**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to investigate and respond to a Hoyer lift incident before placing the Hoyer lift back into care service for 1 of 2 (R2) residents. Additionally, the facility failed to have a system to perform regular maintenance on resident ceiling lift and failed to respond to voiced concerns by nursing staff related to ceiling lift malfunction and safety related to care planned two person Hoyer lift for 1 of 2 (R1) resident viewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R2 and R1. The IJ began on 7/30/23 at 8:22 a.m., when a Hoyer lift being used to transfer R2 would not stop and a different Hoyer lift had to be used to complete the transfer. The Hoyer lift was placed out of service for a short period but returned to service before the facility completed an internal investigation or contacted the manufacturer for direction. Additionally, the facility failed to have a system for routine maintenance related to a ceiling lift used to transfer R1 which had ongoing staff reports of malfunction over the last six months and failed to reassess R1's safe transfer in a Hoyer lift, both potentially causing R1 discomfort and pain. The DON and administrator were notified of the IJ on 9/14/23, at 5:35 p.m. The IJ was removed on 9/15/23, at 5:35 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R2's annual MDS dated [DATE], indicated R2 was cognitively intact, required extensive assist of two with bed mobility, transfers, impairment on upper extremities and used a wheelchair for mobility. R2's Care Plan dated 8/29/23, indicated R2 had spinal Stenosis (narrowing of the spinal canal in the lower part of back), osteoporosis, edema, and lower back pain. Care plan further indicated R2 transferred with assist of two and mechanical lift. 9/12/23-9/15/23, R1 was in the hospital and unable to be observed or interviewed. Incident Report dated 7/30/23 at 8:22 a.m., indicated R2 was being transferred by two staff and Hoyer lift out of bed. Resident was being lowered down and Hoyer lift would not stop. R2 ended up sitting in sling about a foot off the ground; the Hoyer would not stop when stop button was pushed, needed another Hoyer to complete transfer. The report indicated staff assisted resident with another Hoyer lift and four staff to place resident in her wheelchair. Hoyer machine was taken off the floor and a repair slip completed for maintenance. Report indicated no injuries occurred to R2. During interview on 9/13/23 at 7:00 p.m., NA- B stated on 7/30/23, she was transferring R2 with the Hoyer lift out of bed when the lift automatically just started to lower to the ground, NA-B stated R2 had jerking movements with her body and maybe that caused the lift to lower on its own. NA-B also stated with R1 they have had issues with the ceiling lift battery not charging and she had told the MND several times and he just told us to make sure we have the battery on the charger correctly. NA-B stated we tried that, and it doesn't charge the battery. During interview on 9/14/23 at 8:07 a.m., MND stated he was aware of the incident with R2 and looked over the Hoyer lift but was unable to find anything wrong with the lift, so he put the lift back on the floor for staff to use. The MND confirmed he never called the manufacturer to see if it was safe to put back on the floor despite the manufacturer primarily working with the lifts, completing the maintenance on a routine basis and all the lifts having just been checked two weeks prior to the incident. The MND did state he had never called the manufacture for a concern since they come out every 6 months to do their safety checks and maintenance on them. During interview on 9/14/23 at 8:30 a.m., director of nursing (DON) stated she was aware of the incident with R2 and the lift lowering R2 to the floor. DON added, since MND looked at the lift and was unable to find anything wrong, she felt there was no reason to complete an investigation on the incident. During interview on 9/14/23 at 9:14 a.m., EZ Way Service and Sales Support staff stated the EZ Way Hoyer lift should have been removed from the floor and not been put back onto the floor until calling EZ Way, due to the possibility of brake failure of the machine and needing to complete two checks over the phone and if that did not work a technician might need to come out to look over the machine. During interview on 9/14/23 at 10:00 a.m. EZ Way representative (R)-A stated the facility had preventive maintenance done on the EZ Way lifts and stands on 9/20/22 and then on 7/17/23 and 7/18/23. The R-A stated the facility should have had preventative maintenance done in March 2023 but was not scheduled. EZ Way, INC. Service Manual revised 7/11/22, indicated the manufacturer suggests that the following components and operating points be scheduled for inspection at intervals not greater than six months. Any detected deficiency must be rectified before the lift is put back into service. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, required extensive assist of two with bed mobility and total assist of two with transfers. The MDS indicated R1 had limited mobility in upper and lower extremity and used a wheelchair for mobility. R1's care plan dated 8/17/23, identified R1 was bariatric and had peripheral vascular disease, inflammation of lower extremity, lack of coordination, abnormal posture, significant pain management needs and was on hospice care. The care plan indicated a two person assist with activity of daily living care and mechanical lift for transfers. On 9/12/23 at 12:43 p.m., during observation and interview R1 was observed being transferred from wheelchair to bed using a ceiling lift by nursing assistant (NA)-C, NA-D and trained medical aide (TMA)-B. R1 was several inches off her wheelchair when the ceiling lift stopped, staff were observed working with the remote to get the lift working. R1 was observed to be jerked up and down by the lift during this time and yelling out, ouch and was crying. Staff stopped and put her back in chair. Staff reported they told leadership the ceiling lift was not working, again. Per interviews with (NA)-C, NA-D and (TMA)-B the ceiling lift had not been functioning correctly for over six months. Staff expressed they believed R1 preferred the ceiling lift, and it was safer and more comfortable for her to use than the EZ Way Hoyer Lift. The staff stated when they have used the Hoyer lift in the past some of them have had to stand on the legs of the lift to prevent it from tipping over. Additional concerns the staff expressed included the ceiling lift stopping and jerking R1, causing her unnecessary pain during transfers. They expressed this was something that had been ongoing despite complaints they had made to leadership and requests for repairs to maintenance. When they put maintenance request in, MND would instruct them to put the battery on the charger tilted or crooked to get it to charge, which was not a sustainable solution. During same observation surveyor attempted to interview R1 but she was not interviewable. A second observation and interview on 9/12/23 at 1:10 p.m., during transfer from the wheelchair to her bed using the EZ Way Hoyer Lift. The MND was asked by facility leadership to demonstrate how to use the EZ Way Hoyer Lift safely with R1. MND and NA-C, NA-D and TMA-B were observed hooking R1 up to the EZ Way Hoyer Lift from her wheelchair, bed was in low position, MND was running the EZ Way Hoyer Lift while the aids were guiding R1. When R1 was in the air, the EZ Way Hoyer Lift wheel was observed to lift off the ground two inches and the transfer had to be halted due to the bed being in the wrong placement position for transfer (bed in low position), which caused R1 to yell out in pain. Interview with DON confirmed the transfer with R1 was not completed the way she would have transferred R1. According to manufacturer during an interview on 9/14/23 at 3:30 p.m., the EZ Way Hoyer Lift is not safe or stable to use if the wheels are not all on the ground during transfers and if the wheels are lifting off the ground, this could be because of a bent frame or broken bolt(s). After observation of resident transfer on 9/12/23, at 1:10 p.m. Hoyer was not removed from resident care and staff were not immediately retrained. A Physical Therapy Treatment Encounter Note indicated an evaluation was completed on 9/13/23 with R1 which indicated, .Physical Therapy recommends a minimum of three staff for Hoyer transfers and that staff move Hoyer lift slowly for resident comfort and safety. During interview on 9/13/23 at 11:52 a.m., DON stated the MND does the training with the staff on the Hoyer lifts and assumed he received training from the EZ Way. The DON stated the MND was not a NA or trained in patient care and should not have had him transfer R1. During interview on 9/13/23 at 2:34 p.m., MND stated he encouraged staff to scan the QR code on the lifts and watch the video for training on the lifts. The MND stated he had not received training from EZ Way to transfer residents in the Hoyer lifts. During interview on 9/15/23 at 9:00 a.m., MND stated the ceiling lifts were purchased from Direct Supply company but he was told by corporate they were no longer working with Direct Supply for the ceiling lift (for approximately a year and a half) so he was not able to purchase replacement batteries for the lift. MND stated he was not aware of any contracted routine maintenance for the ceiling lift and confirmed he had not completed any routine maintenance on the lift himself but had directed staff to put the battery on the charger different ways to get it to charge better. During interview 9/20/23 at 6:20 p.m., the facility nurse consultant stated she had been the consultant with the facility for the past year and was not aware the ceiling lift was being used for resident care. The IJ that started on 7/30/23 was removed on 9/15/23, when it was verified through observation, interview and document review the facility removed the Hoyer lift and ceiling lift from resident care pending inspection/routine maintenance check, retrained staff on safe transfers with the EZ Way Hoyer lifts and reviewed policies and procedures to ensure alignment with regulatory standards. All staff were educated on the procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure medications to prevent blood clotting were administered, and associated blood testing was performed, in accordance with physician orders for 1 of 1 residents (R3) reviewed who was at increased risk for recurrent stroke, clots, and/or decreased blood supply to tissues/organs causing a shortage of oxygen, after an ordered blood test was not performed resulting in missed subsequent anticoagulation orders and anticoagulation therapy for a 14 day period. These findings resulted in an immediate jeopardy (IJ) situation, for R3 when the facility failed to take adequate, systemic action(s) to analyze R3's missed blood testing, missed and/or incorrectly administered anticoagulants, failed to update R3's medical provider related to the surrounding anticoagulants and/or blood test concerns, and failed to provide staff education to potential factors which contributed to the error thus causing the potential for similar reoccurrences and potential harm for R3. In addition to the resident in immediate jeopardy, the facility failed to ensure insulin (blood sugar regulator) medication was administered in accordance with physician orders for 1 of 1 residents (R6) who was provided insulin outside of ordered parameters during a medication pass observation. This resulted in potential harm that is not immediate jeopardy. The immediate jeopardy began on 8/28/23, when the facility failed to perform a physician ordered INR (international normalized ratio - blood clotting rate) blood test which led to a lack of subsequently provided anticoagulant order(s). As a result, R3 was not administered anticoagulants from 8/28/23 through 9/10/23. In addition, after the anticoagulation clinic updated the facility on 9/11/23, related to R3's 8/28/23 missed INR and resultant anticoagulant therapy, R3 missed two additional doses on 9/15/23 and 9/17/23, and received one dose higher then ordered on 9/16/23. This resulted in immediate risk of serious harm for R3. The facility administrator, the clinical nurse consultant (NC)-A, and licensed practical nurse (LPN)-E were notified of the immediate jeopardy at 2:26 p.m. on 9/20/23. The immediate jeopardy was removed on 9/21/23 at 12:35 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R3's admission Minimum Data Set (MDS), dated [DATE], identified R3 was moderately cognitively impaired with a diagnosis of vascular dementia (lack of blood carrying oxygen/nutrients to the brain). In addition, R3 was diagnosed with peripheral vascular disease (abnormal narrowing of arteries), aortic valve stenosis (narrowing), thoracic aortic ectasia (dilation), cerebrovascular disease (impacted blood flow in the brain), hypertension, cardiomyopathy (disease of heart muscles), and intestinal infarct (blocked arteries in intestines. The MDS identified R3 was administered anticoagulant medication for the four days following his facility admission. R3's face sheet listed diagnoses of prior stroke, atherosclerotic heart disease (buildup of plaque in artery walls), and below the knee amputation. A nursing progress note, dated 8/11/23, identified R3's facility tested INR value was 1.4. Results were faxed to the Anticoagulation Clinic (ACC). An Anticoagulation Monitoring Pharmacy Clinic (ACC) progress note, dated 8/11/23, indicated R3's facility tested INR value continued to be far low of goal range. Goal range of 2.5-3.5 with indicators for anticoagulant use of embolic stroke, aortic valve replacement, and long term (current) use of anticoagulants. The note indicated R3 was at high thrombotic risk due to history of stroke and valve replacement. Due to continued low INR, and prior history of R3 requiring approximately 10 mg (milligrams) weekly dose of warfarin (anticoagulant), the ACC wanted to be aggressive over the weekend with dosing and ordered the following: -Start enoxaparin (anticoagulant) 120 mg subcutaneous (SQ) daily (QD). -Warfarin two (2) mg QD on 8/11/23 through 8/13/23. -INR check 8/14/23. -Give morning (am) dose of enoxaparin on 8/14/23 and await warfarin instructions. An ACC progress note, dated 8/14/23, indicated R3's INR value was 2.3 and considered subtherapeutic. The following orders were provided: -Administer warfarin three (3) mg today 8/14/23 and then return to weekly dosing. -Discontinue enoxaparin. -INR check on 8/18/23. R3's August Medication Administration Record (MAR) identified warfarin 3 mg was scheduled during the evening (pm) shift on 8/14/23; however, the code 9 (other-see progress notes) was charted A nursing progress note, dated 8/14/23 at 9:31 p.m., indicated R3 felt unwell and refused his pm medications; however, took them when offered at bedtime. Once administered, he immediately vomited and his medication was expelled. He declined to attempt the medications again. In review of R3's record, it was not evident the ACC or physician were notified of the expelled medications or R3 not feeling well. R3's progress note, dated 8/15/23 at 4:16 a.m., identified R3 was sent to the emergency department (ED) for stroke symptoms identified as unable to speak clear, speech mumble[d]/slurred, unable to follow direction, cold, clammy, diaphoretic, unable to grasp or follow finger with eyes. R3's blood pressure was 124/70 and his pulse was 125. 911 was called. A medical provider hospital Summary of Hospitalization note, dated 8/18/23, identified R3's assessment was consistent with recurrent cardiac thromboembolism. R3 was diagnosed new a splenic infarction, multiple acute appearing left-sided cerebral infarctions (strokes), and acute myocardial injury. R3's hospital laboratory report indicated the following hospital INRs: -8/15/23: 2.5. -8/19/23: 3.0. R3's hospital Discharge summary, dated [DATE], indicated he was stable and ready to return to the facility. An ACC progress note, dated 8/24/23, indicated R3's INR was 2.3 and identified as near low. The following orders were provided: -Warfarin 2 mg on 8/24/23, 8/25/23, 8/26/23. -Warfarin 1 mg on 8/27/23. No additional warfarin orders were provided past 8/27/23. -INR check on 8/28/23. R3's medical record lacked evidence R3's ordered 8/28/23 INR check was entered into R3's orders for completion and/or completed by facility staff. R3's August and September MARs, date range 8/28/23 through 9/10/23, lacked evidence R3 was administered anticoagulant medication(s). An ACC progress note, dated 9/11/23, indicated the ACC contacted the facility and spoke to licensed practical nurse (LPN)-E to follow up on R3's anticoagulant therapy. The ACC directed the facility to check R3's INR. The INR value was 1.2 (subtherapeutic). The note indicated R3 lacked warfarin administration since 8/27/23. Due to hospitalization in August for splenic infarction, R3 required bridging with enoxaparin until his INR was within 10% of his goal range (2.2). Updated warfarin orders were provided with an INR check ordered for 9/15/23. An ACC progress note, dated 9/15/23, indicated R3's INR was 2.0 and continued to be subtherapeutic (not within his 10% goal range). The following orders were provided: -Enoxaparin 100 mg SQ QD. -Warfarin 2 mg on 9/15/23. -Warfarin 1 mg on 9/16/23 and 9/17/23. -INR check on 9/18/23. R3's September MAR, date range 9/15/23 through 9/17/23, identified the following: -9/15/23: lack of evidence R3 was provided 2 mg of warfarin as ordered. -9/16/23: R3 was provided 3 mg total of warfarin (2 more mg than ordered) (two separate warfarin orders signed off: one for 1 mg and one for 2 mg). -9/17/23: The enoxaparin was not administered and indicated a chart code of 9 (other-see progress notes). Corresponding nursing notes did not identify why the doses of enoxaparin was not administered. An ACC progress note, dated 9/18/23, indicated R3's INR was 1.4 (subtherapeutic). The note identified the following information: -R3 missed the 9/15/23 warfarin. -R3 was administered 3 mg of warfarin on 9/16/23. -R3 was not administered the 9/17/23 enoxaparin. -Updated warfarin and enoxaparin orders were provided. -INR check on 9/22/23. On 9/18/23, facility medication error reports were requested. One of the reports, dated 9/18/23, indicated R3 missed the 9/15/23 ordered warfarin. The report identified the ACC clinic was updated; however, the report did not include and/or identify an analysis of causal factors that led to the error or corrective action plan to prevent or reduce the risk of future errors. No error reports were provided for the missed doses of anticoagulation on 8/28/23 through 9/10/23, 9/16/23, and 9/17/23. When interviewed on 9/18/23 at 1:26 p.m., R3 denied medication administration concerns and stated he took Coumadin (warfarin) to thin his blood as his heart did not beat as it should, he suffered a past heart attack, and only was at 30 percent heart pumping capacity. He felt all his INR values were within range and he was provided his medications as ordered. He expected his medications to be administered as ordered and expected the provider to be updated if concerns were identified. On 9/18/23 at 3:56 p.m., the ACC registered nurse (RN)-C was interviewed via telephone and indicated the clinic currently managed R3's anticoagulation therapy in which over the past couple weeks R3's INR readings were far low . which indicate[d] no warfarin was given. She explained an INR reading of 0.9 or 1.1 would be an expected value for a person not taking anticoagulant medication. It took approximately five to seven days of missed anticoagulant medication to show a value of 1.1 or lower and then another five to seven days, possibly up to 10 days, to return to the anticoagulation goal range. The only reason an INR reading would value at 1.1 or lower for someone who took anticoagulants was missed medication. The facility was responsible to check the INRs as ordered and update the ACC with the results. RN-C reported the ACC was not updated on 8/28/23 on R3's INR value. ACC staff realized this on 9/11/23 and contacted the facility to inquire. Facility staff denied R3 missed any anticoagulant medication and were unsure as to why the INR was low. RN-C explained R3's low INR values were concerning as R3 had multiple comorbidities and a heart valve which increased his risk for blood clots and associated death. When interviewed via telephone on 9/19/23, at 2:07 p.m., R3's nurse practitioner (NP)-A stated R3 required daily warfarin due to his blood clotting risk in relation to his blood clotting history and multiple comorbidities. If one dose of warfarin was missed it would be concerning; however, would not be a matter of life or death. If 14 days of warfarin were missed, R3 would be at huge risk for recurrent stroke, clots, and it could lead to his death. She stated, after she reviewed R3's clinic chart, the chart lacked information the facility updated her, or the physician, related to R3's medication errors 8/27/23 through 9/10/23, 9/15/23, 9/16/23, and 9/17/23. She explained she expected the facility to update the clinic when medication errors occurred as she and the physician were overall responsible for R3's medical care and may have insight into potential concerns. She reviewed the ACC notes she was able to access and stated she was concerned there appeared to be a lack of facility follow-up to determine why R3's INRs were so subtherapeutic after the ACC clinic updated the facility of their concerns. During an interview on 9/19/23 at 5:49 p.m., LPN-A denied knowledge of anticoagulant concerns with R3 or that staff brought concerns to her while she was in a charge role. In addition, she denied management staff questioned her on any potential concerns related to R3 and she denied recent education related to anticoagulant therapy and/or associated processes was provided to her. When interviewed on 9/19/23 at 6:20 p.m., trained medication aide (TMA)-A denied knowledge of anticoagulant concerns with R3; however, on 9/15/23 R3's warfarin was not found in the facility, and they awaited it from pharmacy. She explained registered nurse (RN)-B took over around 6:00 p.m., thus, she was unsure if it was administered. She was unsure if she updated RN-B that evening; however, she updated LPN-E before she left. She denied management staff questioned her on any potential concerns related to R3 or that she was provided recent education related to anticoagulant therapy and/or associated processes. A Thrifty [NAME] Pharmacy packing slip report, dated 9/15/23, identified four 1 mg warfarin tablets were brought to the facility for R3 which would have covered the 9/15/23 order. During interview on 9/19/23 at 6:43 p.m., management LPN-E explained after an order was initially processed another nurse, typically the night nurse, was expected to double check the order to decrease any potential processing errors. She reviewed R3's anticoagulant therapy orders and the MARs from 8/14/23 through 9/18/23. She stated the 8/28/23 INR lab order was not processed into R3's MAR and thus was not completed as ordered, no anticoagulants were administered from 8/28/23 through 9/10/23 and on 9/15/23, R3 received two more milligrams of warfarin on 9/16/23 than ordered, and enoxaparin was not administered on 9/17/23 as ordered. She was unable to explain the reason the 8/24/23, 9/11/23, and 9/15/23 orders were not double checked by a second nurse. In addition, she was unable to explain the reason for the errors other than processing concerns and a system failure related to the double check process. She was unaware of R3's missed INR lab on 8/28/23 and the missed associated warfarin orders, or of ACC's communicated concerns; however, she was aware of the three medication errors that started on 9/15/23. She explained the facility had not started an investigation or staff education into any of R3's medication errors and had yet to complete medication error reports for the 9/16/23 and 9/17/23 incidents. LPN-E stated if a medication was missed, the medical provider was expected to be updated. She was unsure if R3's provider was updated; however, she explained being he was followed by the ACC they updated the ACC instead of the provider. In addition, she explained if a resident who required anticoagulation therapy valued an INR around 1.1, that resident was at a very high risk for clots and she would have expected monitoring above and beyond the typical monitoring the facility provided for signs and symptoms of anticoagulant therapy bleeding risk, such as monitoring for blood pooling, extremity pain, and stroke like symptoms. When interviewed on 9/20/23 at 10:15 a.m., RN-B, who was the assistant director of nursing, stated order double checks were an expected part of order processing. This was to be completed within a day or two after the order was initially processed and was completed by management or floor nurses if they noticed orders in the double check file. Typically, the night charge nurse completed the double checks; however, that staff member was no longer employed. An INR value of 1.1 for a resident requiring anticoagulant was a concern as that meant the blood was too thick and they were at risk for clotting. She expected the charge nurse to investigate a low INR value as they were responsible for the medications and orders that day. In addition, when INR values were low and/or subtherapeutic, she expected the charge nurse to contact the ACC and discuss a plan of action. Furthermore, she expected an assessment to be completed if a resident missed anticoagulation medication to ensure resident stability, and to update the medical provider for additional orders, especially since the risk of missed anticoagulation therapy was higher and could increase other medical complications related to clotting. It was not a facility practice to set up missed medication assessment monitoring: We probably should. When a medication error was identified, staff were expected to complete an incident report by the end of the shift to help rule out any potential concerns, to determine required education if applicable, and to ensure the facility's processes were completed for when errors occurred. RN-B was unaware of the concern severity related to R3's anticoagulation therapy and thus she was unsure as to what occurred or what was investigated/implemented; however, she was aware of his 9/17/23 missed enoxaparin. She explained this error occurred as the medication was not in the facility. She stated staff should have followed the on-call pharmacy processes to request the medication on 9/17/23 instead of waiting until the next day (Monday). In addition, she stated staff should have contacted the ACC or the provider to update for additional instructions as R3 was at a definite risk for clotting and another infarction with possible death. RN-B stated missed anticoagulants were a significant medication error in which R3's anticoagulation medication errors certainly could have been harm [for R3]. During interview on 9/20/23 at 12:10 p.m., the administrator stated he was not aware of any systemic medication concerns prior to being updated on R3's anticoagulant and INR concerns after the abbreviated survey started. He expected orders to be processed as directed and was unaware of what nursing did to ensure process accuracy. If an INR value was reported to be low, he expected staff to verify the result and verify the resident was provided the ordered medication(s). In addition, he expected a root cause analysis and for the provider to be updated. He expected the nurse managers (RN-B, LPN-E) to also follow-up and fully investigate any sort of medication and/or order concern. When interviewed via telephone on 9/21/23 at 8:45 a.m., the medical director (MD)-A stated an INR value of 1.1 for an anticoagulated resident would be suspicious as it indicated they were not provided the ordered medication, especially if there were not orders in place to decrease the anticoagulation for procedures or surgery. R3's INR values, missed 8/28/23 INR, and missed/incorrect anticoagulation therapy was discussed. A one-time missed dose would not be a significant concern; however, there was a concern for R3 due to the multiple missed medication and lower INR values. He stated the facility required an order entry process change and expected the facility to be more hypervigilant with warfarin residents. He explained at a minimum a nurse should be in charge every day for quite a while to review all warfarin residents to ensure they were provided ordered medication(s) and INRs were completed as ordered. In addition, he expected these residents to be monitored and the provider to at least receive an FYI (for your information) fax to update on anticoagulation concerns such as a missed anticoagulant dose(s). The immediate jeopardy that began on 8/28/23, was removed on 9/21/23, after the facility reconciled all anticoagulation orders for residents who received warfarin, which included R3, and reviewed INR orders to ensure they were properly scheduled. In addition, R3's provider was updated with no new orders provided. The medical director was updated. Incident reports on identified medication errors were completed with root cause analysis and reviewed by the QAA (quality assurance) committee. Staff education was provided to all licensed nurses and TMAs on the importance of anticoagulation medication administration and INR lab draw order compliance as well as the process for medication administration, provider notification, order processing, and completion of ordered labs draws with communication of results. For staff not in attendance, required recorded education was to be completed before their next working shift. Furthermore, an INR Tracking Log was added to the facility anticoagulation system with daily audits initiated by nursing leadership along with weekly warfarin administration audits. Policy and procedure reviews were conducted with plan for facility QAA committee to review progress of the abatement plan weekly until further notice. Despite this removal plan and actions taken, noncompliance remained at the lower scope and severity level 2 D as the facility failed to ensure insulin (blood sugar regulator) medication was administered in accordance with physician orders for 1 of 1 residents (R6) who was provided insulin outside of ordered parameters during a medication pass observation. _____________________________________________________________________________________ R6's quarterly MDS, dated [DATE], indicated R6 was cognitively intact and was diagnosed with diabetes and utilized insulin seven days a week. A Endocrinology Diabetes Program progress note, dated 5/30/23, identified R6 was educated on the importance of maintaining good glycemic control due to potential complications of uncontrolled diabetes. R6 was diagnosed with type 2 diabetes mellitus with stage 3 chronic kidney disease and diabetic neuropathy requiring insulin use. The note's Plan section indicated adjusted insulin orders with NovoLog orders directing NovoLog to be given before each of R6's meals. A NovoLog, NovoLog FlexPen Prescribing Information PDF, dated 2/23, indicated a section labeled Dosage and Administration. This directed administration within 5 - 10 minutes before a meal . R6's Order Summary Report identified R6 was ordered the following: -Blood sugar (BS) checks four times a day (QID). -NovoLog FlexPen 100 unit/ml (milliliters) seven (7) units subcutaneously (SQ) three times a day (TID). Give prior to meals. -NovoLog FlexPen 100 unit/ml per sliding scale TID (0-149 = 0; 150-200 = 2; 201-251 = -4; 252-302 = 6; 303- 353 = 8; 354-404 = 10; greater than 400 call on call provider. R6's September Medication Administration Record (MAR) identified the NovoLog was scheduled for 7:30 a.m., 11:30 a.m., and 4:30 p.m. (half hour prior to mealtimes). During a medication pass observation on 9/18/23 at 12:56 p.m. (one and a half hours after scheduled), LPN-D stated R6's BS check around 11:50 a.m. was 206 and he had yet to receive his lunch time insulin. She reviewed R6's electronic MAR (eMAR) orders and calculated he required 11 units of NovoLog based on his scheduled and sliding scale instructions. She prepped the FlexPen and administered the 11 units of NovoLog insulin to R6. She exited R6's room and documented the administration in the eMAR. Immediately following, LPN-D was interviewed. She stated she provided insulin to residents after they ate as being provided insulin if they did not eat too good would not be good as their blood sugar could drop too low. LPN-D explained she was expected to read the entire order prior to medication administration and follow the directions as ordered; however, after she reviewed R6's orders, she stated she did not read the entire order as expected and did not follow the administration directions. In addition, she stated she was not aware of the direction to provide the insulin a half hour before meals, and if she had, she would have questioned this direction and would have investigated the order to ensure a transcription error was not made as in her history of nursing it was general nursing practice to administer insulin after meals. She denied there were risks to residents, including R6, if insulin was administered after meals versus prior to as directed. A review of R6's September MAR identified the following scheduled NovoLog insulin administration documented by LPN-D: -9/5/23 7:30 a.m. dosing: BS 127. Time stamped 9:43 a.m. -9/5/23 11:30 a.m. dosing: BS 189. Time stamped 1:15 p.m. -9/6/23 7:30 a.m. dosing: BS 149. Time stamped 10:07 a.m. -9/13/23 7:30 a.m. dosing: BS 147. Time stamped 9:24 a.m. -9/13/23 11:30 a.m. dosing: BS 152. Time stamped 1:05 p.m. -9/18/23 7:30 a.m. dosing: BS 166. Time stamped 10:15 a.m. -9/18/23 11:30 a.m. dosing: BS 206. Time stamped 1:05 p.m. R6's nursing progress notes, dated 9/5/23 through 9/18/23, lacked rationalization(s) for insulin administration not being provided as ordered i.e., poor intake, illness, R6 preferences and/or refusals prior to meals. On 9/20/23 at 10:15 a.m. RN-B was interviewed. She expected staff to follow the five rights of medication administration which included ensuring the order directions were followed. If a medication was directed to be provided before meals, she expected the medication to be given prior to meals. If there were concerns related to order directions, she expected staff to communicate with the provider and/or the pharmacy for clarification. She would be concerned if R6 was provided his NovoLog after meals as he required this before meals to prevent blood sugar spikes. When interviewed via telephone on 9/21/23 at 8:45 a.m. R6's medical provider MD-A stated the diabetic center managed R6's insulin and he would defer directions to them as they may have specific reasons why the insulin was scheduled as it was; however, he explained the typical timing of NovoLog would be five to ten minutes before meals. He explained if given prior to meals, a half hour in R6's case, the insulin would have time to peak and cover blood sugars during the meal, thus making the insulin more effective for improved blood sugar control. MD-A was concerned when updated on the medication pass observation as R6's A1C (glycosylated hemoglobin) lab was 8.1 which indicated R6's diabetes was slightly uncontrolled. On 9/21/23 at 4:40 p.m. the diabetic NP-B was interviewed via telephone. She stated NovoLog rapid acting was typically dosed prior to meals which was a long-standing practice. She explained the general rule was to administer the insulin 15 to 30 minutes prior to meals to decrease pre-meal blood sugars, thus, assisting in blood glucose control maintenance surrounding mealtimes when the blood sugar again would rise. If the insulin was provided after meals, the rising blood sugar acquired during the meal, on top of the blood sugar prior to the meal, would then have to be chased which led to decreased blood glucose control. An Administering Medication policy, dated 12/2012, identified medications were to be administered in a safe and timely manner, and as prescribed. It directed medications must be administered in accordance with the orders within one hour of their prescribed time, unless otherwise specified i.e., before and after meal orders. The administering staff must check the label THREE (3) times to verify the right resident .right dosage, right time .before giving the medication. An Adverse Consequences and Medication Errors policy, dated 4/2014, defined a medication error as the preparation or administration of medications which were not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples included, but not limited to, a medication omission, wrong dose, or wrong time. The policy directed that any resident who received any medication with potential for adverse consequence would be monitored to ensure any such consequences were promptly identified and reported and if a medication error was identified the resident would be monitored for possible medication-related adverse consequences. In the event of a significant medication-related error, immediate action was to be taken to protect the resident's safety and welfare. Examples of significant were defined as requiring medication discontinuation or dose modification and/or life threatening. Any significant medication error was to be promptly reported to the attending provider and the error information documented in an incident report and the resident's chart. A Medication Order policy, dated 11/2014, identified the purpose of the policy was to establish uniform guidelines in the receiving and recording of medication orders. The policy lacked information related to any established guidelines for medication and/or procedural order processing. A policy related to order processing was requested. None was provided. An Anticoagulation - Clinical Protocol policy, dated 11/2018, directed staff and the physician would collaborate in ensuring anticoagulants were assessed for risk, properly prescribed, and monitored for possible complications related to supratherapeutic INR values. The policy lacked information related to ACC collaboration and their role in resident anticoagulation needs. In addition, the policy lacked information related to resident monitoring when subtherapeutic INR values are present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents were free from allegations of physical and verbal abuse by staff for 2 of 2 residents (R1, R4) reviewed for abuse. This resulted in an Immediate Jeopardy (IJ) when R1 reported nursing assistant (NA)-A pulled the door shut while his arm was in the the doorway, resulting in R1 sustaining a substantial skin tear in the process. In addition, R4 was verbally abused by NA-A, when NA-A called R4 a bitch. The IJ began on 5/17/23, when the facility failed to prevent and protect R1 from physical abuse when nursing assistant (NA)-A was forceful with R1 during cares. This resulted in a skin tear to R1's right forearm. The administrator and the director of nursing (DON) were notified of the IJ on 5/24/23, at 5:32 p.m. The facility had implemented actions to prevent recurrence by 5/24/23, so F600 was issued at past non-compliance. Findings include: A facility 5 day report submitted to the State Agency (SA) on 5/22/23, indicated NA-A had requested a bandage for R1 on 5/17/23 at approximately 7:30 p.m. Licensed practical nurse (LPN)-A went into R1's room, and observed a fresh skin tear to R1's right forearm. The area was still actively bleeding. When LPN-A asked NA-A what happened, NA-A stated, He was being a complete jerk and fighting me while I was putting him to bed. NA-A stated R1 receied the skin tear from his wheelchair. NA-A stated she did not ask for help with R1's cares, or give R1 a chance to calm down. R1 was interviewed immediately and stated, She pulled the door shut very hard, she did not slam it but pulled it shut hard and continued to pull it shut while my arm was still in the door. R1's admission Record dated 3/13/23, indicated R1's diagnoses included dementia without behavioral disturbance, anxiety, depression, and generalized muscle weakness. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, required assist of two staff and a mechanical lift for transfers, was non-ambulatory, and required limited assistance with activities of daily living (ADLs). R1's care plan dated 3/13/23, indicated R1 had impaired cognitive function. Staff intervention included to use simple words, and approach in calm manner. The care plan further indicated R1 was non-ambulatory, and required extensive assistance of two staff and and EZ lift (mechanical lift) with transfers. R1's progress note dated 5/17/23 at 8: 43 p.m., indicated family member (FM)-A was informed R1 was physically abused as evidenced by a 5 centimeter (cm) x 2.5 cm skin tear on the right arm. The note indicated the staff member was suspended immediately. The note further indicated R1 was in his room sleeping and safe. R1's progress note dated 5/17/23 at 9:21 p.m., indicated R1's primary physician was notified about the abuse allegation. The progress note further indicated the DON assessed R1 head to toe, and no other injuries were noted. A report was made to the State Agency (SA). The DON immediately suspended NA-A who was escorted out of the facility pending the outcome of the investigation. R1's progress note dated 5/18/23 at 11:41 a.m., indicated R1 was able to sleep overnight and felt safe in his environment. On 5/23/23 at 1:38 p.m., R1 was interviewed and stated, I don't remember what really happened and acknowledged doing good and stated he felt safe. On 5/23/23 at 2:47 p.m., LPN-A was interviewed and stated NA-A requested a bandage for R1 who had sustained a large skin tear. Upon assessment, LPN-A stated she tried to clean the wound and was unsuccessful. LPN-A stated she called the DON for assistance, who came with the social worker (SW)-A to assess and put a dressing on the wound. LPN-A stated NA-A denied any physical abuse towards R1, instead NA-A stated R1 scratched his arm on the wheelchair, but no blood was found on the wheelchair. LPN-A stated NA-A had a poor attitude at work, and that had been brought forward to the DON on multiple occasions. On 5/23/23 at 3:40 p.m., registered nurse (RN)-A stated the DON informed her of the alleged physical abuse of R1. RN-A stated NA-A had a negative attitude toward staff. RN-A stated she had heard NA-A called a resident a bitch, but believed it was an isolated incident. RN-A stated she was not sure about any follow-up regarding the incident. On 5/23/23 at 3:54 p.m., RN-B stated the DON alerted her of R1's alleged physical abuse. RN-B stated some allegations were made against NA-A, and stated she felt like the DON took care of it. RN-B also stated NA-A's poor attitude could affect how she provided care to the residents. On 5/24/23 at 9:23 a.m., NA-A was interviewed. NA-A denied physical abuse with R1. NA-A stated while she was caring for R1, he refused to take his shirt off. NA-A stated R1 became agitated, pinched, and scratched the back of her arm, but he did not leave any marks. NA-A stated she was able to put the EZ lift sling around R1, and she transferred him into bed. NA-A acknowledged when R1 became agitated, she should have reapproached R1 and called for help. R4's admission Record dated 10/14/22, indicated R4's diagnoses included severe dementia with agitation, delirium, and major depressive disorder. R4's admission MDS dated [DATE], indicated R4 had severe cognitive impairment, required extensive assistance with transfers, was non-ambulatory, and required limited assistance with ADLs. R4's care plan dated 5/3/23, indicated R4 had severe cognitive impairment, hard of hearing, and at risk for harm from others and to self. Staff intervention included adjust tone of voice, anticipate any non-verbal needs, use terms, gestures she can understand, approach in calm manner, call by name, and remove unwanted stimuli. On 5/24/23 11:23 a.m., the DON stated she became aware of the allegations of NA-A calling R4 a bitch. The DON stated she did not recall when this was, but thought it had been within the last couple of weeks. The DON stated she had interviewed some staff and residents, and did not determine anything had occurred. The DON stated she did not report the allegation of verbal abuse to the SA. The DON stated she did complete a verbal teachable moment with NA-A, but did not document it. The DON further stated she was working at the time of the allegation of physical abuse towards R1, and was aware. The DON stated she sent NA-A home immediately after the allegation was made. The DON stated she started providing education to all staff. On 5/24/23 at 1:10 p.m., NA-C was interviewed and stated sometime in April, NA-A called R4 a bitch after R4 pinched her in the arm. NA-C stated she thought that was verbal abuse; however, NA-C did not immediately report the incident, but reported it to LPN-A a couple days later. On 5/24/23, at 2:55 p.m., LPN-A stated a month and half ago, probably around March 14th, on the p.m. shift, she was in the dining room when NA-C came to her. LPN-A stated NA-C told her NA-A called R4 a bitch a couple days ago. LPN-A stated she directed NA-C to talk to the DON. LPN-A stated she did not document the allegation, nor did the DON talk to her about the allegation. R4's progress notes reviewed from 3/1/23, through 5/24/23, lacked documentation of the allegation of verbal abuse. The facility Vulnerable Adult policy revised 2/6/23, directed the facility to provide a supportive and safe environment for all residents to the extent possible through the deployment of trained and qualified staff to meet residents' needs as identified in both the individual resident care plan and the facility assessment. The IJ was removed on 5/24/23, when it was determined NA-A was suspended pending further investigations with a follow-up plan to either terminate or provide education with ongoing monitoring for compliance. The facility Vulnerable Adult policy was reviewed with no changes. Residents and staff were interviewed to determine if any other residents sustained either verbal or physical abuse, and no further incidents were reported. The facility completed re-education of all staff on abuse procedures including reporting of allegations of abuse and how to care for residents with difficult behaviors. Staff were interviewed on 5/24/23, and verified re-education had occurred. F600 was issued at past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide routine resident condition monitoring after the facility was notified by the pharmacy of an albuterol nebulizer medication national shortage and communicate this shortage, and missed inhaler medications, to the provider for alternative medication utilization for 1 of 3 residents (R1) to prevent acute respiratory changes and hospitalization. This resulted in an immediate jeopardy for R1. In addition, the facility failed to provide the same condition monitoring and provider updating for 2 of 2 residents (R2, R3) who were ordered ipratropium-albuterol (DuoNeb) nebulizer treatment and/or demonstrated acute respiratory symptoms at the same time they were not provided ordered medication due to the shortage. The immediate jeopardy began on 2/17/23, when the facility failed to routinely monitor and update R1's provider when the pharmacy notified the facility of an albuterol nebulizer medication national shortage and were unable to dispense R1's ordered albuterol. In addition, R1 missed 11 doses of Advair inhaler. This resulted in hospitalization for R1. Administrator, director of nursing (DON), assistant directors of nursing (ADON)-A and ADON-B, and director of clinical services (DCS)-A were notified of the immediate jeopardy at 7:00 p.m. on 3/7/23. The immediate jeopardy was removed on 3/9/23, but noncompliance remained at the lower scope and severity level D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Record face sheet identified R1's primary admission diagnosis was chronic obstructive pulmonary disease (COPD). R1's COPD care plan, initiated on 7/17/22, identified R1 was at risk for SOB (shortness of breath) and respiratory infections with a goal R1 would remain free of signs/symptoms (s/s) of respiratory distress and maintain optimal functioning within limitations of the disease process. The care plan directed staff with the following interventions: administer medications/puffers as ordered, observe for effectiveness and side effects, monitor for signs of respiratory infection/distress, adventitious (not per R1's normal) lung sounds, SOB, coughing, elevated temperature, increased respiratory rate, report as necessary to the physician. R1's physician orders indicated R1 was prescribed on 9/6/22, albuterol sulfate (treats wheezing and shortness of breath caused by breathing problems such as asthma, chronic obstructive pulmonary disease) nebulizer solution inhaled orally three times a day (TID) for diagnosis of acute respiratory failure with hypoxia and every four hours as needed (PRN) for SOB and wheezing. In addition, R1 was prescribed on 6/30/22, Advair Diskus (fluticasone-salmeterol, steroid and bronchodilator combination medicine that is used to prevent asthma attacks) inhaler which directed one puff inhaled orally two times (BID) a day related to diagnosis of acute respiratory failure with hypoxia. The facility's pharmacy fax binder identified pharmacy Reorder Forms and Packaging Slips with the following information: -2/10/23, R1's albuterol was requested. The binder lacked evidence the albuterol was dispensed and lacked a follow-up notation related to dispensing concern. -2/14/23, R1's Advair and albuterol were requested. The binder lacked evidence the Advair or the albuterol were dispensed and lacked follow-up notation related to dispensing concerns. -2/17/23, R1's albuterol was requested. The Reorder Form identified a handwritten Back order next to the request. -Three other Reorder forms, undated, identify staff requested R1's Advair and albuterol. The binder lacked evidence of a follow-up notation related to Advair dispensing concerns; however, the other two forms identified handwritten notations the albuterol was on back order and was unable to be dispensed, and the other one indicated the albuterol was out. R1's Medication Administration Record (MAR) identified R1 missed 11 of 20 doses of the Advair from 2/12/23 through 2/21/23, and 15 of 18 doses of the albuterol from 2/16/23 through 2/21/23. Indications for the missed doses identified med not available. R1's MAR, and associated Treatment Administration Record (TAR) 2/1/23 through 2/28/23, lacked documented evidence R1's respiratory status was monitored in relation to the missed doses of Advair and albuterol. R1's progress notes identified the following entries: -2/12/23, 7:50 a.m. Advair was not located in the cart or found in his room. -2/12/23, 8:25 p.m. Advair was not available. -2/13/23, Advair was out waiting on pharmacy. -2/14/23, Advair request was faxed to pharmacy. -2/16/23, 11:48 p.m. R1 was weak and seemed a bit off. He had been coughing, his pulse was elevated at 109, and he was assessed to have slight expiratory wheezes in his upper left lobe. -2/17/23, 11:42 a.m. Advair request was faxed to the pharmacy. -2/17/23, 11:43 a.m. albuterol was not administered due to a shortage. -2/17/23, 12:37 p.m. albuterol was not administered due to a shortage. -2/17/23, 4:38 p.m. entered by ADON-B, R1 had an order for albuterol nebulizers; however, the pharmacy reached out and stated, There is a shortage and that they are unable to get albuterol at this time. -2/19/23, 4:28 p.m. R1 complained of chest pain. Vitals were assessed without identified concerns and his lung sounds were clear. -2/19/23, 8:49 p.m. R1 was provided cough syrup in response to a bad cough in which he was losing [his] voice. -2/20/23, 5:59 a.m. R1 reported a stuffy nose. -2/20/23, 10:27 p.m. albuterol was not administered due to a national shortage. -2/20/23, 10:27 p.m. Advair will be ordered. -2/20/23, 12:48 p.m. albuterol was not administered due to a national shortage. -2/20/23, 11:07 p.m. R1 coughed all PM [evening] shift in which his cough was loose and productive. R1 was administered PRN cough syrup. -2/21/23, 12:44 p.m. albuterol was not administered due to a national shortage. -2/21/23, 10:20 p.m. R1 was provided emergency room (ER) transport orders due to wheezing, chest congestion and mild chest tightness and discomfort. -2/21/23, 10:30 p.m. R1 was sent to the ER as he complained of chest pain, coughing, audible wheeze and chest congestion. R1's progress notes dated 2/12/23 through 2/21/23, lacked documented evidence R1's provider was updated related to missed medications, the albuterol national shortage, and/or his change in respiratory condition prior to 2/21/23, order to send R1 to the ER. R1's ED provider note dated 2/21/23, identified R1 presented with chest pain and SOB. R1 reported the nursing home did not have any nebs for him and he usually receive[d] one. Note indicated, R1 had diffuse wheezing and bibasilar crackles and R1 complained of a lot of chest pain. He received three doses of DuoNeb and one dose of an intravenous (IV) steroid. On 2/22/23, at 1:35 a.m. R1 required 2 liters of oxygen for oxygen saturations of 81% and diagnosed with a COPD exacerbation. R1's hospital History and Physical dated 2/22/23, identified R1 reported 7-10 days worth of cough, runny nose, congestion leading up to ER visit. Additionally, the facility apparently failed to provide R1 with his normal albuterol treatments for two weeks prior to this episode. R1 wheezed and demonstrated course upper airway sounds, wet cough. R1's Discharge summary dated [DATE], identified the discharge diagnosis was Acute hypoxic respiratory failure - COPD exacerbation - resolved. He was medically stable, and his lungs were clear to auscultation bilaterally on room air. On 3/3/23, at 9:58 a.m.: R3 was observed sitting in his room. No obvious signs of respiratory distress noted, appeared comfortable. When interviewed on 3/3/23, at 10:13 a.m. R1's hospital medical provider (MD)-B stated if R1 were provided his ordered inhaler [Advair] and albuterol he would not have had that flair [exacerbation] and thus R1 would not have required hospitalization. R1 likely had a viral illness which could have been managed in the facility if he were administered the inhaler and nebulizer, with a possible clinic visit for follow-up of symptoms and adjusted treatment at most. MD-B indicated she based her thoughts on his hospital symptoms and how well he responded to the nebulizer medication he received at the hospital. During an interview on 3/3/23, at 12:57 p.m. pharmacy tech (PT)-A stated albuterol sulfate shortages have occurred for at least two months. This shortage included DuoNeb and did not include Advair, adding the medications were last supplied to the pharmacy the beginning of February and a restock time frame was unknown. She expected the facility to update the providers for alternative orders if the pharmacy was unable to dispense medications. R1's albuterol was last dispensed on 2/6/23, for an equivalent of 30 doses (10 days based on the TID order) and the Advair was last dispensed on 2/20/23. When interviewed on 3/3/23, at 1:29 p.m. registered nurse (RN)-A explained R1 missed albuterol doses due to the shortage. She was unsure why R1 missed Advair doses and was unaware of any Advair dispensing concerns, indicating she just hoped [the Advair] was in the room but it was not there. RN-A confirmed R1's provider was not updated on the missed Advair and albuterol, which were missed for maybe a couple weeks despite managements knowledge of the shortage. Additionally, RN-A stated it had been a while since these medications were last dispensed for any resident, a few residents continued to have scheduled and/or PRN albuterol/DuoNeb orders. RN-A stated R1's acute respiratory status changes and reported chest pain should have been reported to the provider when first noted in order to get a hold of the concerns and keep on top of it to prevent hospitalization especially due to R1's increased risk for respiratory concerns related to his diagnosis, decreased mobility, and time of year. RN-A stated the facility lacked a protocol for respiratory monitoring when acute changes or medication concerns were present; however, monitoring was important to keep tabs on the resident to update the provider with more specific details, and if monitoring was not completed, the resident could get worse, could be detrimental, and could lead to hospitalization. RN-A added, We saw it with [R1]. When interviewed on 3/3/23, at 2:32 p.m. trained medication aide (TMA)-A stated she would be significantly concerned if R1 complained of chest pain as this was not a complaint he reported, and potentially indicated something was going on with his health. R1's complaints of chest pain, especially with his lung issues, was a change in R1's condition and she expected the nurses to update providers when residents presented with changes in condition for follow-up orders to manage the change. During an interview on 3/3/23, at 2:54 p.m. licensed practical nurse (LPN)-A stated she assessed R1's complaints of chest pain on 2/19/23, which was not a reoccurring complaint for him. She was aware of the albuterol shortage; however, not aware of the DuoNeb shortage. On 2/19/23, R1 was free of any immediate signs of distress. She did not doubt he had chest pain but felt the pain was food related; however, chest pain potentially indicated a change in condition which required the provider to be updated. She passed this information on to the night shift and asked them to keep an eye on R1; however, she denied she initiated respiratory and/or cardiac monitoring for R1 or contacted the provider. She denied it was facility practice to set up monitoring for acute changes. During an interview on 3/3/23, at 3:31 p.m. R1 stated he had a terrible cold, in which everything is congested, he had increased phlegm and terrible chest pain because he did not get this machine. As R1 pointed to his nebulizer machine he stated, This thing helps me a lot .if I do not get it, kaput and performed a thumbs down movement with his hand. Additionally, he stated there was a pharmacy issue for why he was not provided the nebulizer and if staff would have figured it out, he would have avoided hospitalization. He also required the inhaler (as he made a motion as if to self-administer an inhaler) to help manage his respiratory condition, which he was not often administered before the hospitalization. The symptoms started about a week before he went to the hospital when he experienced chest pain like a [NAME] kicking [him]. This chest pain scared him. He updated staff about the chest pain and his not feeling well; however, they did not do anything for me .they should have called [his provider] sooner. R1 added that he was much worse on 2/21/23, but now he continued to have periods of chest pain which comes and goes; however, this no longer scared him as he overall felt better. When interviewed on 3/3/23, at 4:09 p.m. ADON-B stated when a resident experienced condition changes she expected them to assess the resident, update the provider, and initiate monitoring each shift for approximately a week related to the signs and symptoms presented to prevent any progressive sickness that could occur and to assist with updating the provider with comprehensive assessed details on the status changes. She was aware of R1's missed albuterol due to the shortage; however, was unaware he missed inhaler doses. It was important to monitor and update the provider with changes to prevent adverse impacts to the resident, such as R1's hospitalization. When interviewed on 3/6/23, at 12:53 p.m. MD-C stated she first learned of R1's hospitalization after the fact .through the grapevine and was first updated on the shortage when she visited for rounds on 2/23/23. She reviewed R1's clinic record during the interview and indicated there were no records the facility contacted the clinic related to R1's missed medications and/or his acute respiratory changes. She expected the facility to contact her right away after they were unable to procure medications and after changes in resident status, especially a sign or symptom change not improved with ordered and/or standing order medications, for alternative medication and/or treatment orders to be provided. R1's Advair was ordered as a preventative medicine after he experienced several ER visits, and because R1 was not administered the inhaler as ordered, he was hospitalized . If the facility had updated her as expected, she would have adjusted R1's Advair and/or albuterol orders and potentially kept him from being hospitalized . During an interview on 3/6/23, at 2:28 p.m. RN-C stated there were a couple residents having respiratory issues who were sent to the hospital because the facility did not have any nebs to treat them, adding R1 was one of them. RN-C indicated she was unaware of a systemic process to ensure all the residents were reviewed for the impacted medication shortage or if all the providers were updated. It was important to update providers for alternative orders, especially if the residents were ordered PRN nebulizers and required this for acute respiratory distress. Residents were at risk of increased respiratory concerns with ceased breathing if they were not administered ordered respiratory medications timely. She explained the facility did not utilize standing orders and if a resident were unable to be provided an ordered as needed nebulizer, staff contacted the provider for stat (immediate) orders which had the potential to delay treatment. In addition, it was not standard practice to implement respiratory monitoring when respiratory symptoms were identified and thus, she did not set up monitoring for R1. She denied she updated R1's provider after she assessed his condition changes during two of the five days prior to his hospitalization, nor updated the provider related to R1's missed medications; however, she was expected to update the provider with such assessed changes, for example., productive cough, expiratory wheezes, and lack of ordered medication supply. When interviewed on 3/6/23, at 3:15 p.m. the DON stated she was updated on the albuterol shortage on 2/27/23, after she contacted the pharmacy about R1's missed albuterol. She denied knowledge of the DuoNeb shortage or that R1 missed multiple doses of his Advair. She instructed the floor nurses to notify providers of the shortage; however, did not follow up to ensure this was completed, did not conduct any audits to determine the scope of the albuterol shortage in the facility, did not reach out to additional pharmacies or to the consulting pharmacist to inquire about the shortage, and did not contact the medical director. She expected staff to notify the providers right away when there was a medication concern or a change in resident condition, especially if there was chest pain to avoid further changes and/or hospitalization. She confirmed the facility currently worked on initiating facility standing orders and she expected staff to routinely check the pharmacy book to ensure requested medications were brought by the pharmacy. If not, a pharmacy inquiry was expected: This is not happening as expected. The DON stated R1's provider should have been updated on 2/16/23, and staff should have initiated respiratory monitoring due to his risk of further condition changes and respiratory distress, along with pneumonia. During a follow-up interview on 3/7/23, at 12:20 p.m. ADON-B stated she personally spoke to the pharmacy on or around 2/17/23 (Friday) about their inability to dispense R1's albuterol due to shortage. She updated the floor nurses after the conversation; however, did not perform any additional actions related to the shortage for R1 or any other residents with albuterol or DuoNeb orders. On 2/20/23 (Monday), management discussed the shortage in the morning meeting and in response R1's provider was to be updated during 2/23/23, provider rounds. She denied an all-house audit was completed to look for other impacted residents after the meeting. The immediate jeopardy that began on 2/17/23, was removed on 3/9/23, after the facility obtained alternative nebulizer orders for those residents who were prescribed albuterol and/or DuoNeb, audited 72-hours of all resident progress notes for changes in condition and updated providers and families with identified changes, and audited 72-hours of all medications charted as unavailable and obtained alternative provider orders. In addition, the facility communicated with the dispensing pharmacy and the medical director related to processes for medication dispensing concerns, implemented a process for resident assessments and monitoring in the event of dispensing concerns, educated nursing staff related to provider notification with status changes and medication dispensing concerns, and educated nursing leadership related to system management and expectations related to identification of missed medications and follow-up, but the noncompliance remained at the lower scope and severity level D. R2's admission Record face sheet identified R2 was diagnosed with COPD, obstructive sleep apnea (OSA), chronic oxygen dependence, nicotine dependence, and morbid obesity with alveolar hypoventilation (rare disorder in which a person does not take enough breaths per minute). R2's COPD care plan, initiated 12/27/22, identified R2 was at risk for SOB, impaired breathing, and respiratory infections with a goal R2 would remain free of complaints and/or s/s of SOB. The care plan directed staff with the following interventions: administer medications/puffers as ordered, observe for effectiveness and side effects, monitor for signs of respiratory infection/distress, adventitious lung sounds, SOB, coughing, elevated temperature, increased respiratory rate, report as necessary to the physician. R2's MAR, dated 2/23, directed staff to administer DuoNeb four times (QID) to R2 for chronic respiratory failure with hypoxia. The MAR identified R2 missed 5 of 15 doses of the DuoNeb from 2/20/23 through 2/23/23. Indications for the missed doses identified med not available. R2's MAR, and associated treatment administration record (TAR), 2/1/23 through 2/28/23, lacked documented evidence R2's respiratory status was monitored in relation to the missed doses. R2's progress notes identified the following entries: -2/20/23, DuoNeb was not administered due to out of stock. -2/21/23, 1:19 p.m. DuoNeb was not administered due to national shortage. -2/23/23, 2:35 a.m. R2 was congested with audible wheezes and SOB. PRN albuterol nebulizer was administered. Follow up at 5:41 a.m. identified the PRN nebulizer was Ineffective. -2/23/23, 7:58 a.m. R2 coughed and wheezed. PRN albuterol was administered. -2/23/23, 9:43 a.m. DuoNeb was not administered due to faxed pharm shortage. -2/23/23, 12:43 p.m. DuoNeb was not administered due to shortage. -2/23/23, 7:40 p.m. an unidentified TMA requested LPN-B to assess R2's lung sounds. R2 was wheezing with short rapid breathing. TMA was instructed to administer a nebulizer. R2 declined provider/ED follow-up. The progress notes lacked R2's provider or the on-call provider was updated. In addition, R2's progress note lacked a follow-up assessment or evidence of routine monitoring related to her changes in condition. -2/24/23, 5:46 a.m. At 2:18 p.m. R2 left for the ER after staff found her pale purple lips. Her breathing was very deep and rapid with expiratory and inspiratory wheezes. Oxygen saturation was 83% on 4 liters of oxygen, and her pulse was 110. R2 initially did not want to present to the ER; however, after about 10 minutes of staff encouragement she agreed to ER transport. R2's ER Provider Note, dated 2/24/23, indicated R2 was provided a DuoNeb enroute to the hospital and she required 10 liters of oxygen per mask. R2 was unable to give additional history on arrival due to increased work of breathing. Later, R2's oxygen was decreased to 5 liters per a mask and was able to maintain oxygen saturation level of 94%; however, she continued with diffuse wheezing, increased work of breathing, and productive cough. She was initially diagnosed with pneumonia and COPD exacerbation. R2's hospital Discharge summary, dated [DATE], identified R2 passed away on 2/26/23. She was admitted for cough, exertional dyspnea, and hypoxemia and subsequently diagnosed with acute on chronic hypoxic and hypercapnic respiratory failure, healthcare associated pneumonia, acute exacerbation of end-stage COPD. R2 was treated with antibiotics and required intermittent noninvasive positive pressure ventilation (ventilation provided by a mask). She held her own' for the first two days but on 2/26/23 began to deteriorate. That evening, after she removed her mask briefly she died rather quickly. R3's admission Record face sheet identified R3 was diagnosed with obstructive sleep apnea. The face sheet was free of additional respiratory diagnoses. R3's COPD care plan, initiated 12/15/22, identified R3 was at risk for medical complications and/or discomfort related to OSA. Interventions directed staff to observe for and report to the provider s/s of sleep apnea which included excessive daytime sleepiness and cognitive decline related to fatigue R3's hospital Discharge summary, dated [DATE], indicated R3 was hospitalized for systemic inflammatory response syndrome (SIRS - exaggerated defense response) due to viral gastroenteritis. His discharge examination identified he was alert, and his lungs were clear without any signs or symptoms of respiratory illness. His condition was stable. R3's progress notes identified the following entries: -3/3/23, 9:54 p.m. R3 was lethargic, not responding and not wanting to bear weight and stand up. The DON checked the [R3] and [he] was deemed to be 'OK.' R3 declined to go to the Dr again. Staff attempted to contact family; however, the note lacked evidence facility contacted the provider. -3/5/23, 10:41 a.m. R3 fell asleep twice during the meal and was observed to be SOB at rest. -3/5/23, 4:25 p.m. R3 presented with heavy breathing, and he was assessed to have expiratory wheezes in the upper and lower left lobes. -3/6/23, 5:50 a.m. R3 presented with wheezing. He was lethargic and hard to arouse. -3/7/23, 8:05 a.m. R3's provider was updated via fax at 8:00 a.m. R3 was assessed to have course lung sounds with crackles and expiratory wheezes and 3+ bilateral feet pitting edema. He was very lethargic and was unable to stay awake. His respiratory rate was 25. -3/7/23, 12:52 p.m. R3 was transported to the ER. The progress notes lacked evidence R3's provider or the on-call provider were updated prior to 3/7/23. In addition, R3's progress note lacked evidence of routine monitoring in response to his condition changes. R3's MAR, dated 3/23, directed staff to administer DuoNeb QID PRN for SOB, cough or with exercise, ordered 3/3/23 and discontinued 3/6/23. Budesonide one vial inhaled PRN for prophylaxis for one day was ordered on 3/6/23. The MAR lacked evidence R3 was administered the PRN DuoNeb from 3/5/23 through 3/6/23 or the Budesonide on 3/6/23 in response to his respiratory s/s. The facility's pharmacy fax binder identified pharmacy Reorder Forms and Packaging Slips with the following information: -2/19/23, R2's DuoNeb was requested. -One Reorder Form, undated, identified R2's DuoNeb was requested, and the form identified a handwritten out under the request. -The binder lacked documented evidence staff requested R3's DuoNeb and/or a rationalization as to why it was not dispensed. On 3/6/23, at 2:15 p.m. R3 was observed sitting up in wheelchair in day room. No s/s of respiratory distress or ancillary muscles to breath. Surveyor attempted to interview R3 but he appeared to be sleeping. During a follow-up interview on 3/6/23, at 12:13 p.m. PT-A stated R2's DuoNeb was last dispensed to the facility on [DATE] (30-day equivalent). R3's DuoNeb was never dispensed. When interviewed on 3/6/23, at 12:53 p.m. MD-C reviewed R3's clinic record, and current pile of faxes, and indicated there were no records the facility contacted the clinic related to R3's acute respiratory changes and/or a request for an alternative PRN nebulizer. She explained at R3's baseline he was very with-it and can talk to you. After she was updated on R3's 3/3/23 to 3/6/23 progress note entries, she stated she expected R3 would be administered his PRN DuoNeb and if the facility was unable to obtain it, they should have requested an alternative right away. In addition, she expected staff would have updated her on 3/3/23 related to his status changes especially as he did not have respiratory concerns during his recent hospital stay and newly presented onset of wheezing and altered cognitive level; adding, he was at risk for developing heart failure as he experienced an MI (myocardial infarction) during his hospital stay so his respiratory s/s potentially were cardiac in nature. During interview on 3/6/23, at 1:42 p.m. MD-C reviewed R2's clinic record and indicated there was no evidence the facility contacted the clinic related to R2's acute respiratory changes and/or an update related to her missed DuoNeb medication. MD-C also denied the facility contacted him related to any of his other residents adding, he found out about R2's status and passing when he received a request for the death certificate. MD-C indicated he was unaware of an albuterol or DuoNeb shortage and he expected the facility to contact him with changes in resident statuses, especially as respiratory concerns cannot wait long to be addressed and if there were issues obtaining medications stating, if the facility would have updated him on her progress when the symptoms started, he most likely would have ordered steroid medication as he would have presumed she was having an exacerbation of her respiratory diagnoses. However, he did not feel her exacerbation was attributed to five missed DuoNeb doses as R2 also received a long-acting nebulizer medication, was a smoker, lacked good underlying health, had terrible lung disease, and had a higher mortality rate, thus her being sent to the ER was unavoidable. In addition, R2 was finding a way to exit this mortal coil, and he was unsurprised by her death. On 3/6/23, at 2:15 p.m. R3 was approached, and an interview attempted. He was free of s/s of observed respiratory distress. His eyes were closed, his head slightly bent (appeared asleep) and did not arouse to his name being called and/or physical touch. When interviewed on 3/3/23, at 1:29 p.m. RN-A stated R3 was very tired and slow to wait up earlier that morning; however, he was not feeling good. R3 lacked any outward s/s of respiratory distress; however, she did not listen to his lungs or assess his respiratory status as shift report lacked indicated of any respiratory concerns. RN-A stated R4 was slowly declining and coughed more with eating. R4 was free of s/s of respiratory concerns earlier that morning. She stated neither R3 nor R4 had a DuoNeb supply in the med cart. Based on this, if R3 required a PRN DuoNeb, she would call MD-C, or the on-call provider, and request alternative treatment. She explained this was a difficult process as their pharmacy was in Willmar and she questioned how she was supposed to get the adjusted PRN medication other than sending [the resident] to the ER. RN-A stated residents lacked the ability to just bounce back. As residents required ordered medications, it was not going to be good if the medications were not administered as ordered. During interview on 3/6/23, at 2:28 p.m. RN-C stated R2's assessed cough, congestion, short rapid breathing, and audible wheezes on 2/23/23 were new; however, the SOB was normal for her. RN-C was unable to remember if she updated the provider after she assessed R2 and/or a reason as to why R2's provider was not updated. RN-C stated R3 experienced a status decline recently where he was off, and staff did not think he was breathing well, the first night after a hospital return. Due to this, the DON was asked if she would assess R3. RN-C denied she went back to reassess R2 after the DON stated R2 was okay or set up any routine respiratory monitoring. RN-C stated R4 has been okay and lacked evidence of any distress on the overnights. When interviewed on 3/6/23, at 3:15 p.m. the DON stated she expected staff would have updated R2, R3, and R4's providers, or an on-call provider, related to their status changes and related to the shortage to obtain additional orders. She denied she reviewed R2's medical record once the facility was updated on R2's death to audit the record for any concerns or to see if R2 was potentially impacted by the shortage. The DON stated she expected R3 would have received a PRN nebulizer treatment when he presented with respiratory s/s. She denied R4 displayed any changes in his respiratory status; however, she was frustrated as him of all people need [the nebulizer medication] related to his diagnoses. The DON explained residents were at a risk for changes in condition and increased risk of hospitalization, or even worse, if staff failed to perform as expected. A policy Resident Examination and Assessment, dated 2/14, directed staff to notify the physician if any of the following abnormalities were identified: abnormal vital signs, labored breathing, breath sounds that are not clear, productive or nonprod[TRUNCATED]