on site on 08/31/2022. Findings Include: Resident #24: On 8/15/22 at 12:24 PM, Resident #24 was observed sitting in a wheelchair at bedside. She was observed to have 0.9% sodium chloride solution, 1000 cc bag hanging on IV pole with 400 cc remaining in the bag; 600 ml had been administered. The resident pulled up her shirt and showed the fluids were running via a needle into her abdominal subcutaneous tissue. She stated, I think they put it in Thursday. It runs into my stomach. I think I was dehydrated. That is what they said. Observed IV site on right abdomen, taped, no date, time or initials;IV bag not labeled, dated, timed initialed to identify when the fluid administration was initiated. The resident stated, Yesterday morning, they said I have a UTI. They hung another bag yesterday and they gave me a shot. It's once a day. They straight cathed me. I can't walk. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #24 was admitted to the facility on [DATE] with diagnoses: Heart disease, kidney disease, diabetes, morbid obesity, weakness, urinary incontinence, and hypothyroidism. The MDS assessment dated [DATE] revealed the resident needed assistance with all care and had full cognitive abilities with a Brief Interview for Mental Status score (BIMS) of 15/15. A review of the physician orders identified 3 orders for Sodium Chloride Solution 0.9%: 1. Use 75 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days, start date 8/10/2022 and end date 8/11/2022. 2. Use 100 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days, start date 8/11/2022 and end date 8/12/2022. 3. Use 100 ml/hr intravenously one time only for Fluid electrolyte imbalance for 2 days. There was no order to provide the electrolyte fluid replacement subcutaneously via hypodermoclysis. The order indicated intravenously ( via an intravenous catheter inserted into a blood vessel). A review of the Medication Administration Records and Treatment Administration Records revealed three entries for fluid replacement therapy: 1. Order date 8/10/2022, Sodium Chloride Solution 0.9%, Use 75 ml/hr intravenously one time only for Fluid/electrolyte imbalance for 2 days, discontinue date 8/11/2022. There was one entry initialed and timed as given on 8/10/22 at 3:54 PM. The 8/11/22 entry was blank. 2. Order date 8/11/2022, Sodium Chloride Solution 0.9%, Use 100 ml/hr intravenously one time only for Fluid/electrolyte imbalance for 2 days, discontinue date 8/12/2022. There was one entry initialed on 8/11/2022 at 4:51 PM. The entry on 8/12/2022 was blank. 3. Order date 8/12/2022, Sodium Chloride Solution 0.9%, Use 100 ml/hr Intravenously one time only for Fluid/electrolyte imbalance for 1 day, Stop after 2 liters. At 100 ml/hr, it would take 20 hours to administer 2 liters of fluid (1000 ml per liter/2000 ml = 2 liters). There was one entry signed as given on the MAR on 8/12/2022 at 3:03 PM. The 8/13/2022 entry was blank and all other dates in August 2022, including 8/14/2022 and 8/15/2022 were crossed off, because the order had discontinued. On 8/15/22 at 3:15 PM, interviewed the Administrator and Nurse AY during an observation of Resident #24. The resident still had Sodium Chloride 0.9% solution being administered via hypodermoclysis ( a small needle into the subcutaneous tissue in the abdomen.) There was a small dressing over the needle site without a date. The tubing lay on the floor on a soiled piece of brief. The bag of fluids was undated. The Administrator was asked what the tubing was laying on and stated, A piece of a brief. On 8/15/22 at 3:25 PM, reviewed medical record documentation for Resident # 24 with Nurse AY and the Administrator. Nurse AY said she inserted the needle for the hypodermoclysis, unclear on the date and said she made a note. The Nurse was asked if she had assessed or documented on the fluids that were still being administered and she said she had not because there was no order for the fluids. On review of the progress notes, There were two nursing notes on 8/9/2022 the day before the IV fluids were ordered that provided the following: 8/9/2022 at 11:49 AM, written by a provider, Note Text: Staff alerted writer that resident was experiencing fever (100.6), chills, and had 2 episodes of emesis . Rapid Covid-19 test administered with negative results . Orders as follows: 1. STAT CBC, CMP 2. STAT UA with C/s 3. STAT (xray) . 8/9/2022 at 4:23 PM, a nurses note, Note Text: Resident complained of feeling very sick to her stomach and nauseated along with having chills . Resident will be seen by (doctor) this evening . From 8/10/2022 until 8/15/2022 there was no nursing note indicating electrolyte replacement fluids were being administered via hypodermoclysis. There was no mention of insertion of the needle, the site on the abdomen or the resident's response to therapy. On 8/15/2022 at 4:10 PM, a Late entry physician/provider note revealed, Scheduled follow up for resident (Resident #24) who is being seen for management of acute UTI (urinary tract infection) and colitis (bowel inflammation) . Orders as follows . 0.9% normal saline for gentle hydration for 3 liters total . On 8/16/2022 at 1:01 AM, a nurses note provided, Note Text: IV fluids completed, d/c (discontinue) order, pt (patient) tolerated the IV well, IV site pain free, no swelling, area is red and cool to touch . There was no another note or assessment until 8/23/2022 at 11:28 AM, provider note, Resident assessed today for follow up . after completion of IM antibiotic therapy for acute UTI with gentle hydration via hypodermoclysis . Resident #24 had 3 orders for IV fluids from 8/10/2022 to 8/12/2022. The fluids were to be completed by 8/13/2022. They were still being administered subcutaneously via the same abdominal site on 8/15/2022. The needle had been in place for 6 days. The site had not been changed. There was no nursing assessment, dressing changes, monitoring, or notation of the total amount of fluids administered to Resident #24. A review of the Care Plans for Resident #24 provided the following: (Resident #24) has dehydration or potential fluid deficit related to diabetes, mobility, (pressure ulcer), date initiated 1/27/2021 with Interventions: Hydration interventions per Physician orders, date initiated 1/27/2021; Administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated 1/27/2021. The Care Plan had not been updated since 1/27/2021. There was no mention of the resident's current dehydration, electrolyte fluid replacement or UTI. (Resident #24) has a potential and a (history) of actual Urinary Tract Infection, date initiated 8/31/2021 with Interventions: Monitor/document/report to MD (as needed) for signs and symptoms of UTI . date initiated 4/7/2022 and Obtain and monitor lab/diagnostic work as ordered . date initiated 4/7/2022. There were only 2 interventions. The Care Plan had not been updated to include electrolyte replacement therapy as ordered 8/10/2022. There was no Care Plan that mentioned administration of IV fluids, hypodermoclysis, side effects or monitoring. A review of the facility policies revealed the following: Infusion Therapy: Clinical and Pharmacy Services Policies and Procedures for Long-Term Care: 010-N: Appendix B: Hypodermoclysis Therapy Care Plan, dated April 2017 provided, Problem/Needs: Patient is mildly to moderately dehydrated, and requires short-term hydration . Potential for leaking prominent swelling, and local infection . Assess sites at least every 2 hours during infusion, and at least every shift when not in use . Infuse solutions at appropriate rates for hypodermoclysis: Up to 80 ml/hr at a single site, and 62 ml/hr at each of 2 sites . Rotate subcutaneous sites after 1.5-2 liters has infused at a single site . Rotate sites at least every 24-48 hours . Specific Medication Administration Procedures, date April 2018 M: Document in Nursing Progress Notes: . date . time . Medication, solution . infusion rate . site assessment, complications if any . Patient response to procedure . duration of medication infusion . any untoward reactions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #18: Review of Resident #18's Electronic Medical Record (EMR) revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included paraplegia (paralysis) and adjustment disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to perform Activities of Daily Living (ADLs). Review of Resident #18's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation - Baclofen (muscle relaxer) tablet 10 milligram (mg) at 9:00 PM Resident #30: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included hypertension, diabetes mellitus, and schizophrenia. Review of MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to complete ADLs. Review of Resident #30's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Atorvastatin (cholesterol lowering medication) 80 mg tablet at bedtime (9:00 PM) - Coreg (cardiac/anti-hypertensive medication) 12.5 mg tablet at 9:00 PM - Docusate Sodium (stool softener) tablet 100 mg at 9:00 PM - Metformin (anti-diabetic medication) 500 mg tablet at 9:00 PM - Humalog KwikPen (insulin) 100 unit/milliliter (mL) pen per sliding scale and blood glucose monitoring at 9:00 PM - Moxiflozacin (antibiotic eye medication) 0.5 % solution in right eye at 9:00 PM - Prednisolone Acetate (anti-inflammatory eye medication) 1% in right eye at 9:00 PM - Durezol Emulsion (pain and anti-inflammatory medication) in right eye at 7:00 PM Resident #35: Record review revealed Resident #35 was originally admitted to the facility on [DATE] with diagnoses which included renal failure, diabetes mellitus, and Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to complete ADLs. Review of Resident #35's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation - Vital Sign Monitoring at 9:00 PM - Bipap (Bilevel Positive Airway Pressure)/CPAP (Continuous Positive Airway Pressure) (respiratory ventilation support devices which utilize positive pressure and flow to maintain open airways) setting 22/7 with 5 liters oxygen at bedtime - Lipitor (cholesterol lowering medication) 10 mg tablet at 9:00 PM - Melatonin (supplement commonly used as sleep aid) 3 mg tablet at 9:00 PM - Trazadone (anti-depressant medication) 50 mg at 9:00 PM - Bumex (diuretic medication) 1 mg at 9:00 PM - Coreg 3.125 mg tablet at 9:00 PM - Pepcid (medication commonly used to treat gastric acid disorders) 20 mg at 9:00 PM - Spirolactone (diuretic medication) 25 mg at 9:00 PM - Novolog FlexPen (insulin) 100 units/mL pen per sliding scale and blood glucose monitoring at 9:00 PM - Micatin Cream (anti-fungal medication) 2% topically at 9:00 PM Resident #42: Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included Coronary Artery Disease (CAD), Cerebrovascular Accident (CVA-stroke) with resulting hemiplegia (one sided paralysis), atrial fibrillation (irregular heart rhythm), and seizure disorder. Review of the MDS assessment dated [DATE] revealed Resident #42 was moderately cognitively impaired and required extensive to total assistance to perform ADLs. Review of Resident #42's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation - Atorvastatin 80 mg tablet at 9:00 PM - Snack at bedtime (9:00 PM) due to decreased intake - Lactulose Solution (laxative medication) 10 grams (gm)/15 mL - ordered 30 mL dose at 9:00 PM - Senna- S (stool softener) 8.6/50 mg tablet at 9:00 PM - Hi-Cal Nutritional Supplement 120 cubic centimeters (cc) at 9:00 PM Resident #45: Record review revealed Resident #45 was originally admitted to the facility on [DATE] with diagnoses which included heart failure, CVA with subsequent left sided hemiplegia, kidney disease, COPD, and depression. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive to total assistance to complete ADLs with the exception of eating. Review of Resident #45's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Atorvastatin 20 mg tablet at 9:00 PM - Gabapentin (nerve pain medication) 300 mg at 9:00 PM - Senna-S 8.6/50 mg tablet at 9:00 PM - Lactulose Solution 10 grams (gm)/15 mL - 30 mL (20 gm) dose at 9:00 PM - Salmeterol Xinafoate Aerosol Powder (respiratory medication) 50 microgram (mcg)/dose at 9:00 PM - Ketoconazole (antifungal) shampoo 2% in the PM - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Continuous Oxygen administration and rate monitoring - COPD sign/symptom monitoring Resident #48: Record review revealed Resident #48 was originally admitted to the facility on [DATE] with diagnoses which included heart failure, renal disease, diabetes mellitus, and CVA with resulting hemiplegia. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required extensive assistance to complete all ADLs with the exception of eating. Review of Resident #48's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Norvasc (cardiac/hypertension medication) 5 mg at 9:00 PM - Cymbalta delayed release (antidepressant) 60 mg at 9:00 PM - Lantus (insulin) 34 units and blood glucose monitoring at 9:00 PM - Prilosec (gastric acid and ulcer medication) 20 mg at 9:00 PM - Tylenol 500 mg and pain monitoring at 9:00 PM - Lactulose Solution 10 grams (gm)/15 mL - 30 mL (20 gm) dose at 9:00 PM - Metformin 500 mg at 9:00 PM - Senna-S 8.6/50 mg - two tablets at 9:00 PM - PM Aquaphor Ointment application Resident #51: Record review revealed Resident #51 was originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, Parkinson's disease, and depression. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to extensive assistance to perform ADLs. Review of Resident #51's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Atorvastatin 20 mg tablet at 9:00 PM - Cozaar (cardiac/hypertension medication) 25 mg at 9:00 PM - Seroquel (anti-psychotic medication) 12.5 mg at 9:00 PM - Hi-Cal Nutritional Supplement 120 cc at 9:00 PM - Carbidopa-Levodopa (Parkinson's medication) 25/100 mg at 9:00 PM - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation Resident #68: Record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses which included respiratory failure, esophagus cancer, and failure to thrive. Review of the MDS assessment dated [DATE] revealed Resident #68 was cognitively intact and required limited to extensive assistance to complete ADLs. Review of Resident #68's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Hi-Cal Nutritional Supplement 120 cc at 9:00 PM - Lubricant Eye Drops at 9:00 PM Resident #92: Record review revealed Resident #92 was most recently admitted to the facility on [DATE] with diagnoses with included hypertension, renal failure, Hepatitis C infection, and CVA with resulting hemiplegia. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to complete ADLs. Review of Resident #92's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Atorvastatin 40 mg tablet at 9:00 PM - Coreg 3.125 mg tablet at 9:00 PM - PM Weight monitoring - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM Monitoring - COPD sign and symptom PM Monitoring - PM Pain Evaluation - Biofreeze Gel (topical pain relief) 4% at 5:00 PM and 9:00 PM Resident #123: Record review revealed Resident #123 was originally admitted to the facility on [DATE] with diagnoses which included hypertension, bradycardia, diabetes mellitus, heart disease, and dementia. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to limited assistance to complete ADLs. Review of Resident #123's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Pepcid 20 mg at 9:00 PM - Magnesium Oxide (supplement) 400 mg at 9:00 PM - Senna-S 8.6/50 mg - two tablets at 9:00 PM - Vital Sign Monitoring at 9:00 PM Resident #129: Record review revealed Resident #129 was admitted to the facility on [DATE] with diagnoses which included hypertension, acute kidney failure, and Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistant to complete ADLs. Review of Resident #129's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Melatonin 6 mg at 9:00 PM - Plavix (anticoagulation medication) 5 mg at 9:00 PM - Hi-Cal Nutritional Supplement 120 cc at 9:00 PM - Robaxin (muscle relaxer) 500 mg at 10:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation - Vital Sign Monitoring at 9:00 PM Resident #134: Record review revealed Resident #134 was originally admitted on [DATE] with diagnoses which included dementia, acute kidney failure, gastrostomy (surgically created opening in the stomach for the introduction of food), and dysphagia (difficulty swallowing). Review of Resident #134's MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive to total assistance to complete ADLs. Review of Resident #134's MAR and TAR for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/16/22: - Atorvastatin 20 mg tablet at 9:00 PM - Latanoprost Solution (medication used to treat pressure in eye) 0.005% at 9:00 PM - Plavix 5 mg at 9:00 PM - Docusate Sodium 100 mg at 9:00 PM - Ketoconazole (antifungal) cream 2% at 9:00 PM - Metoprolol Tartrate (hypertension medication) 12.5 mg at 9:00 PM - Juven (nutritional supplement for wound healing) at 9:00 PM - Baclofen 10 mg at 9:00 PM - Enteral Feeding (gastrostomy) 50 cc PM water flush - Sodium Chloride 1 gm tablet at 9:00 PM - Vital Sign Monitoring at 9:00 PM - Covid-19 Sign/Symptom PM (evening) Monitoring - PM Pain Evaluation Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to provide goods, services and necessary care and to prevent neglect from occurring by its failure to administer medications, perform treatments, and complete assessments on the 7:00 PM to 7:00 AM shift on 08/02/22 and 08/16/22. An Immediate Jeopardy (IJ) occurred when, on 8/2/22 on the 7:00 PM to 7:00 AM shift, a nurse for the 1-East Unit did not report for work. The on-site nursing staff did not assume the duties of the nurse. An Agency nurse replaced the nurse at approximately 11:00 PM on 8/2/22 but did not perform the scheduled medications and assessments for the evening of 8/2/22. As a result, no medications were administered nor were assessments completed for the evening of 8/2/22 for 38 of 39 residents reviewed. On 8/16/22 on the 7:00 PM to 7:00 AM shift, Nurse A for the 2-East Unit, had to leave the facility at approximately 10:20 PM due to a family emergency. The on-site nursing staff did not assume the Nurse's duties. As a result, no medications were administered nor were assessments, and/or treatments completed for the evening of 8/16/22 for 29 of 35 residents reviewed. This deficient practice resulted in a determination of Immediate Jeopardy with the likelihood of adverse consequences, serious harm and/or death due to the failure to administer physician-ordered medications, perform treatments and assessments for the management of medical conditions and diagnoses that include diabetes, cardiac disease, seizures, pain and other diagnoses and medical conditions. Immediate Jeopardy: The Immediate Jeopardy began on 08/02/22. The Immediate Jeopardy was identified on 08/25/22. The Administrator was notified of the Immediate Jeopardy on 8/25/22 at 9:50 AM and was asked for a plan to remove the immediacy. The Immediate Jeopardy was removed on 08/17/22 based on the approval and implementation of the facility's Removal Plan as verified on site on 08/25/22. Findings include: A review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, effective date on 9/11/2020, revealed, .An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator . Definitions of Abuse and Neglect . f. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Resident #10: A review of Resident #10's medical record, revealed an admission into the facility on [DATE] with diagnoses that included hyperlipidemia, heart failure, chronic kidney disease, anemia, hypertension (high blood pressure), hypothyroidism, lymphedema and edema. A review of the MDS, dated [DATE], revealed a BIMS score of 15/15 that indicated intact cognition and needed extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. On 8/16/22 at 1:03 PM, an observation was made of Resident #10 lying in bed. The Resident was interviewed and conversed in conversation. The Resident complained of short staffing and stated, They just don't have enough on afternoons and nights. About three weeks ago, there was no nurse staffed on the hall, and indicated the hall was left in the evening with no nurse and stated, We didn't get our medication. The Resident reported being upset/scared with having no nurse and stated, I have an open wound on my leg, I can't get out of bed, and reported she could hear other residents coming out to try to find the nurse and get their medications. The Resident reported it was a Saturday night on the 7 to 7 shift, in the evening, and stated, No one scheduled. The day shift nurse left, and they had no one to cover. Review of Resident #10's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/2/22: Mirtazapine 7.5 mg (milligrams) for depression at 9:00 PM. Ammonium Lactate Lotion 12% to lower legs topically for dry skin at 9:00 PM. Carvedilol 6.25 mg for hypertension at 9:00 PM without a blood pressure monitored. Sennosides-Docusate for constipation at 9:00 PM. Sodium Bicarbonate 650 mg for hypertension at 9:00 PM. Covid-19 signs/symptom monitoring for PM. Prostat Sugar Free for wound healing at 9:00 PM Pain-evaluate pain every shift for PM. Resident #67: A review of Resident #67's medical record revealed an admission into the facility on [DATE] with diagnoses that included chronic peripheral venous insufficiency, diabetes, heart disease, hypertension (high blood pressure) and history of Covid-19. A review of the MDS assessment, dated 6/23/22, revealed a BIMS score of 15/15 that indicated intact cognition and needed extensive assistance with ADLs that included bed mobility, transfers, dressing, toilet use and personal hygiene. On 8/17/22 at 12:06 PM, an observation was made of Resident #67 lying in bed. The Resident was interviewed and conversed in conversation. The Resident reported she took insulin for diabetes and complained of not getting her insulin until late at night, sometimes not until one or two o'clock in the morning. The Resident reported one night there was no nurse taking care of Residents and did not receive her insulin that night at all. The Resident indicated she had waited for the Nurse to come in with her medications and stated, I had fallen asleep but I had issues with my blood sugar all day (the next day after not receiving her evening dose of insulin). Review of Resident #67's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/2/22: Basaglar KwikPen (Insulin) 20 Units at 9:00 PM. Rosuvastatin 20 mg for cholesterol at 9:00 PM. Sennosides 8.6 mg, two tablets at 9:00 PM. Trazodone 50 mg for depression at 9:00 PM. Carvedilol for Beta Blocker at 9:00 PM. Metformin for diabetes at 9:00 PM. Omeprazole for ulcer management at 9:00 PM. Vital signs for the PM. Covid-19 signs/symptoms monitoring for the PM. Pain evaluation for the PM. Tizanidine 4 mg for musculoskeletal therapy at 10:00 PM. Resident #97: A review of Resident #97's medical record, revealed an admission into the facility on 4/11/22 with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, muscle weakness, depressive disorder, hypertensive heart disease, asthma, osteoarthritis and chronic pain. A review of the Minimum Data Set (MDS) assessment, dated 7/15/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, that indicated intact cognition and the Resident needed supervision with Activities of Daily Living (ADL) that included bed mobility, transfers, walking, dressing, toilet use and personal hygiene. On 8/16/22 at 11:24 AM, an observation was made of Resident #97 dressed and lying in bed. An interview was conducted with the Resident. When asked about pain and pain management, the Resident indicated he had problems with pain in his back, shoulders, pretty much all over. The Resident reported having scheduled pain medication. The Resident complained that he did not always get his medication at night for pain and medication for sleep. When asked about why he had not received medication, the Resident stated, There was no nurse in the building to give the medication, so I didn't get it. When asked why there was no nurse, the Resident was unsure but indicated a couple weeks ago there was no nurse on the floor at night. He reported wondering why he was not getting his medication and was told by the CNA that there was no nurse. The Resident indicated that he had heard other Residents asking for medication also. Review of Resident #97's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/2/22: Mirtazapine for depression at 9:00 PM. Fluticasone-Salmeterol 500-50 mcg/dose (micrograms per dose) at 9:00 PM. Naproxen for pain at 9:00 PM. Covid-19 Signs/Symptoms monitoring for the PM. Clonazepam for anxiety at 9:00 PM. Pain evaluation for PM. Vital signs for PM. Resident #103: A review of Resident #103 medical record revealed an admission into the facility on 4/20/22 with diagnoses that included urinary tract infection, Type 2 Diabetes Mellitus, hypertension, weakness, cellulitis, and peripheral vascular disease. A review of the MDS assessment, dated 7/18/22 revealed a BIMS score of 15/15 which indicated intact cognition and the Resident needed extensive assistance with bed mobility, dressing and toilet use. On 8/17/22 at 11:07 AM, an observation was made of Resident #103 lying in bed. An interview was conducted with the Resident and the Resident conversed with conversation. When asked about staffing, the Resident reported that a nurse did not show up for work and there was no nurse to take care of the people on the unit and stated, No insulin, no meds. The Resident indicated they did not have a nurse on the unit and that him and his roommate did not receive any medications that night. The Resident reported that he took medication for diabetes and that insulin was usually given at night but he never got the medication that night. The Resident stated, It's happened more than once, and indicated he had missed his insulin and other medications. Review of Resident #103's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/2/22: Insulin Glargine 30 Units for diabetes at 9:00 PM. Blood Sugars monitoring for diabetes at 9:00 PM. Guaifenesin ER (extended release) 600 mg at 9:00 PM. Metformin 500 mg for diabetes at 9:00 PM. Clonidine 0.2 mg for blood pressure management at 9:00 PM. Cyclobenzaprine 5 mg for spasms at 9:00 PM. Gabapentin 300 mg for nerve pain at 9:00 PM. Resident #112: A review of Resident #112's medical record, revealed an admission into the facility on 7/16/22 with diagnoses that included chronic obstructive pulmonary disease with exacerbation, weakness, difficulty in walking, pressure ulcer of sacral region stage 3, pain, and opiate dependence. A review of the MDS assessment dated [DATE] revealed a BIMS score of 13/15 that indicated intact cognition and the Resident needed supervision assistance with bed mobility, transfers, walking in room and corridor and needed limited assistance with dressing, toilet use and personal hygiene. Review of Resident #112's Medication Administration Record, revealed medications taken for pain and opiate dependence included the following: Aspirin EC (enteric coated) 81 mg (milligrams) for Pain; Lidocaine Pain Relief 4% Patch to apply to abdomen topically one time a day for Pain; Suboxone Sublingual Film 8-2 mg (Buprenorphine HCl-Naloxone HCl) one film sublingually two times a day for opiate dependence; Acetaminophen 325 mg, three tablets every six hours for Pain; and Methocarbamol 750 mg, one tablet four times a day for muscle relaxer. On 8/17/22 at 10:51 AM, an observation was made of Resident #112, sitting on his bed, dressed. An interview was conducted with the Resident and the Resident conversed with conversation. The Resident was asked if he had any pain or discomfort. The Resident indicated he had pain and took medication. The Resident reported not getting his medication about two weeks ago. The Resident expressed concern that there was no nurse to give medication, he didn't get his medication and worried about it happening again and stated, I was in mental anguish, do I have to put up with this every time! When asked if he was scared about missing his medication the Resident stated, It was more of an anger. I had to prepare myself mentally to prepare if I have to deal with it again, and talked about concern of going into withdrawals and having pain that night and stated, There was the mental aspect (of going through withdrawal) and the pain was involved. I felt like I was a bum on the street, and talked about trying to find pain medication and going through withdrawals. Review of Resident #112's electronic Medication Administration Record (MAR) and Treatment Administration Record (TAR) for August 2022 revealed the following medications, treatments, and assessment/monitoring were not administered and/or completed on 8/2/22: Docusil 100 mg for constipation at 9:00 PM. Fluticasone-Salmeterol inhalation aerosol powder breath activated 100-50 MCH/ACT, two puffs at 9:00 PM. Senna-Docusate for stool softener at 9:00 PM. Suboxone Sublingual Film 8-2 mg(Buprenorphine HCl-Naloxone HCl Dihydrate for opiate dependence at 9:00 PM. Prostat sugar free for wound healing at 9:00 PM. Pain- Evaluate Pain every shift for pain Evaluation for the PM. Vital signs for the PM. Methocarbamol 750 mg for muscle relaxer at 9:00 PM. A review of the nursing staff schedule, provided by the facility, for 8/2/22 revealed Unit 1E (East) had Nurse AF scheduled and crossed off for the 2nd shift nurse (7 PM to 7 AM) with Nurse AC written below the other Nurse's name. On 8/18/22 at 4:52 PM, an interview was conducted with Certified Nursing Assistant (CNA) AG regarding the complaints of Resident's not receiving their medication and not having a nurse available. The CNA was asked what took place on that night. The CNA reported that on Tuesday, (8/16/22), there was an agency nurse that had come in and then she just left. She didn't tell anyone she was leaving, she just left, and reported there was no nurse on the 2-East unit when CNA AG came into work at 11:00 PM on 2-East that night. The CNA was unsure what time Nurse A had left the building. The CNA reported that Residents were asking for medication and stated, We told them someone was coming we just didn't know when. The CNA indicated that there was no Nurse that came to the Unit until the next agency Nurse arrived about 11:30 PM or 12:00 AM. The CNA reported no communication or seen a Nurse on the Unit until agency Nurse AA arrived. The CNA reported that Nurse A left the keys for the medication cart/narcotic keys behind the printer/fax machine at the nurses station and had seen the agency Nurse AA retrieve the keys left there. When asked about another night (8/2/22) there was no nurse on the 1-East Unit, the CNA stated, It was kind of the same situation. We didn't have a nurse. The CNA was unsure why there was not a Nurse. The CNA reported that she worked the third shift that night and when she had gotten to work, there was no nurse on the 1-East Unit until an agency Nurse came in but was unsure when the Nurse had gotten there. The CNA reported that Residents were calling and asking for there medications. On 8/22/22 at 1:32 PM, an interview was conducted with the Staff Coordinator (SC)AI. The SC indicated that the other Staff Coordinator AJ no longer worked at the facility and that she was filling in. A review of the schedule for 8/2/22 with Staff Coordinator AI revealed that Nurse AC was on for the night shift that was from 6 PM to 6 AM. The SC reported not being able to know when the Nurse had come in due to Agency Nurses not punching in, they sign a paper with the time they arrive and give it to there agency and indicated the only way to know when she came in was to check the kiosk when they screen for Covid-19 upon entering the building. SC stated, Day shift (Nurse) should not have left until someone came in. On 8/22/22 at 1:36 PM, Nurse AC was contacted on the phone by Staff Coordinator AI and an interview was conducted. When asked about working on 8/2/22, Nurse AC reported she had not been scheduled but had been informed of the opening that night. The Nurse indicated she had come in about 11:00 to 11:30 PM to work the 1 East Unit. The Nurse indicated there was no Nurse on the Unit when she arrived, did not receive report from a nurse and had gotten the keys from a staff Nurse (AK) who was on the 2-West Unit. When asked if Nurse AK had given her report, Nurse AC reported she had not gotten report. When asked if she had done a narcotic count with the Nurse from the 2-West unit, the Nurse stated, No. I did my own personal count. When asked if the evening medications were passed, the Nurse indicated she had not gotten report from another nurse but that some of the Residents said they didn't get their meds. When asked why she had not passed the evening medications, the Nurse stated, The medications were due four hours prior to me entering the building. When asked who was responsible for Resident care, the Nurse reported she did not know and that she had no other contact with other nurses. When asked if she had talked to Administrator (NHA) or the Director of Nursing (DON) regarding no Nurse on the Unit when she arrived and no nursing duties provided to the Residents, the Nurse reported she had not talked to the Administrator or DON. The Nurse stated, There was no Administration here to talk to that night. I talked to (name of Staff Coordinator AJ) the next day. I thought they were aware. I thought she (Staff Coordinator) would let them (Administration) know. On 8/22/22 at 1:51 PM, Nurse AF, who was scheduled, and name crossed out on 2nd shift (7 PM to 7 AM shift) for 1-East Unit on 8/2/22, was phoned by SC AI and an interview was conducted. Nurse AF was asked if she had been scheduled to work the 7 PM to 7 AM shift on 8/2/22. The Nurse indicated she looked at her past schedule and reported she had not been scheduled that day but had been scheduled the following day and stated, She (Staff Coordinator AJ) probably had me down in error. I wasn't supposed to be there that day. The interview continued with Staff Coordinator AI regarding the lack of Nurse coverage for the 1-East Unit on 8/2/22 7 PM to 7 AM shift. SC indicated that the two nurses on day shift needed to stay and both needed to count the narcotics and stated, They should decide who will stay until a Nurse comes in. Nurse AE who was the nurse on the day shift was called, but there was no answer after two calls made by SC. Nurse AK who was the Nurse on the 2-West Unit, was contacted by SC, but there was no answer. Nurse AD who was scheduled on the day shift on the 1-East Unit on 8/2/22 was contacted and an interview was conducted. The Nurse verified that she had worked on 8/2/22 on the 1-East Unit on the day shift when a Nurse did not show for the 7 PM to 7 AM shift. Nurse AD reported that the medication/narcotic keys were left with Nurse AK and report was given to that Nurse and stated, I counted and gave report. It was time for me to leave, and did not talk to the Administrator or Director of Nursing about the Nurse not coming in and that no-one talked to her about staying over.