**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with family, staff, Nurse Practitioner (NP), and Medical Director, the facility failed to prevent significant medication errors when required seizure medication (lacosamide) was not administered during the timeframe of 1/10/25 to 1/14/25 as a result of the medication not being available from the pharmacy. Resident #98 was ordered lacosamide twice daily. The medication supply was depleted and it was not administered as ordered on 1/10/25, 1/11/25, and the morning dose on 1/12/25. On the afternoon of 1/12/25 the lacosamide order was put on hold for two days for the documented reason of hold until pharmacy arrival. On the morning of 1/14/25 an additional hold order was entered into the medical record for the time period of one day with no documented reason noted on the order. That same morning (1/14/25) Resident #98 experienced a seizure at the facility. She was administered intramuscular (IM) Ativan (medication used to treat seizures) with no effect. The resident continued to seize. Emergency Medical Services (EMS) were contacted for transfer to the hospital. Resident #98 was given 5 milligrams of versed (sedative medication) by EMS enroute to the hospital with no change in the resident's condition. At the hospital, Resident #98 was admitted to the intensive care unit (ICU), required intubation (a medical procedure where a tube is inserted into the airway to support breathing), and she remained in the hospital until 2/4/25. This deficient practice affected 1 of 2 residents reviewed for significant medication error. Findings included:Resident #98 was admitted to the facility on [DATE]. Her diagnoses included epilepsy (seizure disorder) and nontraumatic intracerebral hemorrhage (brain bleed). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #98 had severe cognitive impairment. The MDS documented that she had a seizure disorder diagnosis and received anticonvulsant medication. The medical record indicated Resident #98 had a seizure on 11/4/24. Resident #98 was transferred to the hospital and was hospitalized from [DATE] until 11/19/24. Resident #98 was readmitted to the facility on [DATE] after her hospitalization. On 12/20/24 a progress note by NP #2 indicated Resident #98 was sent to the hospital for an acute change in condition with significant hypoxia and unresponsiveness. A hospital Discharge summary dated [DATE] indicated Resident #98 was hospitalized from [DATE] until 1/4/25 when she was discharged back to the facility. She was hospitalized for acute respiratory failure and presumed aspiration pneumonia. The hospital discharge summary included the following orders for seizure medications:- lacosamide 10 milligrams (mg)/ milliliter (ml), 20 ml twice daily for seizure. The instructions stated, pick up at [facility pharmacy] pharmacy. The instructions did not indicate a 5-day supply was ordered.- levetiracetam (seizure medication) 100 mg/ml, 15 ml twice daily for seizure-divalproex sodium (seizure medication) 125 mg delayed release capsule, 8 capsules twice daily for seizure A progress note dated 1/4/25 indicated Resident #98 returned to the facility from the hospital. Resident #98's active care plan as of 1/4/25 included an area initiated on 4/19/23 that indicated she was at risk for seizure activity related to a diagnosis and history of seizure disorder. The care plan goal included to be free from seizure activity. The care plan interventions included administering medications as ordered. Resident #98's physician orders for January 2025 included the following orders related to seizure medications:- On 1/6/25 an order dated 11/19/24 was discontinued and re-entered for lacosamide 10 milligrams (mg)/ milliliter (ml), give 20 ml by mouth two times a day for seizures. There were no changes to the order when it was re-entered.- On 1/6/25 an order dated 11/19/24 was discontinued and re-entered for levetiracetam 100 mg/ml, give 15 ml by mouth two times a day for seizures. There were no changes to the order when it was re-entered. - On 1/6/25 an order dated 11/19/24 was discontinued and re-entered for divalproex sodium delayed release sprinkle 125 mg capsule, give 8 capsules by mouth two times a day for seizures. There were no changes to the order when it was re-entered. A controlled substance medication count page for lacosamide indicated the last dose of lacosamide was signed out on 1/9/25 at 8:18 PM by Nurse #4. Resident #98's January 2025 Medication Administration Record (MAR) indicated levetiracetam and divalproex sodium were administered as ordered. Lacosamide was documented as last administered at 8:00 AM on 1/10/25 by Nurse #1. An interview was conducted with Nurse #1 on 8/26/25 at 2:45 PM. Nurse #1 reported she really could not remember with any certainty, but thought she had given Resident #98 the last dose of her lacosamide on the morning of 1/10/25 since she had documented it on the MAR. The January 2025 MAR indicated lacosamide was documented as not administered on 1/10/25 at 8:00 PM by Nurse #2. The coding for non-administration on the MAR was documented as other/ see nurse note. A MAR progress note dated 1/11/25 at 3:38 AM by Nurse #2 regarding lacosamide read, waiting on pharmacy clarification.A phone interview was conducted with Nurse #2 on 8/27/25 at 4:19 PM. Nurse #2 said she had worked at the facility for three-four months and had left sometime around the end of January. Nurse #2 stated she did not specifically remember in January 2025 when Resident #98's lacosamide ran out. She said she did not recall the medication or not having the medication but said she remembered there were issues sometimes with receiving medications from pharmacy and it was not uncommon for the facility to not have a medication that was ordered for a resident. She reported if she coded the non-administration reason as other for Resident #98's lacosamide it was most likely an issue with not having the medication from pharmacy. Nurse #2 stated all she could say was that if a medication was put on hold it was because they did not have the medication. Nurse #2 said she had been told by the facility that if medication was not available then she had to contact the provider to get an order to hold the medication. Nurse #2 explained the standard practice for what she did if a medication was not available. She explained she started by calling the pharmacy first. She said if it was a controlled medication the pharmacy would usually have a certain number of times, they could refill the medication before needing a new prescription. Nurse #2 stated if there were refills left on a prescription the pharmacy would send the medication on the next pharmacy delivery to the facility. She reported if the pharmacy needed a new prescription to refill a medication, then the next step would be to call the provider, and the provider would give an order to hold the medication or go ahead and send a new prescription to the pharmacy for them to send the medication. Nurse #2 said the pharmacy would deliver medications if a medication was not available in the facility's back medication supply system. She indicated it could take a couple of hours to receive the delivery. Nurse #2 stated she could not say she remembered calling anyone about Resident #98's lacosamide in January 2025 because it had been several months ago. The January 2025 MAR indicated lacosamide was documented as not administered on 1/11/25 at 8:00 AM by Medication Aide #1. The coding for non-administration on the MAR was documented as hold/ see nurse note.There was not a corresponding MAR progress note present in the medical record. A phone interview was conducted with Medication Aide #1 on 8/28/25 at 3:13 PM. Medication Aide #1 said it had been a while since she had worked at the facility but reported she remembered Resident #98 and was aware of her seizure history. Medication Aide #1 knew lacosamide was a medication used for seizures. She remembered in January not having Resident #98's lacosamide because she had been waiting for it to be delivered from pharmacy. She did not recall the exact date in January but said she had let a nurse know Resident #98 was out of lacosamide. She stated she thought it was Nurse #3 she had let know. Medication Aide #1 reported the nurse told her Resident #98's lacosamide had been ordered from pharmacy. The January 2025 MAR indicated lacosamide was documented as not administered on 1/11/25 at 8:00 PM by Medication Aide #2. The coding for non-administration on the MAR was documented as other/ see nurse noteA MAR progress note dated 1/11/25 at 10:54 PM by Medication Aide #2 regarding lacosamide read, on order.Medication Aide #2 was unavailable for interview. The January 2025 MAR indicated lacosamide was documented as not administered on 1/12/25 at 8:00 AM by Nurse #1. The coding for non-administration on the MAR was documented as other/ see nurse noteA MAR progress note dated 1/12/25 at 10:47 AM by Nurse #1 regarding lacosamide read, awaiting pharmacy arrival.On 1/12/25 at 3:24 PM Nurse #1 entered an order from Medical Director #1 to hold Resident #98's lacosamide for 2 days. Under reason for hold the order read, hold until pharmacy arrival. On 1/14/25 at 10:12 AM Nurse #1 entered an additional order from Medical Director #1 to hold Resident #98's lacosamide for 1 day. There was not a reason listed for the hold. The January 2024 MAR from indicated Resident #98's lacosamide was on hold from 1/12/25 at 8:00 PM through 1/14/25. An interview was conducted on 8/26/25 at 2:45 PM with Nurse #1. She stated she recalled in January 2025 when Resident #98's lacosamide ran out. Nurse #1 said she did not vividly remember speaking to Medical Director #1 about Resident #98's lacosamide or obtaining the order to hold it but said she would not have entered a hold order without talking to a provider. She explained that a nurse had to get an order from a provider to hold a medication. Nurse #1 reported she thought she had called the pharmacy about the lacosamide but could not remember exactly.A phone interview was conducted with Nurse #3 on 8/29/25 at 11:00 AM. She recalled Nurse #1 had typically worked on Resident #98's hallway in January. She explained Nurse #1 was the nurse who would have been responsible for notifying the provider that Resident #98 was out of her lacosamide and needed a new prescription sent to pharmacy because she was the assigned nurse for the hall. Nurse #3 thought she recalled Nurse #1 saying she had notified the Nurse Practitioner (NP) about needing a new prescription for lacosamide. Nurse #3 reported there was not a consistent way during that time of how to notify a provider of things and that sometimes text messages were sent to providers instead of calling. Nurse #3 indicated she thought there had been some sort of miscommunication with the provider and the lacosamide did not get ordered. She said, that tended to happen a lot there [at the facility]. Nurse #3 explained it was not uncommon for a resident to run out of controlled medication because there had not been consistency and follow up during that time with prescriptions and the pharmacy.A progress note dated 1/14/25 at 10:43 AM by Nurse #1 indicated a Nursing Assistant (NA) found Resident #98 in her room convulsing. The resident was assessed and her oxygen level was 83 (normal range is 95-100% on room air) on 2 liters via nasal cannula and her heart rate was 130 (normal range is 60- 100). Medical Director #1 was called to the room. Ativan 2 mg was given IM. After 10 minutes of continuance of convulsions, Medical Director #1 ordered the resident to be sent out for further evaluation. An additional progress note dated 1/14/25 at 10:51 AM by Nurse #1 indicated Emergency Medical Services (EMS) were in facility at that time. An interview was conducted on 8/26/25 at 2:45 PM with Nurse #1. She recalled the morning of 1/14/25 and said Medical Director #1 had been at the facility. Nurse #1 reported she had notified Medical Director #1 on the morning of 1/14/25 that Resident #98 was out of her lacosamide and needed a new prescription sent to the pharmacy to refill the medication. Nurse #1 remembered not long after she asked for the new prescription for lacosamide Resident #98 started having a seizure. She recalled around 10:30 AM on 1/14/25 a staff member came and got her because they were concerned Resident #98 was having a seizure. She could not recall who the staff member was. Nurse #1 reported when she went to Resident #98's room, she was still alert but her entire body was shaking. Nurse #1 explained the staff member stayed with Resident #98 and she immediately went and got Medical Director #1 to come to the resident's room. She remembered Medical Director #1 gave orders to try to treat the seizure at the facility, but it was not effective. Nurse #1 stated after about 10 minutes Medical Director #1 ordered Resident #98 to be transferred to the hospital and EMS was called. A progress note dated 1/14/25 at 10:21 AM completed by Medical Director #1 indicated Resident #98 was found to have a seizure that day (1/14/25). It was unknown how long the resident was seizing prior to staff finding her, but staff were aware for about 7 minutes. IM Ativan was given with no effect. Upon searching the building, staff could not locate any more Ativan, and there was no diazepam (seizure medication), phenytoin (seizure medication) or any other seizure medication available that could be given. For this reason, EMS was called. The resident's oxygen saturation remained stable on supplemental oxygen throughout the process. The resident normally took lacosamide and divalproex sodium, however staff reported the lacosamide ran out a few days ago. Under assessment/ plan the note indicated epilepsy, unspecified, intractable, with status epilepticus (a medical emergency characterized by prolonged or recurrent seizures that do not stop on their own). The resident was noted to be treated with Ativan IM without effect, there were no more treatment options available, and the resident was at risk of becoming unstable so she was being transferred to the emergency room (ER). The note said a new prescription for lacosamide was given today to facilitate refill when the resident returned to the facility. An interview was conducted with Family Member #1 on 8/27/25 at 10:00 AM. Family Member #1 remembered when Resident #98 had the seizure in January and went to the hospital. He said he noticed Resident #98 had not been getting her seizure medication at the facility for several days before she had the seizure. Family Member #1 stated he had recognized Resident #98's seizure medication was not in the medication cup when the nurses had brought in her medications. He stated he asked a nurse about her seizure medication and was told it had been ordered. Family Member #1 did not remember the nurse's name. An EMS report dated 1/14/24 indicated a call was received from the facility at 10:37 AM and EMS arrived on scene at 10:47 AM. Under primary impression it stated, seizures with status epilepticus. The report said facility staff stated the patient has been seizing for 45 min and for 15 minutes prior to calling 911. They administered 2 mg of Ativan with no changes. Staff also stated the patient has not received her lacosamide in several days. The EMS report said 5 mg of versed was administered with patient response unchanged. The EMS report documented they departed from the facility at 11:00 AM.A hospital intensive care unit (ICU) history and physical note dated 1/14/25 stated Resident #98 was brought to the ER with altered mental status with concerns for ongoing seizure activity. She had persistent tonic (sudden intense muscle stiffening) clonic (rhythmic, convulsive jerking) activity despite 5 mg of IM versed given by EMS. The note stated she had acute on chronic respiratory failure secondary to seizure. An addendum to the note stated indicated the resident had known seizure disorder, chronic obstructive pulmonary disease with chronic respiratory failure (lung disease), prior intracranial hemorrhage presenting with uncontrolled seizures requiring airway protection. It was noted to be unclear if she had been getting all her recommended seizure medications at the facility. A hospital Discharge summary dated [DATE] listed diagnoses of acute hypoxic respiratory failure (sudden condition when the body cannot get enough oxygen into the blood due to a problem with the lungs), chronic respiratory failure (long term condition were the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide), shock (life threatening medical condition when the body's organs and tissues do not receive enough blood and oxygen), urinary tract infection (UTI), and seizure disorder. The discharge summary indicated she was admitted to the ICU and required intubation for airway protection in the setting of secretion intolerance/ aspiration (inhalation of foreign material into the lungs). The discharge summary said Resident #98's home medication regimen included levetiracetam, lacosamide, and valproic acid. It was reported after a pharmacy review that Resident #98 had not been getting the lacosamide at her facility for unclear reasons. The discharge summary stated the UTI may have also triggered breakthrough seizures. The note said she had completed treatment for UTI and possible aspiration. Resident #98 was discharged back to the facility on 2/4/25. On 8/28/25 at 9:02 AM a phone interview was conducted with Medical Director #1. He reported he was the facility's former Medical Director and had left his position at the facility sometime around the end of January 2025. Medical Director #1 stated it was recognized on 1/14/25 when Resident #98 was sent out to the hospital that she had not been receiving her lacosamide and was out of the medication. He reported that the nurse who worked on the medication cart was responsible for notifying the provider when a new prescription was needed (controlled drugs require a new prescription from the provider when refill limits were reached). Medical Director #1 recalled he signed a new prescription for Resident #98's lacosamide the morning of 1/14/25 and then not long after that she had a seizure. He recalled during the morning on 1/14/25 Resident #98 had a seizure and the nurse came and got him. He reported when he went to Resident #98's room that she was having a seizure and was not responsive. He said Resident #98's seizure was treated with 2 mg of IM Ativan and it was not effective. He explained Resident #98 continued to seize and that was why he sent her out to the hospital. Medical Director #1 remembered Resident #98 had been intubated during her hospitalization to protect her airway. He explained intubation was done when someone had altered mental status or decreased alertness and was not able to keep stuff out of their airway. Medical Director #1 reported Resident #98 being out of lacosamide was recognized as a problem and brought to his attention the same day she was sent to the hospital. He said he had not been aware before 1/14/25. Medical Director #1 said he did not remember giving the order to hold Resident #98's lacosamide. He said it may have been another provider and defaulted to his name on the order because he was the Medical Director. He stated he could not speak to the hold order. Medical Director #1 said it was a tough question for how many doses of seizure medication he would be comfortable with someone with a seizure history like Resident #98 missing. He reported his ultimate preference would be for her not to miss any doses of seizure medication but that he thought missing a couple of doses would not be consequential. He explained a couple of doses would be 1 or 2 doses. He stated Resident #98 had seizures even when she got her seizure medication so he would not like for her to miss any doses. He did not recall exactly when her last seizure was prior to 1/14/25, but said he recalled she had a prior seizure that required hospitalization. Medical Director #1 explained Resident #98 had a higher risk for seizure than the average person. He explained the resident had a lower seizure threshold and required the 3 different seizure medications. Medical Director #1 stated seizure medications raised someone's threshold for seizures (the point when someone is likely to have a seizure). He indicated not getting a seizure medication and/or the presence of an infection could lower someone's seizure threshold and that when the seizure threshold was lowered someone was more likely to have a seizure. He stated Resident #98 not receiving her lacosamide was one factor among several that could have contributed to what happened on 1/14/25. Medical Director #1 said, should she have received them [the medication lacosamide], yes. Did it make things worse that she did not get it? Probably, but I cannot say anything would have been different 100% if she had received the lacosamide. A phone interview was conducted on 8/26/25 at 2:24 PM with Pharmacist #1. Pharmacist #1 said a prescription was received on 1/4/25 for a 5-day supply of lacosamide for Resident #98. She explained no other prescription was received until 1/14/25 when Medical Director #1 sent a prescription to the pharmacy for the lacosamide. Pharmacist #1 reviewed documentation and said she did not see a request from the facility for the lacosamide to be refilled before 1/14/25. Pharmacist #1 said the facility had to contact the pharmacy when a medication needed to be refilled. She explained a lacosamide prescription could have up to 5 refills per legal requirements and after that, a new prescription was needed from the provider. She said it was the facility's responsibility to keep up with medications and when they need to be refilled. She reported the facility was supposed to request a refill of a medication when they were down to a 3- or 4-day supply of a resident's medication. Pharmacist #1 explained the half-life (how long it takes for half of the medication to leave the body) of lacosamide was 13 hours. Pharmacist #1 said missing 9 doses of lacosamide would absolutely increase the risk of someone having a seizure. She stated that how much of a risk would depend on the patient's seizure history. Pharmacist #1 said someone would not have a prescription for lacosamide along with other seizure medications if there was not a concern about seizures. She reviewed Resident #98's medication record and reported Resident #98 also took divalproex sodium and levetiracetam for seizures. Pharmacist #1 stated she would say lacosamide was pretty important for Resident #98 for preventing seizures. Pharmacist #1 explained she would consider Resident #98's missed doses of lacosamide to be significant since she had a seizure, and it sent her to the hospital. Pharmacist #1 further explained if someone was taking three medications for seizures, they would be at a higher risk and more prone to seizures to need three medications to control them. Pharmacist #1 said if the facility had someone on those seizure medications, they should be aware and be managing those medications and when they need to be refilled or reordered in the case that there are no more refills. She reported that the facility did not have lacosamide in their back up medication system. She further reported that the pharmacy was available 24 hours per day. She explained the pharmacy had contracts with local pharmacy's and that if the facility let them know they needed a medication they had carrier delivery available 24 hours a day that would be able to deliver the medication. A phone interview was conducted on 8/29/25 at 2:12 PM with Pharmacist #2. He explained the facility's electronic computer system and pharmacy system were connected. He further explained that the facility could reorder medications through the electronic computer system. Pharmacist #2 said if a controlled medication was reordered and there were no prescription refills left for the medication, the pharmacy would send a fax to the facility. He explained there were two separate faxes the pharmacy sends. One fax stated there were no refills left for the medication prescription and the second fax was a preprinted prescription for the medication for the provider to sign. He stated both faxes were sent to the facility. Pharmacist #2 reviewed documentation and said he did not see any request by the facility for the medication to be refilled before 1/11/25. He stated the facility had requested Resident #98's lacosamide to be refilled through the facility's electronic computer system on 1/11/25. Pharmacist #2 explained there were no refills left on the lacosamide and that the pharmacy had sent a fax to the facility on 1/11/25. He reported there were no other requests through the facility's electronic computer system to refill the medication. A phone interview was conducted with NP #1 on 9/2/25 at 11:39 AM. NP #1 reported she no longer worked at the facility but recalled Resident #98. NP #1 remembered Resident #98 went to the hospital in January and that she was on seizure medications. NP #1 stated the nurses were supposed to let providers know when a prescription was needed for a controlled medication refill. NP #1 said she imagined that the nurses would have let her know a new prescription was needed for Resident #98's lacosamide, but that she did not remember the week of 1/14/25 specifically or what happened. NP #1 reported the nurses were usually pretty good about telling her when there was only a day or two left of a medication and a new prescription was needed. NP #1 reported Resident #98's prescription may have been missed somehow but that she did not remember that specifically as an incident. A phone interview was conducted on 8/27/25 at 1:29 PM with Medical Director #2. He explained he was the interim Medical Director after Medical Director #1 left in January. He did not remember the exact date Medical Director #1 had left the facility. Medical Director #2 reported he was familiar with Resident #98 and had reviewed the case involving the incident from January with her missed doses of lacosamide and hospitalization. He reported he was not surprised to be getting a phone call about the case. Medical Director #2 remembered Resident #98 had been out of her lacosamide for a few days and he said that it was a little unusual. He said the pharmacy could take a little time to send medications sometimes, but he recalled her (Resident #98's) lacosamide was held for 4 days and said that was outside of the norm and unusual. Medical Director #2 reported Resident #98 had a pretty good seizure disorder and that one or two missed doses of the lacosamide or it being held for one or two doses would be acceptable. He said missing more than one or two doses would not be acceptable because it would increase the risk of Resident #98 having a breakthrough seizure. Medical Director #2 stated holding her seizure medication for that long was longer than he would have held it for and was a little beyond his comfort level. Medical Director #2 stated it was a significant event when Resident #98 seized. He reported there were other things that could cause someone to have a seizure and explained that a UTI could increase the risk but that it was hard to miss the omission of the medication. Medical Director #2 reported he thought the lack of medication likely contributed to Resident #98's seizures. A phone interview was conducted on 8/28/25 at 12:36 PM with Medical Director #3. He explained he was the facility's current Medical Director and started in March. Medical Director #3 reported he was aware of the history that had occurred involving Resident #98 and her lacosamide. He said he thought the missed lacosamide doses were a mistake and that it was an issue. Medical Director #3 explained Resident #98's seizure disorder was complicated, and it would be hard to say a particular number of missed doses exactly that would lead to a seizure because she had seizures even on her medications. He was unable to recall the date of Resident #98's last seizure prior to 1/14/25. Medical Director #3 said Resident #98's infection likely contributed to her having a seizure and that he felt the seizure had been more severe because of the complications the resident had. Medical Director #3 stated he thought the missed doses of lacosamide may have contributed to her possibly having a seizure but that she was on other seizure medications. He agreed Resident #98's nine (9) missed doses of lacosamide would lower her seizure thresh hold making her more likely to have a seizure. He said he did not think Resident #98 not getting her lacosamide was alright by any means. An interview was conducted with the Administrator, the Administrator in Training (AIT), and the Director of Nursing (DON) on 08/28/2025 at 4:30 PM. The DON stated she had not been the DON in January. The Administrator primarily spoke during the interview. The Administrator reported Resident #98 had been hospitalized and returned to the facility on 1/4/25. She could not recall the reason for that hospitalization. She explained she believed the hospital had given a prescription for a 3-day supply of lacosamide. The Administrator said the pharmacy did not have a prescription to refill the lacosamide, but the nursing department had thought the pharmacy had the prescription. The Administrator stated the nurse, she said she did not know which one specifically, had called the pharmacy about the medication and had been told the medication would arrive. The Administrator stated when the medication did not arrive the nurse notified the physician and got an order to hold the medication until it came from the pharmacy. She reported during the hold process of the medication; she thought it was Nurse #1 who had called the pharmacy to check on the medication and had been told it was coming. The Administrator explained that on the morning of 1/14/25, Resident #98's lacosamide was not available and Medical Director #1 was in the building so Nurse #1 had gone to him about the lacosamide, and Medical Director #1 sent a prescription to the pharmacy that morning. The Administrator reported then later that same morning Resident #98 had a seizure. She stated Medical Director #1 was in the building at the time and had gone to see Resident #98. She reported that the Medical Director had tried to do things at the facility to stop the seizure, but it was not effective, and Resident #98 was sent out to the hospital by EMS. The Administrator explained the assigned nurse was responsible for contacting the provider for a prescription when needed and that the nurse should have gotten the prescription. She said when the medication did not arrive from pharmacy the nurse should have escalated that by letting the DON or management know the medication had not come. The Administrator reported it should have been identified in the morning clinical meeting by the DON, Unit Manager, or Staff Development Coordinator that typically attended the morning clinical meeting that Resident #98's lacosamide was not available. The Administrator said she thought it had been mentioned in the clinical morning meeting about the lacosamide not being there, but it was assumed that since there was a hold order obtained from the physician the physician was aware, and the medication was in the process of being delivered. The Administrator said at the time, nursing was not following processes. The Administrator indicated nurses were to contact the pharmacy before a medication ran out and were to notify the provider a new prescription was needed before a medication ran out. She said there was not good oversight by the former DON and there had not been thorough clinical meetings at the time. She explained that was why changes in management were made and why corporate management had been in the building to make changes. The Administrator said lacosamide was not an available medication in the facility's back up medication system. She stated the nurse should have been persistent in obtaining the controlled prescription for the lacosamide and said it was their duty as a nurse to obtain it. The Administrator said Resident #98's missed doses of lacosamide was a significant medication error. The Administrator was notified of immediate jeopardy on 8/27/25 at 5:40 PM. The facility provided the following Corrective Action Plan with a correction date of 1/22/25: 1. How will corrective action be accomplished f

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, Nurse Practitioner, Medical Director, and Podiatrist interviews the facility failed to apply the ordered dressing for a resident (Resident #31) with diabetic foot ulcers when the Treatment Nurse Aide (NA) applied a Coban 2 two-layer compression system (a two layer system: a Comfort Foam Layer (Layer 1) and a Compression Layer (Layer 2) that provides therapeutic compression) to Resident #31's feet instead of using regular Coban (a self-adherent wrap). Resident #31 experienced the toes on his right foot turning purple after the right foot dressing was applied by the Treatment NA and dusky gray skin discoloration under the left foot dressing when the dressing was removed. Had the dressing been left in place, there was a high likelihood for blood circulation problems, vessel blockage or development of new wounds. In addition, the facility failed to perform wound assessments for Resident #31 who had diabetic foot ulcers and failed to obtain treatment orders for a new wound that had been found to Resident #31's right heel one week and three days prior. This deficient practice occurred for 1 of 1 resident reviewed for diabetic foot ulcers (Resident #31). Immediate jeopardy began on 7/24/24 when the Treatment NA applied Coban 2 two-layer compression system onto Resident #31's left and right feet instead of regular Coban during his diabetic foot ulcer dressing change. Immediate jeopardy was removed on 7/26/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective and to address the deficient practices in examples 1.b. and 1.c. The findings included: 1.a. Review of the package instruction inserts for Coban 2 two-layer compression system read in part: Coban 2 Compression system is not designed or intended for use except as indicated. Indications for use: Coban 2 Compression System is indicated for the management of venous leg ulcers, lymphedema and other clinical conditions where compression is appropriate. General considerations and warnings: 1. Coban 2 Compression System should be used under the supervision of a licensed health care professional, 2. Wrapping too tightly may impair circulation. Monitor the area of application frequently for signs of discoloration, pain, numbness, tingling or other changes in sensation and swelling. 3. At the discretion of the health care professional patients or their care providers can be trained to apply the bandage for subsequent applications. Directions for use: Apply the Compression System in a dorsiflexed position (foot at 90-degree angle). Layer 1: the inner comfort layer: Apply this layer with the foam side against the skin, using just enough tension to conform to the shape of the leg with minimal overlap. 1. Start the application with a circular winding at the base of the toes, beginning at the fifth metatarsal head (bone in the foot that connects to the base of the toes). 2. The second circle of winding should come across the top of the foot so that the middle of the bandage width approximately covers the articulating (location where two or more bones meet and join) aspect of the ankle joint. 3. Bring the next winding low, around the back of the heel leaving the plantar aspect (bottom of the heel) of the heel uncovered. Covering the plantar heel is not needed and extra winding over the ankle may make the completed application unnecessarily thick. 4. The layer may not conform completely over the Achilles tendon (tendon at the back of the leg that joins the muscles in the calf to the bone of the heel) area. The excess material will be smoothed down without discomfort when covered by the compression layer. 5. Proceed up to the knee with minimal overlap, using just enough tension to conform to the shape of the leg. Cut off excess material. Light pressure applied at the end of the bandage ensures that it stays in place during application of the compression layer. Layer 2: the outer compression layer. The compression layer is designed to be applied at full stretch throughout the application. 1. Start the application with a circular winding at the base of the toes, beginning at the fifth metatarsal head. 2. Complete up to three figures of eight around the ankle ensuring the entire heel is covered with at least two layers. 3. Proceed up the leg with 50 % overlap to cover the entire inner comfort layer. Maintain consistent stretch throughout the bandaging process. 4. Following the application press lightly on the entire surface of the application to guarantee optimal conformability and to ensure that the bandage adheres to itself and to the inner comfort layer. Resident #31 was readmitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of left heel and midfoot and diabetes mellites type 2. Resident #31's hospital Discharge summary dated [DATE] revealed he had diagnoses of bilateral diabetic foot ulcers and peripheral arterial disease (PAD). The discharge summary revealed he had a chronic diabetic ulcer to his right forefoot and a new ulcer to his left lateral heel that required surgical intervention during his hospital stay. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderate cognitive impairment. He was coded for being at risk for development of pressure ulcers. Resident #31 was also coded on the MDS for surgical wounds and surgical wound care. He had no behaviors or rejection of care documented. Resident #31 had a surgical wound care plan last revised on 6/21/24 for right lateral foot converted on 6/8/24 from diabetic ulcer to surgical wound post right foot incision and drainage. He also had a surgical wound care plan for left calcaneal (heel bone) and diabetic ulcer converted to surgical 6/15/24 post debridement and partial closure. The care plan goals included that the wounds would improve by next review and would not become infected. The care plan interventions included treatments as ordered. The podiatry office visit note dated 7/2/24 revealed he had a wound located to his right forefoot overlying the 4th metatarsal and a non-pressure chronic ulcer of the left heel and midfoot. Under instructions the note read: Right foot primary dressing: Aquacel silver (Ag) (an absorbent wound dressing with silver. The silver has antimicrobial properties), Secondary dressing 4x4 gauze, Kerlix (a gauze wrap dressing), and Coban (a self-adherent wrap). Left foot ulcer primary dressing: Medi Honey (wound treatment used to decrease bacteria in the wound bed), Aquacel Ag, secondary dressing 4x4 gauze, Kerlix, and Coban. Change dressings Monday, Wednesday, Friday and as needed for drainage. Resident #31's care plan last reviewed on 7/8/24 revealed he had a skin care plan for potential for impaired skin integrity related to decreased mobility, bladder/bowel incontinence and need for extensive assistance with bed mobility. The care plan goal was for Resident #31 to not develop further breakdown through the next review. The care plan interventions included: to conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. The podiatry office visit note dated 7/22/24 stated Resident #31 was being seen for follow up of a wound, located on the right lateral dorsal (top) foot and left medial plantar (bottom of the foot) heel. Under the section of the note labeled: skin right foot and ankle the note read ulcer, NEW blister on the medial heel. Right foot and heel primary dressing: Aquacel silver (Ag), Secondary dressing 4x4 gauze, Kerlix, and Coban. Left foot primary dressing: Medi Honey, Aquacel Ag, secondary dressing 4x4 gauze, Kerlix, and Coban. Change dressings Monday, Wednesday, Friday and as needed for drainage. A review of Resident #31's active physician orders and Treatment Administration Record (TAR) for July 2024 revealed that Resident #31 had the following wound care orders: - An order dated 7/10/24 that read: Left foot apply Medi Honey, Aquacel, 4x4, kerlix and Coban every day shift every Monday, Wednesday, Friday for wound care - An order dated 7/10/24 that read: Right foot apply, Aquacel silver (Ag), 4x4, kerlix and Coban. every day shift every Monday, Wednesday, Friday for wound care. A continuous wound care observation and interview was conducted on 7/24/24 from 1:35 PM to 2:22 PM when the Treatment NA completed wound care for Resident # 31. The Treatment NA gathered the wound care supplies from the treatment cart that included: 4x4 gauze, wound cleanser, Kerlix, Medi Honey, and a box labeled Coban 2 two- layer compression system (provides high compression through a 2-layer compression bandage system, it is used in the treatment of conditions such as venous leg ulcers and lymphedema). The Treatment NA removed Resident #31's left foot dressing. An ulcer was visible to the lateral left heel with areas of thick dark tissue along the edge, sutures were present along the edge, the center of the wound had areas of granulation (new) tissue and mild slough (by-product of the inflammatory phase of wound healing) The Treatment NA sprayed wound cleanser on to a layer of 4x4 gauze and cleaned the left heel wound. She then applied Medi Honey to a layer of 4x4 gauze and applied it directly against the wound. The Treatment NA used kerlix to wrap the left foot from midfoot to approximately 3 inches above the ankle. The Treatment NA opened the box labeled Coban 2 two- layer compression system and removed the two wraps from inside the box. She proceeded to wrap Resident #31's left foot using the foam layer from the 2-layer compression system box. She started the wrap at the left mid foot and wrapped it upward and around the ankle in a figure 8 pattern. The wrap extended approximately 3 inches above the ankle. She then overlapped the foam layer by wrapping it back down from the ankle to midfoot. The Treatment NA wrapped the foam layer around the mid foot 3 times, cut the wrap using scissors, and smoothed it to self-adhere at the top of the midfoot. The wrap was applied with Resident #31's left foot in the dropped position. The Treatment NA opened the outer compression layer wrap from the Coban 2 two- layer compression system. Starting at the left mid foot she wrapped the outer layer compression wrap over the foam layer in an upward motion to approximately 3 inches above the ankle and then back down to the midfoot. She cut the outer layer compression layer wrap with scissors and smoothed the wrap to self-adhere on the top of the mid foot. The Treatment NA removed the dressing from the right foot. The Treatment NA sprayed wound cleanser on to a layer of 4x4 gauze and cleaned the right lateral forefoot wound. The wound was surgically closed with sutures. She applied Medi Honey to a layer of 4x4 gauze and applied it directly against the wound. The Treatment NA used kerlix to wrap the right foot from mid foot toward the toes and then back upward to mid foot and back to the toes four times. The Treatment NA used the foam layer and wrapped the right foot starting at mid foot and down toward the toes then back up to mid foot 4 times until the remainder of the foam layer wrap was used. She smoothed the edge of the foam layer to self-adhere at the mid foot. She applied it with wrap to his right foot with the foot in the dropped position. The Treatment NA then used the remainder of the compression layer wrap and wrapped Resident #31's right foot starting midfoot and down toward the toes and then back up to the mid foot three times. The wrap stopped at the top of the toe line and his toes were visible sticking out of the wrap. An observation at 2:12 PM of Resident #31's right foot revealed all his toes were a dark purple color. The color of his left foot and toes was a normal fair ivory skin tone. The Treatment NA did not check the snugness of the wraps or the circulation to Resident #31's left or right foot after the wraps were applied. The Treatment NA reapplied the off-loading boots to Resident #31's left and right foot. Adjusted his blankets and went to exit his room. At 7/24/24 at 2:17 PM the Treatment NA was stopped by the surveyor and asked if Resident #31's toes on his right foot were normally a purple color. The Treatment NA went back to Resident #31's bedside to check his toes. His toes continued to be a purple color. The Treatment NA stated that Resident #31's toes were not normally purple and that the dressing was too tight. The Treatment NA completely removed the outer layer compression wrap and the foam layer wrap from the right foot (the two wrap layers were adhered together). Once the 2-layer wrap was removed from the right foot, Resident #31's toes turned normal skin color and the purple discoloration resolved. The Treatment NA smoothed the wrap and then reapplied it with visible looseness around Resident #31's right foot. The color to the left foot and toes continued to remain normal skin color. An interview was conducted with the Treatment NA on 7/24/24 at 2:24 PM. The Treatment NA explained she had used the box labeled Coban 2 two-layer compression system for Resident #31's wound care because the order had said to use Coban. The Treatment NA stated that she had not previously used the box labeled Coban 2 two-layer compression system for Resident #31's wound care. She explained she had first seen the Coban 2 two-layer compression system box on the treatment cart a couple of days ago. The Treatment NA stated she thought it had been ordered for Resident #31 because it said Coban on the box. The Treatment NA said she had previously used the individual packaged flexible cohesive bandage when doing Resident #31's wound care. The Treatment NA explained that when she had seen the new box labeled Coban 2 two-layer compression system on the treatment cart she had thought that was what she was supposed to use because the box said Coban on it and the packaging for the flexible cohesive bandage she had been using did not say Coban on it. She stated that she had used both wraps that had been in the Coban 2 two-layer compression system box because she thought the two wraps together was what Coban was. The Treatment NA confirmed that Coban was what had been ordered for Resident #31's wound care and not the two-layer compression wrap system she had applied. The Treatment NA stated she had not applied the Aquacel that was part of his treatment orders, because the facility had been out of Aquacel for two weeks. The Treatment NA stated she had told UM #1 that the Aquacel had been out. On 7/26/24 at 10:15 AM a follow up interview was conducted with the Treatment NA. She stated that after performing Resident #31's wound care on 7/24/24 she went to the Assistant Director of Nursing (ADON) and told the ADON she had put the wrong wrap on when performing Resident #31's wound care to his feet. She stated she told the ADON she had applied the box labeled Coban 2 two-layer compression system instead of regular Coban. The Treatment NA stated she told the ADON that she had applied both wraps from the Coban 2 two-layer compression system box and did not think she had applied the correct wrap. The Treatment NA said she told the ADON she needed more information and clarification because she did not understand Resident #31's wound care orders and had done the dressing wrong. The Treatment NA stated she asked the ADON to check the dressings she had applied to Resident #31's feet to make sure the dressings were correct because she had applied the two-layer wrap instead of the regular Coban. The Treatment NA stated she had also talked to Nurse #4 and asked her to check the dressings she had applied to Resident #31's feet and asked her to assess his feet. The Treatment NA stated that she told Nurse #4 about Resident #31's right foot toes turning blue when she had applied the dressing to his right foot. The Treatment NA said she had received education on generic equivalent for brand name wound care products. She stated that she did not realize there was a generic for Aquacel. An interview was conducted with the ADON on 7/25/24 at 3:52 PM. The ADON stated that the Treatment NA had self-reported after doing Resident #31's wound that she had done his dressings wrong. She stated that the Treatment NA had said she had messed up the entire dressings to Resident #31's feet and done it wrong. The ADON said she did not go and check the dressings on Resident #31's feet. The ADON stated she asked Nurse #4 to check Resident #31's dressings. The ADON explained Nurse #4 said the dressings to Resident #31's feet were put on correctly and looked fine and that was why she did not go look at it herself. The ADON said that on 7/24/24 Nurse #4 had assessed Resident #31 and checked his circulation and said it looked fine and the dressings on his feet were appropriate. A telephone interview was conducted with Nurse #4 on 7/25/24 at 4:01 PM. Nurse #4 stated the Treatment NA was anxious about the dressings she had applied on Resident #31's feet and had asked her to assess the situation. Nurse #4 said she had looked at the bandages applied to his left and right feet and was able to insert her middle finger up under the dressing and that the dressings were not tight. Nurse #4 stated she checked Resident #31's circulation in his feet and it was good. Nurse #4 stated she did not see any purple discoloration to his toes or skin. She said she did not have any concerns about the dressings on his feet or she would have redone them. Nurse #4 confirmed that Resident #31 had a 2-layer wrap in place to his left and right feet. Nurse #4 said she could see a foam layer and then an outer layer when she assessed the dressings to Resident #31's feet. Nurse #4 said that she could not remember exactly what Resident #31's wound care orders were but that the order included Kerlix and then Coban for the finishing dressing. Nurse #4 stated that she had not checked Resident #31's orders before she had gone to assess and check his dressings. Nurse #4 stated an upper management lady had asked her to check the dressings, but she could not remember specifically who. She stated that the Treatment NA had also asked her to check Resident #31's dressings to his feet because she was worried about his profusion (blood flow to tissue) and had said she had done the dressing wrong. A telephone interview was conducted with the Podiatrist on 7/24/24 at 5:31 PM. The Podiatrist said Resident #31 did not have sensation or feeling in his feet but that his toes turning purple on his right foot would mean the dressing was too tight. She stated that if the dressing to his right foot had been left in place it could have caused issues. She explained the issues that could be caused were circulatory/ occlusion issues with a tourniquet effect. It could cause irritation and could cause new wounds to develop if it was too tight. The Podiatrist said she had not ordered compression wraps for Resident #31. She said compression wraps were for patients with venous ulcers or who had a lot of swelling, and that Resident #31 did not have any of that and compression wraps were not appropriate for him. An observation and interview were completed on 7/25/24 at 8:56 AM with Unit Manager (UM) #2 when she went to assess the dressings on Resident #31's feet. Resident #31 was lying in bed with his offloading boots on both feet. The same dressings were in place to Resident #31's feet that had been applied by the Treatment NA on 7/24/24. Resident #31's toes to his right foot were normal skin color. UM #2 removed the dressing from his right foot, there was no skin discoloration under the dressing. The wounds to his right foot had not changed in appearance from the prior observation on 7/24/24. Resident #31's left foot from the end of the dressing at his mid foot to his toes was a normal color. UM #2 removed the dressing from his left foot. Resident #31's skin that had been covered by the dressing had a noticeable color difference. His skin under where the dressing had been removed was a dusky light gray, you could see a prominent outline of where the dressing had been from the discoloration. There was a small maroon/ purple area of discoloration approximately 0.5 x 0.5 cm (centimeters) located on the top of his left foot located approximately 2 inches below the ankle. UM #2 confirmed there was a discoloration of the skin under where the dressing had been to his left foot. UM #2 stated she was not sure what the small maroon/ purple area of discoloration was to the top of his foot. UM #2 touched the area, and it did not blanch, she said the area did not feel raised or fluid filled. The wound to Resident #31's left heel was visualized with no changes from the prior observation on 7/24/24. When UM #2 removed the dressings from Resident #31's feet she stated there was a foam layer and then an outer layer over the foam and said it was the type of dressing she had seen used for compression wraps. UM #2 said Resident #31's orders were just for Coban and that she did not know why the Treatment NA had applied the Coban two-layer compression instead of just the Coban. An observation and interview were conducted with the Nurse Practitioner (NP) on 7/25/24 at 12:50 PM. The NP said that if compression wraps were applied too tight in extreme cases it could cause blood flow impairment but more likely would cause skin irritation or breakdown. The NP said if compression wraps were not applied in accordance with manufacturer instruction/ direction it could cause worsening of wounds. She said if you used any product not as recommended or designed to be used it could cause issues. The NP removed the dressings from Resident #31's left and right feet. The skin color under the dressing to his left foot had normalized. The NP visualized the small area of purple discoloration to the top of Resident #31's left foot. The surrounding area of Resident #31's left foot was normal skin color. The NP said she was unsure what the area was. She said if Resident #31's foot was in the dropped position, she could feel that the area was over a boney prominence. The NP said she could not feel the boney prominence if the left foot was positioned in the flexed upward position. Resident #31 did not have sensation in his feet or complain of any pain when examined by the NP. The NP stated that the area could be a new area of irritation from his dressing or could possibly be a bruise from the area being bumped on something. She was unsure how he could have bumped into the area because he always wore foam padded offloading boots on both of his feet. The NP said that Resident #31 was not a reliable historian. A telephone interview was conducted on 7/26/24 at 3:05 PM with the Medical Director (MD). The MD stated he had been informed there had been an issue with wound care for Resident #31. He said if Resident #31's dressing was applied too tight and was left on for too long it could cause issues. He said if Resident #31's right foot dressing had been left in place until the next time it was scheduled to be changed two days later it could have caused issues. He said the issues it could cause depended on how tight the dressing was and if it was tight enough to block blood flow. He said if the dressing created light pressure it could cause swelling or back up of venous blood. He said if the dressing was extremely tight the dressing could cause lack of blood flow and that could cause necrotic areas to occur but said that could take a while to occur. He said a while depended on how much blood flow the area was getting that it could be hours or days. He said Resident #31's dusky gray skin discoloration that had been under the left foot dressing could have been from the dressing but that he was not sure. He said with Resident #31's left foot toes being normal color it did not sound like blood flow had been compromised. He said Resident #31's right foot toes turning purple meant the dressing to his right foot had been applied too tight. The MD stated the Treatment NA should have followed wound care orders and not placed the Coban 2 two-layer compression system on Resident #31. The MD stated it had been human error that the Treatment NA had not known difference. An interview was conducted with the Director of Nursing (DON) on 7/25/24 at 10:20 AM. The DON said the Coban that was part of Resident #31's order was to secure the dressing and was not for compression. She said the Treatment NA should have checked Resident #31's circulation and that the dressings to Resident #31's feet were not applied too tight. The DON stated the Treatment NA should have used what had been ordered for Resident #31's wound care dressings. She said the Treatment NA should not have used the Two-layer compression system and that she should have used regular Coban for his dressing change. The DON stated that if the dressing to Resident #31's right foot where his toes had turned purple had been left in place it could have caused an issue. The DON explained the dressing could have caused decreased circulation to his toes and that decreased blood flow could have caused more wounds and more problems for Resident #31. The DON said the dusky gray skin discoloration that had been present when the left foot dressing had been removed could be from it being applied too tight or from swelling. An interview was conducted on 7/25/24 at 5:45 pm with the Administrator. The Administrator stated that the Treatment NA should have followed the wound care orders for Resident #31. She said the Treatment NA should not have placed compression wraps on Resident #31 if it was not part of his orders. The Administrator said that if the Treatment NA had been unsure if she was using the correct thing then she should have asked the nurse. The Administrator stated that the Treatment NA should have checked Resident #31's circulation after applying the dressings to his feet before leaving his room. The Administrator was notified of the immediate jeopardy on 7/25/24 at 5:45 PM. The facility provided the following allegation of immediate jeopardy removal. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to follow physician's orders for Resident #31's diabetic ulcer to the right foot (aquacell silver, 4x4 gauze, kerlix and coban). Resident #31's diabetic ulcer of the left foot (medihoney, aquacell, 4x4 gauze, kerlix and coban). Because all residents with wounds are at risk when a physician's order is not followed and can cause worsening of the wound and other complications the following plan has been devised: On 7/25/2024, the licensed nurse unit manager immediately removed the incorrect dressing from Resident #31's right foot ulcer when notified by the surveyor that on 7/24/24 the incorrect dressing was applied. A registered nurse assessed the dressing on Resident #31's left foot ulcer on 7/24/24 to ensure it was not impeding circulation with no alteration in circulation noted. On 7/25/24, the licensed nurse applied the correct dressing per physician's order. On 7/25/24 the DON assessed Resident #31 for pain and completed a full skin assessment on resident there was no increase in pain or new skin alterations observed. On 7/25/24 the nurse practitioner assessed the resident and was notified of the incorrect wound dressing. No new orders were received at that time due to no harm or significant changes in wound status resulting from incorrect dressing. On 7/25/24 Resident #31's family was present in the facility and notified of incorrect treatment. On 7/25/24 the Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed an audit of all current facility residents with all pressure and non-pressure wound care orders to ensure the correct physician ordered treatment was in place. All resident treatments and dressings were correct and matched the physician's order. The Regional Director of Clinical Reimbursement (RDCR) reviewed resident's care plans to ensure appropriate care plans were in place for all current facility residents with non-pressure and pressure wounds. The ADON removed the two-layer compression system from the treatment carts and supply room to ensure it would not be confused with coban. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 7/25/24, the Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), Regional Director of Clinical Services (RDCS), Unit Manager, Minimum Data Set (MDS) Nurse, and Medical Director conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting to review the facility Wound Treatment Management Policy and to determine root cause of the deficient practice. By root cause analysis, the QAPI committee determined that the facility failed to follow the Wound Treatment Management Policy by failing to follow physician's order for wound care treatments due to basic human error related to the two-layer compression system bandage box being labeled Coban2 being applied instead of coban which was ordered (generic form labeled latex flexible cohesive bandage). A plan was formulated by the QAPI committee to address the identified issue to include a review of education, audit/monitoring needs, and QAPI committee responsibilities in reviewing for compliance. To address the root cause the facility implemented education on differentiating the two types of wraps and removed the Coban2 from the treatment carts and supply room. On 7/25/24, the DON and ADON completed education to current facility and agency Licensed Nurses on the facility Wound Treatment Management Policy and Medication Orders Policy. Education included the following: a) the facility's wound care protocol and the expectation of each Licensed Nurse for following physician's orders when administering wound care b) the 5 p's circulation acronym pain, pallor, pulse, paresthesia, and paralysis when observing resident's for circulatory compromise related to wound treatment dressing and role of Licensed Nurse c) how to differentiate two layer compression system from coban when administering wound treatments d) the risks of applying the incorrect dressing that could include worsening wounds, tourniquet effect, circulatory occlusion, infection, loss of limb. The current facility and agency Licensed Nurses and newly hired facility and agency licensed nurses not receiving education on 7/25/24 will not be allowed to work until completed. The DON will utilize an active employee list to track completion of education. This responsibility was communicated to the Director of Nursing by the RDCS on 7/25/24. Education will also be included during orientation for newly hired facility and agency Licensed Nurse, to be completed by Director of Nursing or Nurse Manager. Effective 7/25/24, the facility will not assign unlicensed assistive personnel (UAP) to provide wound treatments moving forward. UAP staff and licensed nursing staff notified of change in staffing assignments by DON and ADON on 7/25/24. Effective 7/25/24, the DON notified a licensed nurse who has received education that they will be assigned to administer wound care treatments on 7/26/24. The ADON or DON will ensure a licensed nurse is assigned to provide wound treatments moving forward. Effective 7/25/24, the Administrator and Director of Nursing will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: 7/26/24 On 07/26/24, the facility's credible allegation for immediate jeopardy removal with correction date of 07/26/24 was validated on-site by record review, observation, and interviews with staff. Interviews with facility and agency licensed nurse interviews were conducted and revealed they[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #31 was readmitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of left heel and midfoot and diabetes mellites type 2. Review of Resident #31's hospital Discharge summary dated [DATE] revealed he had diagnoses of bilateral diabetic foot ulcers and peripheral arterial disease (PAD). The discharge summary revealed he had a chronic diabetic ulcer to his right forefoot and a new ulcer to his left lateral heel that required surgical intervention during his hospital stay. Review of the podiatry office visit note dated 7/2/24 revealed he had a wound located to his right forefoot overlying the 4th metatarsal and a non-pressure chronic ulcer of the left heel and midfoot. The office note did not mention a wound to his right heel. Review of the podiatry office visit note dated 7/22/24 stated Resident #31 was being seen for follow up of a wound, located on the right lateral dorsal (top) foot and left medial plantar (bottom of the foot) heel. Under the section of the note labeled: skin right foot and ankle the note read ulcer, NEW blister on the medial heel. An observation and interview were conducted with the Treatment Nurse Aide (NA) on 7/24/24 at 1:35 PM. The Treatment NA was observed performing the wound care for Resident #31's bilateral foot wounds. The Treatment NA stated that the wound to Resident #31's right heel was a new wound. The Treatment NA explained she had found the right heel wound one week and three days ago while she had been performing the wound care for his other foot ulcers. The Treatment NA stated she had been putting iodine on it every day. She said there was not an order for the iodine to be applied to Resident #31's right heel, the Treatment NA stated the Iodine was an off the record thing. The Treatment NA stated she had told Unit Manager (UM) #1 about the new area to Resident #31's right heel and that UM #1 had told her to put iodine on it. The Treatment NA said she had not spoken to anyone else about the right heel wound. The Treatment NA explained she could not enter orders into the electronic computer system and that she just remembered she needed to put Iodine on it every day. An interview was conducted with UM #1 on 7/24/24 at 4:11 PM. UM #1 stated that she was not aware that Resident #31 had a new wound to his right heel. She said the Treatment NA had not come to her about the wound to Resident #31's right heel and that she had not told the Treatment NA to put Iodine on it. A review of the electronic medical record for Resident #31 revealed there was not a treatment order for the right heel wound. An interview was conducted with the Podiatrist on 7/24/24 at 5:31 PM. The Podiatrist stated that the wound to Resident #31's right heel was a new wound. She stated that she had seen the right heel wound during Resident #31's office visit on 7/22/24. The Podiatrist said the facility had not notified her about the new wound on the right heel. The Podiatrist stated that if the facility had notified her, she would have given treatment orders for the right heel. An interview was conducted with the Medical Director on 7/26/24 at 3:05 PM. He stated that he knew Resident #31 had wounds to both of his feet but could not remember specifically where they were located. The Medical Director reviewed his notes and could not find where he had been notified of the new wound to Resident #31's right heel. The Medical Director stated he expected the staff to notify the wound care provider of new wounds or that they could notify him if unable to reach the wound care provider, so new wound care orders could be given. An interview was conducted with the Director of Nursing (DON) on 7/26/24 at 4:34 PM. The DON stated that the Treatment NA should have notified the nurse when she found the new wound to Resident #31's right heel and that then the nurse should have notified the physician to get new wound care orders. The DON said there were no wound care orders for the right heel because the Treatment NA had not reported the wound. An interview was conducted with the Administrator on 7/26/24 at 5:23 PM. The Administrator stated that the Treatment NA should have notified the nurse when she found the wound to Resident #31's right heel and then the nurse should have notified the physician and obtained orders for wound care. The Administrator stated there was a breakdown in communication. Based on record reviews, staff, and Medical Director (MD) interviews, the facility failed to notify the physician of a Urologist appointment on 5/16/24 for Resident #53 that resulted in an order for a CT (computed tomography) scan for renal stones (small, hard deposit that forms in kidneys) and a follow-up appointment following the CT scan to determine treatment which included surgery for removal of renal stones and right ureteral (tubes composed of smooth muscle that transport urine from the kidneys to the urinary bladder) stent exchange (procedure that replaces an existing stent with a new one) not being completed. Resident #53 experienced and was treated for urinary tract infections (UTI) and on-going hematuria (blood in urine) while waiting to see the urologist. Resident #53's prolonged treatment for his renal stones made him susceptible to persistent kidney obstruction, which could cause permanent kidney damage and a higher risk for sepsis (bodies improper response to an infection). This deficient practice affected 2 of 3 residents reviewed for notification (Resident #53 and #31). Immediate jeopardy began on 5/16/24 when the facility failed to notify the physician of ordered treatment from the urologist following a urology appointment for Resident #53. Immediate jeopardy was removed on 7/27/24 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Example #2 for Resident #31 was cited at a scope and severity of D. Findings included: 1. Review of Resident #53's hospital Discharge summary dated [DATE] revealed he had been hospitalized from [DATE] to 4/25/24 for obstructing ureteral stones with hydronephrosis (swelling of one or both kidneys due to urinary buildup), UTI, and sepsis. Diagnostics showed he had an obstructing right mid ureteral stone with upstream moderate hydronephrosis and several punctate (stone with sharp points) left ureteral stones. Urology was consulted during his hospitalization to provide intervention for his urinary obstruction. He was taken to the operating room on 4/19/24 by the urologist and a stent was placed in his right ureter. His discharge summary read in part, return to the facility today, follow-up with urology next 1-2 weeks, for needed surgery for treatment of renal stones and possible stent exchange. Resident #53 was readmitted to the facility on [DATE] with diagnoses including calculus (kidney stones) of kidney, UTIs, sepsis, and aphasia (language disorder affecting communication). Review of facility transportation schedule for May 2024 revealed Resident #53 had a scheduled urology appointment on 5/16/24 at 9:00 AM. There was no record of the 5/16/24 urology appointment or office notes from the appointment in Resident #53's electronic medical record. A telephone interview was conducted on 7/24/24 at 1:18 PM with the Urology Office Practice Manager. The practice manager revealed Resident #53 was seen at the urology office for a scheduled appointment on 5/16/24 accompanied by staff from the facility. After reviewing the office note from 5/16/24, the practice manager stated Resident #53 was seen for follow-up for renal stones and stent placement and recommended order for CT scan to determine treatment for renal stones and stent. She revealed Resident #53's order for the CT scan for renal stones was completed by the urology office during the visit, uploaded into the system, so it would be available for imaging when the CT appointment was made. The practice manager stated the facility was responsible for making sure the imaging appointment was made to complete the CT scan and then once the CT scan was completed a follow-up appointment would need to be made for treatment. She revealed this information was verbally discussed with Resident #53 and the facility staff that accompanied him to the visit and provided in writing as part of the office note given to the facility staff on that day. She stated the facility never followed through with making the appointment for the CT scan and the order from 5/16/24 was still in the system, and according to Resident #53's records no referrals or request for appointments had been made until last week on 7/18/24, when an appointment was requested for Resident #53's on-going hematuria and scheduled for 8/07/24. Review of urology office note dated 5/16/24 read in part: Resident #53 was accompanied to appointment by nursing assistant (NA) #11, ordered for CT scan of renal stones to be completed to determine size and quantity of renal stones and then follow-up appointment with urology for surgical treatment to remove renal stones and stent placement. The surveyor requested and received a copy of this office visit note dated 5/16/24 from urology office on 7/24/24. Review of Resident #53 medical progress notes from May 2024 through July 2024 revealed the following: A medical provider progress note dated 6/11/24 read in part: follow-up visit for urinary problems, Resident #53 was found to have blood in urine by staff, an order was provided for a urinalysis (UA) and complete blood count (CBC). Plan of treatment: monitor for further hematuria, UA pending, KUB (kidney, ureter, bladder) ordered and pending. An order entered by the Medical Director (MD) dated 6/11/24 read in part: one time UA with C&S (culture and sensitivity) for blood in urine and complaint of pelvic pain and one-time KUB for pelvic pain. Lab results showed Resident #53 had a UA, CBC, and CMP (complete metabolic panel) completed on 6/12/24. The urine C&S report dated 6/14/24 showed CBC and CMP were normal, UA showed 3+ blood, 2+ leukocytes, nitrite positive, and urine culture was negative with no growth and range within normal limits. KUB showed replacement of g-tube was needed due to cap malfunction. A medical provider progress note dated 6/14/24 read in part: follow-up visit: Resident #53 had recurrent hematuria, and last two cultures had no growth. Plan of treatment: follow up urine culture, start cefadroxil (antibiotic to treat bacterial infections) empirically (antibiotics are administered prior to the specific cause of the infection is known) considering hematuria, check CBC, referral to urology for recurrent hematuria. An order entered by the MD dated 6/14/24 read: order for urology consult. A progress note from the Nurse Practitioner (NP) dated 6/17/24 read in part: Resident #53's urine culture remains negative, plan to continue with antibiotics due to hematuria and urology appointment pending. A medical provider progress note dated 6/18/24 read in part: start antibiotic empirically considering hematuria and pyuria (high levels of white blood cells in urine), have to treat empirically with evidence of UTI but no growth, referral to urology for recurrent hematuria to evaluate for other possible causes as well A progress note from the NP dated 6/21/24 read in part: Resident #53 still has blood in his urine, currently on antibiotics for UTI although cultures were negative, urology appointment pending. A nursing progress note dated 6/25/24 read in part: staff noted Resident #53 crying ow when peri care performed, some redness noted to testicles and dark red/brown urine noted to briefs. Peri care was performed and cream to peri area applied. Staff will continue to notify the physician for continuation of Resident #53's symptoms while on antibiotics and will continue to monitor. A progress note from the NP dated 6/25/24 read in part: Staff reported dark urine in Resident #53's brief, he denies any pain, fever, or chills. He is more interactive today than typical, smiling, in no distress. Able to speak a few words. He has urology appt pending for hematuria. Recently completed antibiotic for suspected UTI. He denies issues today, history always difficult to obtain due to aphasia but he is more interactive today than usual and shakes his head no and says no when I ask about pain, fever or chills. Dark urine may be due to known hematuria, urology appt pending. Recently finished antibiotics for suspected UTI although cultures were negative. No signs of infection today, vitals stable, mood stable. A medical provider progress note dated 7/02/24 read in part: Resident #53 had recurrent hematuria, last two cultures had no growth though evidence of UTI present through inflammatory cells, started empiric antibiotics. Plan of treatment: treated with antibiotics empirically considering hematuria and pyuria, however hematuria persists, urology appointment previously requested and remains pending to evaluate for other possible causes as well such as bladder tumor. A progress note from the NP dated 7/10/24 read in part: continued blood in urine per staff, urology appointment pending for hematuria. A medical provider telehealth note dated 7/14/24 read in part: hematuria with foul odor. Orders received: Obtain CBC (rule out anemia), UA w/ CX (test for germs or bacteria in urine that can cause an infection) (rule out infection) STAT (with no delay) and notify a clinician of any change in condition. A progress note from the NP dated 7/15/24 read in part: Staff reported blood in urine with an odor, UA was ordered over the weekend by the on-call physician but had not been completed. Resident #53 reports pain from urinating, although it is difficult to get a full answer due to aphasia. Resident #53 nods 'yes' when asked if he had fever or chills, nods no to back pain or nausea. Plan of treatment: UA for odor and potential dysuria. Resident #53 has had blood in his urine for the last few weeks and is pending urology appt. Lab results showed Resident #53 had a UA completed on 7/16/24. The urine C&S report dated 7/18/24 showed no growth of organisms and levels within normal limits. An order was received from the NP on 7/18/24 for urology consult. An interview was conducted on 7/23/24 at 1:47 PM with the Medical Director (MD). The MD revealed he was familiar with Resident #53 and his on-going bladder issues. He stated Resident #53 was seen at the hospital in April 2024 for altered mental status and was diagnosed with a UTI and sepsis secondary to renal stones and required placement of a stent. He revealed Resident #53's hospital discharge recommendations were for him to follow-up with urology within 1-2 weeks for needed surgery as treatment for his renal stones and stent exchange. The MD stated to his knowledge there had not been a urology consult scheduled for Resident #53 at this time, although he had ordered and continued to note the need for a urology consult in his progress notes and asked surveyor if she could possibly make the appointment since one had not been made. He revealed Resident #53 had on-going hematuria with no positive UA and needs a urology appointment to determine further treatment. An interview was conducted on 7/25/24 at 11:07 AM with the Director of Nursing (DON). She stated she had started her employment as the DON at the facility on 5/28/24 but had previously worked at the facility as the DON for a year prior. She stated she was not employed with the facility during the time of Resident #53's hospitalization in April 2024 and was not aware of him being seen for a follow-up appointment with urology on 5/16/24 and she had not been made aware of any orders from that appointment for a CT scan of renal stones to be completed or a follow-up appointment for treatment needing to be made. She revealed the facility should have made sure the physician was aware of Resident #53's urology appointment on 5/16/24 and the outcomes from the appointment to ensure the CT scan and follow-up appointment had been completed in a timelier manner especially since Resident #53's on-going hematuria could have been from the renal stones and stent placement and all his UAs were normal. A follow up telephone interview was conducted on 7/25/24 at 2:48 PM with the MD. The MD stated he had no knowledge of Resident #53 being seen for a urology appointment on 5/16/24 and had never received any orders or office visit notes from that appointment for him to review. The MD asked how the Surveyor was made aware of the urology appointment the resident had on 5/16/24. The MD was informed the appointment was listed on the facility transportation schedule for May 2024 and the Surveyor contacted the urology office for information about the appointment and received the office visit notes. The Surveyor read MD the note from the urology office visit on 5/16/24 and notified him of the order for the CT scan and need for follow-up appointment to determine treatment. The MD stated again he had no knowledge of the 5/16/24 appointment and reported he should be made aware of all resident appointments so he can know to look for visit notes from the appointment to review for any changes in medications, diet orders, and recommended treatments. He revealed he had written in Resident #53's progress notes since May 2024 to present that he needed a urology consult and wrote a specific order for a urology consult in June 2024 and each time he asked administration or nursing staff about the urology consult he was always told they were in the process of making the appointment or the appointment was pending. He stated physician orders should be followed and completed in a timely manner and Resident #53 matter should have been taken seriously and handled before now due to the seriousness with his on-going hematuria with normal labs. The MD revealed he believed due to Resident #53 having normal labs that his on-going bleeding was coming from his renal stones, stent, or from something possibly worse like a bladder tumor. He also revealed Resident #53 often appeared comfortable, and although his pain level was hard to determine due to his aphasia, Resident #53's pain would come and go depending on if the stones were moving. When the MD was asked if he was aware of Resident #53 having a urology appointment scheduled for 8/07/24, he stated no he had not been made aware of that appointment until now. The Surveyor informed the MD of the appointment. An interview was conducted on 7/26/24 at 3:21 PM with the Administrator. The Administrator stated she began her employment with the facility in June 2024 and was not familiar with Resident #53's medical issues or his need for a scheduled consult appointment until now. She revealed the facility should have followed-up from Resident #53's May 2024 appointment and made sure all orders and recommendations were followed. She revealed the physician should be notified of all orders, recommendations, and follow-up appointments for residents, so they are followed by staff and completed in a timely manner. The facility was notified of immediate jeopardy on 7/26/24 at 6:56 PM. The facility provided the following plan for IJ removal. F580: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to notify the Medical Director of the appointment with the Urologist, order for CT scan, and follow-up appointment to schedule surgery for treatment. Resident #53 was seen by the Urologist on 5/16/24 and returned with orders for a CT scan for renal stones and a follow-up appointment to schedule surgery for treatment of the renal stones after the CT scan was completed. On 7/26/24, the Quality Assurance Process Improvement (QAPI) Committee (Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), Social Worker (SW), [NAME] President of Operations (VPO), [NAME] President of Clinical and Quality (VPCQ), and Medical Director (MD) held an Ad Hoc meeting to discuss root cause analysis of the facilities failure to ensure the physician is informed of any resident outside medical appointments and provided with any orders or notes from those appointments to be reviewed for any changes in treatment, medications, diet, orders for labs or scans, and follow-up appointments that would need to be scheduled. Root cause analysis determined that the facility failed during clinical morning meeting on 5/17/24 to ensure we received documents from the urology appointment on 5/16/24 which indicated the need for a follow up appointment, CT scan, and an appointment to schedule surgery. The facility has updated the clinical morning meeting process, upcoming appointment schedule and provided education. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 7/26/24, the Regional Director of Clinical Services (RDCS) reviewed the current facility residents to ensure the Medical Director was made aware of upcoming appointments. Upcoming appointments for the next 30 days were placed on the electronic health record dashboard making them accessible to medical director and nurse practitioner. Effective 7/26/24, all current facility and agency licensed nurses and medical records clerk were in-serviced on facility policy on Notification of Change and new process as follows: When a resident is admitted to the facility, the discharge summary is to be reviewed by the admitting nurse to determine if any appointments need to be made after discharge. The licensed nurse will then enter the order for the referral or appointment into electronic health record. This is also to include readmissions and consultations. The licensed nurse will notify the medical director (MD) of the need for an order on the discharge summary, on admission/re-admissions or consultations. The licensed nurse will then place a copy of the order in the medical record box located at each nursing station. Medical records will check each box every morning before the morning meeting and bring the copy of the order for the appointment or consultation to the morning meeting for review. The order will then be verified and entered/updated into the electronic health record (HER) system. A copy of the order will then be given to the transporter by the medical record staff member for the appointment to be placed on the calendar. A copy of the order will then be placed into the MD box for notification. Appointments will be entered onto the EHR dashboard during the daily meeting for MD to review. All appointments will be reviewed daily during the clinical morning meeting for accuracy and follow-up. The previous day's appointments will be reviewed during the daily clinical meeting to make sure that any correspondence has been reviewed and followed up on. Newly hired facility and agency licensed nurses not receiving education by 7/26/24, will receive education prior to first worked shift by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), or Administrator. Effective 7/26/24, the daily schedule will be monitored to ensure education is completed prior to the first shift worked. Education will be completed by the DON, ADON, UM, or Administrator and monitoring of completion will be tracked by the active employee report. Effective 7/26/24, the Administrator and DON are ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 7/27/24 The credible allegation for the immediate jeopardy removal was validated on 08/01/24 with a removal date of 07/27/24. A review of in-service education records dated 07/26/24 indicated education was provided to the Medical Record Clerk and nurses including agency nurses on Notification of change and new process by DON. It was to ensure the Medical Director was informed of any residents outside medication appointments and provided with any orders or notes from those appointments to be reviewed for any changes in treatment, orders for labs or scans, and follow-up appointments that needed to be scheduled. Interviews with the Medical Record Clerk and the nursing staff including agency nurses revealed they had been educated on notifying the Medical Director of upcoming follow up appointment, labs or scans, and an appointment to schedule surgery. They were able to describe the new notification process and verbalized understanding of the in-service education. The audit completed by the Regional Director of Clinical Services on 07/26/24 was reviewed. The Medical Director was made aware of all residents' upcoming appointments. The facility's date of immediate jeopardy removal of 07/27/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, Nurse Practitioner (NP), Medical Director, urology office staff, and the Urologist the facility failed to follow an order from a Urologist appointment on 5/16/24 for a CT (computed tomography) scan for ureteral stones and a follow-up appointment following the CT scan to determine treatment which included surgery for removal of ureteral stones and right ureteral stent exchange for Resident #53. Resident #53 was previously hospitalized for obstructing ureteral stones (kidney stones that get stuck in tubes composed of smooth muscle that transport the urine from the kidneys to the bladder) with hydronephrosis (swelling of one or both kidneys due to urine build up), urinary tract infection (UTI), and sepsis (a serious condition in which the body responds improperly to an infection). Resident #53 also had a stent (a small tube placed in the ureter that allows the urine to drain) placed for renal stone obstruction on 4/19/24 and returned to the facility on 4/25/24. The hospital discharge summary for Resident #53 specified a follow-up appointment for further assessment by Urology within 1-2 weeks for needed surgery to remove renal stones and possible stent exchange. Resident #53 was treated for UTIs and on-going hematuria (blood in urine) while waiting to see the urologist. Resident #53's prolonged treatment for his renal stones made him susceptible to persistent kidney obstruction, which could cause permanent kidney damage and a higher risk for sepsis. This deficient practice affected 1 of 3 residents reviewed for urinary catheter or urinary tract infection (Resident #53). Immediate jeopardy began on 5/16/24 when the facility failed to follow up with urology recommendations for Resident #53. Immediate jeopardy was removed on 7/27/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Findings included: 1. Review of revised care plan dated 2/06/24 revealed Resident #53 was at risk for urinary complication related to incontinence and complications would be avoided or minimized daily through next review. Interventions included Resident #53 was always incontinent, provide incontinence care on routine rounds and as needed, assess, document, and report any signs or symptoms of urinary tract infections (burning, bladder/flank pain, dysuria, fever, foul odor of urine, concentrated urine, change in mental status or unusual behavior) report abnormal findings to physician, evaluate skin with each episode and report any redness, skin breakdown, rash, pain, burning or odorous urine to nurse, and administer medications as ordered. Review of nursing noted dated 4/18/24 revealed Resident #53 was lethargic and had altered mental status. The NP was notified and gave the order to send the resident to the emergency room (ER) for evaluation. Review of Resident #53's hospital Discharge summary dated [DATE] revealed he had been hospitalized from [DATE] to 4/25/24 for obstructing ureteral stones with hydronephrosis, UTI, and sepsis. Diagnostics showed he had an obstructing right mid ureteral stone with upstream moderate hydronephrosis and several punctate (stone with sharp points) left ureteral stones. Urology was consulted during his hospitalization to provide intervention for his urinary obstruction. He was taken to the operating room on 4/19/24 by the urologist and a stent was placed in his right ureter. His discharge summary read in part, return to the facility today, follow-up with urology next 1-2 weeks, for needed surgery for treatment of renal stones and possible stent exchange. Resident #53 was readmitted to the facility on [DATE] with diagnoses including calculus (kidney stones) of kidney, urinary tract infection (UTI), sepsis, aphasia (language disorder affecting communication), hemiplegia and hemiparesis (paralysis) affecting right dominant side. Review of progress note from the NP dated 4/26/24 read in part: continue to monitor closely, will need to follow up with urology soon for renal stone management and stent change versus removal. Review of quarterly Minimum Date Set (MDS) dated [DATE] revealed Resident #53 was severely cognitively impaired and dependent on staff for his activities of daily living. Resident #53 was also assessed as always being incontinent of both bladder and bowel. Review of progress note from NP dated 5/06/24 read in part: continue to monitor Resident #53 closely and will need to follow up with urology soon for renal stone management and stent change versus removal. Review of facility transportation schedule for May 2024 revealed Resident #53 had a scheduled urology appointment on 5/16/24 at 9:00 AM. There was no record of the 5/16/24 urology appointment or office notes from the appointment in Resident #53's electronic medical record. A telephone interview was conducted on 7/24/24 at 1:18 PM with the Urology Office Practice Manager. The Practice Manager revealed Resident #53 was seen at the urology office for a scheduled appointment on 5/16/24 accompanied by staff from the facility. After reviewing the office note from 5/16/24, the Practice Manager stated Resident #53 was seen for follow-up for renal stones and stent placement and recommended order for CT scan to determine treatment for renal stones and stent. She revealed Resident #53's order for the CT scan for renal stones was completed by the urology office during the visit, uploaded into the system, so it would be available for imaging when the CT appointment was made. The Practice Manager stated the facility was responsible for making sure the imaging appointment was made to complete the CT scan and then once the CT scan was completed a follow-up appointment would need to be made for treatment. She revealed this information was verbally discussed with Resident #53 and the facility staff that accompanied him to the visit and provided in writing as part of the office note given to the facility staff on that day. She stated the facility never followed through with making the appointment for the CT scan and the order from 5/16/24 was still in the system, and according to Resident #53 records no referrals or request for appointments had been made until last week on 7/18/24, when an appointment was requested for Resident #53 on-going hematuria and scheduled for 8/07/24. Review of urology office note dated 5/16/24 read in part: Resident #53 was accompanied to appointment by facility nursing assistant (NA) (the name of the facility NA was provided in the note), ordered for CT scan of renal stones to be completed to determine size and quantity of renal stones and then follow-up appointment with urology for surgical treatment to remove renal stones and stent placement. Further Review of Resident #49's electronic medical record revealed: A medical provider progress note dated 6/11/24 that read in part: follow-up visit for urinary problems, Resident #53 was found to have blood in urine by staff, an order was provided for a urinalysis (UA) and complete blood count (CBC). Plan of treatment: monitor for further hematuria, UA pending, KUB (kidney, ureter, bladder) ordered and pending. An order entered by the Medical Director (MD) dated 6/11/24 read in part: one time UA with C&S for blood in urine and complaint of pelvic pain and one-time KUB for pelvic pain. Lab results showed Resident #53 had a UA, CBC, and CMP (complete metabolic panel) completed on 6/12/24. The urine C&S (culture and sensitivity) report dated 6/14/24 showed CBC and CMP were normal, UA showed 3+ blood, 2+ leukocytes (white blood cells), nitrite positive, and urine culture was negative with no growth and range within normal limits. KUB showed replacement of g-tube was needed due to cap malfunction. A medical provider progress note dated 6/14/24 that read in part: follow-up visit: Resident #53 had recurrent hematuria, and last two cultures had no growth. Plan of treatment: follow up urine culture, start cefadroxil (antibiotic to treat bacterial infections) empirically (antibiotics are administered prior to the specific cause of the infection is known) considering hematuria, check CBC, referral to urology for recurrent hematuria. An order entered by the MD dated 6/14/24 read: order for urology consult. A progress note from NP dated 6/17/24 read in part: Resident #53 urine culture remains negative, plan to continue with antibiotics due to hematuria and urology appointment pending. A medical provider progress note dated 6/18/24 read in part: start antibiotic empirically considering hematuria and pyuria (high levels of white blood cells or pus in urine), have to treat empirically with evidence of UTI but no growth, referral to urology for recurrent hematuria to evaluate for other possible causes as well. A progress note from NP dated 6/21/24 read in part: Resident #53 still has blood in his urine, currently on antibiotics for UTI although cultures were negative, urology appt pending. A nursing progress note dated 6/25/24 read in part: staff noted Resident #53 crying ow when peri care performed, some redness noted to testicles and dark red/brown urine noted to briefs. Peri care was performed and cream to peri area applied. Staff will continue to notify the physician for continuation of Resident #53's symptoms while on antibiotics and will continue to monitor. A progress note from NP dated 6/25/24 read in part: Staff reported dark urine in Resident #53's brief, he denies any pain, fever, or chills. He is more interactive today than typical, smiling, in no distress. Able to speak a few words. He has urology appt pending for hematuria. Recently completed antibiotic for suspected UTI. He denies issues today, history always difficult to obtain due to aphasia but he is more interactive today than usual and shakes his head no and says no when I ask about pain, fever or chills. Dark urine may be due to known hematuria, urology appt pending. Recently finished antibiotics for suspected UTI although cultures were negative. No signs of infection today, vitals stable, mood stable. A medical provider progress note dated 7/02/24 read in part: Resident #53 had recurrent hematuria, last two cultures had no growth though evidence of UTI present through inflammatory cells, started empiric antibiotics. Plan of treatment: treated with antibiotics empirically considering hematuria and pyuria, however hematuria persists, urology appointment previously requested and remains pending to evaluate for other possible causes as well such as bladder tumor. A progress note from NP dated 7/10/24 read in part: continued blood in urine per staff, urology appointment pending for hematuria. A medical provider telehealth note dated 7/14/24 read in part: hematuria with foul odor. Orders received: Obtain CBC (rule out anemia), UA w/ CX (test for germs or bacteria in urine that can cause an infection and rule out infection) STAT (without delay) and notify a clinician of any change in condition. A progress note from NP dated 7/15/24 read in part: Staff reported blood in urine with an odor, UA was ordered over the weekend by the on-call physician but had not been completed. Resident #53 reports pain from urinating, although it is difficult to get a full answer due to aphasia. Resident #53 nods 'yes' when asked if he had fever or chills, nods no to back pain or nausea. Plan of treatment: UA for odor and potential dysuria. Resident #53 has had blood in his urine for the last few weeks and is pending urology appt. During the interview conducted with the NP on 7/24/24 at 9:35 AM, she stated that she was made aware during her visit with Resident #53 on 7/15/24 the tests that had been ordered the previous evening by the on-call physician had not been completed. She revealed it was not uncommon for staff to receives orders from the on-call physician and wait before proceeding with those orders until the resident has been assessed by herself or the Medical Director especially if the test could cause the resident discomfort and the issue has been on-going. The NP stated Resident #53 had an on-going issue with blood in his urine and his previous labs had showed no UTIs, so she was fine with staff waiting until she could assess Resident #53 and there were no issues with the test being completed on 7/16/24. Lab results showed Resident #53 had a UA completed on 7/16/24. The urine C&S report dated 7/18/24 showed no growth of organisms and levels within normal limits. An order was received from NP on 7/18/24 for urology consult and was entered and stricken in Resident #53 medical chart on 7/19/24 by the Director of Nursing (DON). Resident #53 had a CT scan of the abdomen, pelvis, and renal stones completed on 7/30/24. The report dated 7/30/24 read in part: ureteral stent in good position, 13 millimeter (mm) stone in the right kidney inferior poles (lower region of kidney) and nonobstructive nephrolithiasis (kidney stones) in the left kidney with 2 punctate stones in the superior (upper region of kidney) and inferior poles. An interview was conducted on 7/23/24 at 1:47 PM with the Medical Director (MD). The MD revealed he was familiar with Resident #53 and his on-going bladder issues. He stated Resident #53 was seen at the hospital in April 2024 for altered mental status and was diagnosed with an UTI and sepsis secondary to renal stones and required placement of a stent. He revealed Resident #53 hospital discharge recommendations were for him to follow-up with urology within 1-2 weeks for needed surgery as treatment for his renal stones and stent exchange. The MD stated to his knowledge there had not been a urology consult scheduled for Resident #53 at this time, although he had continued to request for urology consult and asked surveyor if she could possibly make the appointment since one had not been made. He revealed Resident #53 had on-going hematuria with no positive UA and needed a urology appointment to determine further treatment. An interview was conducted on 7/24/24 at 9:35 AM with the NP. The NP revealed she had been employed at the facility since March 2024 and was familiar with Resident #53. She stated Resident #53 was sent out to the hospital on 4/18/24 for altered mental status and during his hospital stay was diagnosed with sepsis related to UTI secondary to renal stones that required placement of a stent on 4/19/24. She revealed Resident #53 was discharged from the hospital on 4/25/24 and the hospital discharge summary recommended for him to be seen within a week or two at the urology office for needed surgery to remove renal stones and stent exchange. The NP stated she saw Resident #53 at the facility for a follow-up visit from his hospital stay on 4/26/24 and noted in her progress note his need for an appointment to be scheduled with urology to address the treatment for his renal stones and stent placement. She revealed she had discussed the importance of Resident #53 being seen by urology with nursing staff on several different occasions although she could not recall the exact dates and whom she spoke with, and she also continued to note in her progress notes from April 2024 until present about Resident #53's need to be seen by urology for treatment of his renal stones, stent placement, and on-going hematuria. She stated since Resident #53 hospital admission he continued to have on-going bleeding and each time a urinalysis was ordered for possible UTI, the results would show no growth and range within normal limits, and he received antibiotics off and on to assist with the on-going hematuria. The NP revealed no knowledge of Resident #53 having any appointments made with urology or being seen by urology since his hospital stay. She stated she believed Resident #53 on-going hematuria was coming from the renal stones, stents, or possibly from some worse bladder issue but either way he needed to be seen by urology to determine further treatment. An interview was conducted on 7/24/24 at 10:40 AM with the Transport Scheduler. The Transport Scheduler stated she had been in the position as scheduler for resident appointments, transportation coordinator, and medical records since July 2024. She stated she had not received an order or referral for Resident #53 to be seen by the urologist until last week on 7/18/24. The Transportation Scheduler stated she contacted the urology office on 7/18/24 and scheduled an appointment for Resident #53 to be seen on 8/07/24. In discussing the referral process for scheduling resident appointments, the transport scheduler stated she receives an order in her box informing her if an appointment needs to be scheduled for a resident, she then contacts the provider and schedules the appointment, afterwards she places the resident name, appointment time, and name of provider under the date on the transportation calendar. She revealed if facility staff assisted residents with going to the appointment, then they were responsible for bringing back any notes from the appointment and giving them to nursing to review and a copy should also be given to medical records. She stated to her knowledge scheduled appointments were not documented in resident charts only on the transportation calendar until after the appointment is completed and notes or orders from that appointment are received and uploaded into the chart. An interview was conducted on 7/24/24 at 10:55 AM with Unit Manager (UM) #1. UM #1 revealed she had been in her position as Unit Manager since June 2024. She stated she recalled receiving an order for a urology referral for Resident #53 in June 2024 and would have taken it to the transportation scheduler but could not recall who was working as the transportation scheduler at that time. She revealed she was not aware if an appointment was scheduled at that time or not and had no knowledge of Resident #53 having any previous urology appointments. Unit Manager #1 stated she had never been made aware of Resident #53 having a history of renal stones or stent placement and assumed the urology order from June 2024 had been for his on-going bleeding and possible UTI. She revealed Resident #53 having a history of renal stones and stent placement made more sense as to why he continued to have on-going bleeding, pain on and off, and his UAs being negative for UTIs. Unit Manager #1 stated when nursing receives an order to schedule an appointment, that order is given to the transportation scheduler to schedule the appointment and once that appointment has been completed any notes from that appointment should be returned to nursing for review, placed inside book for physician review, and copy sent to medical records. She revealed nursing was not always notified of a resident's scheduled appointment or provided notes from appointment for follow-up. Unit Manager #1 stated now knowing of Resident #53 history of renal stones and stent, urology appointment should have been scheduled sooner especially since he had on-going bleeding with no signs of a UTI. A telephone interview was conducted on 7/24/24 at 11:16 AM with Nurse #10 who stated as of July 2024 he was only working at the facility on an as needed basis but had previously worked as a unit manager on the 200 hall and filled in as the transportation scheduler on an as needed basis during the month of June 2024. He stated he was vaguely familiar with Resident #53 due to him primarily working on the 200 hall and Resident #53 room was on the 100 hall. He also stated he had no knowledge of ever having received any orders regarding Resident #53. Nurse #10 revealed he had never received any orders pertaining to scheduling an appointment for Resident #53 to include during his time as the fill in scheduler and he would have remembered if he had ever received any orders to schedule an appointment for Resident #53 because he was not one of the residents he worked with on his hall so it would have stood out to him more if he had received an order for an appointment. An interview was conducted on 7/24/24 at 1:46 PM with Nursing Assistant (NA) #11 who was named in the urology office note dated 5/16/24 as the facility NA who accompanied Resident #53 to his urology appointment. She stated she had been employed as an NA with the facility and during that time had been required to accompany residents to their scheduled appointments. She revealed she was familiar with Resident #53 and recalled accompanying him to his urology appointment on 5/16/24. NA #11 stated if she remembered correctly Resident #53 appointment was close by and did not last long, and while there the doctor discussed a test that Resident #53 needed to have done prior to coming back and they provided her with paperwork to take back with her to the facility. She revealed upon her return from the appointment, she let the nurse over Resident #53 hall know he was back and provided them with the paperwork from the appointment. NA #11 stated she could not recall who the nurse was working Resident #53 hall on that day but knows she gave them the paperwork and they should have followed up. A follow-up interview was conducted on 7/24/24 at 2:15 PM with the NP. The NP was informed by surveyor of Resident #53 appointment with urology on 5/16/24 and the order for a CT scan to be completed and follow-up appointment to determine treatment. She stated she was not aware of Resident #53 ever being seen by urologist since his discharge from the hospital and had she been made aware she could have followed up with making sure his CT scan was ordered, and his follow-up appointment was made. The NP was also not aware of his urologist appointment scheduled for 8/07/24 and his need for a CT scan prior to that appointment and stated she would place an order to make sure the CT scan was obtained prior to his 8/07/24 appointment, urology office had already placed an order for the CT scan to be completed and had also informed the imaging office. A telephone interview was conducted on 7/24/24 at 4:11 PM with Nurse #11 who was scheduled as the nurse working Resident #53 hall on 5/16/24. Nurse #11 stated he primarily worked the 100 hall and was familiar with Resident #53. He revealed he was not aware Resident #53 had ever been seen by the urologist and did not recall ever being given paperwork for Resident #53 from a urology visit or orders for a CT scan to be completed. He stated typically when a resident returns from an appointment any paperwork they had received from the appointment was given to the scheduler, and if he had been given any paperwork or orders from an appointment, he would have notified the unit manager and placed the paperwork in the physician book for review. An interview was conducted on 7/25/24 at 11:07 AM with the Director of Nursing (DON). She stated she had started her employment as the DON at the facility on 5/28/24 but had previously worked at the facility as the DON for a year prior. She stated she was not employed with the facility during the time of Resident #53 hospitalization in April 2024 and was not aware of him being seen for a follow-up appointment with urology on 5/16/24 and she had not been made aware of any orders from that appointment for a CT scan of renal stones to be completed or a follow-up appointment for treatment needing to be made. She stated during their morning IDT meetings they review physician progress notes regarding residents and discuss any residents with changes of condition. She did recall reviewing physician progress notes for Resident #53 stating his need for a urology consult to be made due to his on-going hematuria, but she assumed a referral for an appointment had been made or was pending awaiting a date. The DON revealed typically when a resident needs a consultation or an appointment to be made with another provider, nursing would input the physician order into the resident chart and provide the scheduler with a referral for them to schedule the appointment. She stated nursing was not always made aware of scheduled resident appointments but they should be so they could enter the date the order for the consult was completed, review visit note from the appointment, contact the provider office to request the visit note if needed, and notify the physician. She revealed the facility should have completed the CT scan and follow-up appointment from Resident #53 urology appointment on 5/16/24 and followed-up in a timelier manner with the physician order from 6/14/24 requesting a urology consult especially since Resident #53 on-going hematuria could have been from the renal stones and stent placement and all his UAs were normal. The DON was asked about Resident #53 receiving antibiotics for UTIs on-going when his UAs showed no growth and within normal limits and she stated she was not aware of Resident #53 receiving on-going antibiotics for UTI but typically when a resident is showing signs of a possible UTI they may start them on antibiotics first while awaiting their labs and UA results but if those show no growth or no signs of UTI then the antibiotics should be stopped and other forms of treatments discussed. A telephone interview was conducted on 7/25/24 at 2:48 PM with the MD. The MD stated no knowledge of Resident #53 being seen for a urology appointment on 5/16/24 and had never received any orders or office visit notes from that appointment for him to review. The MD asked how surveyor was made aware of the urology appointment on 5/16/24 and was informed the appointment was listed on the facility transportation schedule for May 2024 and surveyor contacted the urology office for information about the appointment and received the office visit notes. Surveyor read MD the note from the urology office visit on 5/16/24 and notified him of the order for the CT scan and need for follow-up appointment to determine treatment. The MD stated again he had no knowledge of the 5/16/24 appointment and should be made aware of all resident appointments so he can know to look for visit notes from the appointment to review for any changes in medications, diet orders, and recommended treatments. He revealed he had written in Resident #53 progress notes since May 2024 to present that he needed an urology consult and wrote a specific order for a urology consult in June 2024 and each time he asked administration or nursing staff about the urology consult he was always told they were in the process of making the appointment or the appointment was pending. He stated physician orders should be followed and completed in a timely manner and Resident #53 matter should have been taken seriously and handled before now due to the seriousness with his on-going hematuria with normal labs. The MD revealed he believed due to Resident #53 having normal labs that his on-going bleeding was coming from his renal stones, stent, or from something possibly worse like a bladder tumor. He also revealed Resident #53 often appeared comfortable, and although his pain level was hard to determine due to his aphasia, Resident #53's pain would come and go depending on if the stones were moving. When the MD was asked if he was aware of Resident #53 having a urology appointment scheduled for 8/07/24, he stated no he had not been made aware of that appointment until now, surveyor informed the appointment had been made last week and she had notified the NP of the appointment and the need for Resident #53 to have a CT scan completed prior to his appointment and the NP had written an order for a CT scan to be scheduled but the urology office had already taken care of writing the order for the CT scan and notifying imaging and the CT scan had been scheduled for 7/30/24. An interview was conducted on 7/26/24 at PM with the Administrator. The Administrator stated she began her employment with the facility in June 2024 and was not familiar with Resident #53 medical issues or his need for scheduled consult appointment until now. She revealed the facility should have followed-up from Resident #53 May 2024 appointment and made sure all orders and recommendations were followed and if the facility was not made aware of the appointment, they still should have followed up with the on-going recommendations from the physician for a urology consult prior to now. The Administrator stated she also believed the physicians and the administrative team should have followed-up sooner to see why the urology consult had not been made sooner and what the holdup was with securing an appointment. She revealed all orders, recommendations, and follow-up appointments for residents should be followed and completed in a timely manner. Review of email received from the Urologist on 8/07/24 at 5:10 PM revealed when a patient was seen in the hospital for urinary issues that required a stent, urology would typically have patient follow-up in the office within 1-2 weeks to make sure the patient had recovered from their acute illness and to discuss the next steps in surgical intervention. He stated a CT scan would have been ordered during Resident #53 5/16/24 appointment to re-evaluate the size and location of the renal stones to help with surgical planning. The consequences of not having the CT scan or receiving treatment for the renal stones may cause an increased risk of recurrent infections with the indwelling stent. The Urologist stated with a stent in place, intermittent bleeding was expected, and some patients have pain with stents, and others often tolerate them without difficulty. The Administrator was notified of immediate jeopardy on 7/26/24 at 4:14 PM. The facility provided the following credible allegation of immediate jeopardy removal plan. F690: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to review and process orders from a 5/16/24 urology appointment for Resident #53 to have a CT scan and follow-up urology appointment to schedule surgery for treatment of renal stones after the CT was completed. Because all residents with urology consultations are at risk when urology reports are not received and orders and follow-up appointments are not processed and scheduled, the following plan has been devised: On 7/3/24, a urology referral for Resident #53 was faxed by the facility medical record clerk and appointment received and scheduled for 8/7/24. On 7/25/2024, the Director of Nursing (DON) received and processed a physician order for a CT scan and provided a copy of the order to the medical records clerk who then requested and received an appointment on 7/30/24 for Resident #53. On 7/26/24 the DON and Assistant Director of Nursing (ADON) completed an audit of all current facility residents with urology referrals to ensure orders and follow-up appointments were received and processed. Audit included a review of resident's most recent discharge summaries and current active orders to identify and validate that urology orders and follow-up appointments were received and processed as indicated. Additional residents identified with urology referrals were all validated to have orders and/or follow-up appointment received and processed as indicated. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 7/26/24, the Administrator, Director of Nursing (DON), [NAME] President of Operations (VPO), [NAME] President of Clinical and Quality (VPCQ), Regional Director of Clinical Services (RDCS), Unit Manager, Minimum Data Set (MDS) Nurse, and Medical Director conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting to review the facility process for receiving, reviewing and processing urology consultation reports, referrals and orders and to determine root cause of the deficient practice. By root cause analysis, the QAPI committee determined that the facility failed to have an effective monitoring process that ensures urology consultation reports are received and processed. A plan was formulated by[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with resident, staff and Medical Director, the facility failed to prevent a significant medication error when Nurse #1 administered medications to Resident #1 prescribed for Resident #2 which included Risperidone (antipsychotic medication), Furosemide (a medication used to treat fluid retention and swelling), Lisinopril (a medication used to treat hypertension), and Amlodipine (a medication used to treat hypertension). Nurse #1 identified the error and Resident #1 was sent to the emergency department (ED) on 2/17/24 for further evaluation due to elevated heart rate and hypotension (low blood pressure). While in the ED, Resident #1 complained of having chest pain and feeling weak. An electrocardiogram showed normal sinus rhythm with prolonged QT interval 5-7 seconds (irregular heart rhythm where it takes longer than usual for the heart to recharge between beats). She was given two liters of normal saline bolus and calcium gluconate (medication used to manage hypocalcemia or low calcium levels in the blood, cardiac arrest, and cardiotoxicity due to hyperkalemia or hypermagnesemia). Resident #1 was admitted into the hospital for observation due to the prolonged effect of antihypertensives and being hypotensive on presentation. Resident #1 was discharged back to the facility on 2/19/24 at her baseline with no new orders. This deficient practice affected 1 of 3 residents reviewed for significant medication errors (Resident #1). Immediate jeopardy started on 2/17/24 when Resident #1 was administered medications prescribed for Resident #2. Immediate jeopardy was removed on 2/20/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease. Resident #1 did not have hypertension listed as a diagnosis. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and did not receive antipsychotic medications. The February 2024 physician orders for Resident #1 indicated the following medications: - Amantadine (anti-dyskinetic medicine) 100 milligrams (mg) 1 tablet by mouth one time a day for Parkinson's disease - Magnesium oxide (dietary supplement) 400 mg 1 tablet by mouth one time a day for supplement - Melatonin (hormone that plays a role in sleep) 3 mg 1 tablet by mouth one time a day at bedtime for sleep - Spironolactone (diuretic) 25 mg 1 tablet by mouth one time a day for blood pressure, fluid - Carbidopa-Levodopa (dopamine promoter) ER (extended release) 25-100 mg 1.5 tablet by mouth four times a day for Parkinson's disease A review of Resident #1's Medication Administration Record for 2/17/24 indicated she last received a dose of Carbidopa-Levodopa at 6:00 AM but she did not receive any of her scheduled 8:00 AM medications which included Amantadine, and Spironolactone. Resident #2 was admitted to the facility on [DATE]. The February 2024 physician orders for Resident #2 indicated the following medications: - Amlodipine (calcium channel blocker) 10 mg 1 tablet by mouth one time a day for hypertension - Furosemide (diuretic) 40 mg 1 tablet by mouth one time a day for fluid, hypertension - Lisinopril (angiotensin-converting enzyme inhibitor) 20 mg 1 tablet by mouth one time a day for heart/blood pressure - Risperidone (antipsychotic) 2 mg 1 tablet by mouth two times a day for schizophrenia An incident report dated 2/17/24 at 10:00 AM documented by Nurse #1 indicated Nurse #1 went into Resident #1's room to get her name and asked her for her date of birth . Vital signs were taken. When Nurse #1 went back to the medication cart, another resident (Resident #2) approached her with grievances from the previous night and demanded his medications and was unwilling to wait. Then Resident #1 who Nurse #1 was currently with also wanted her medications and was given the wrong medications (which belonged to Resident #2). An on-call physician and Resident #1's family member were notified. The Director of Nursing, Unit Manager, and Administrator were also notified. Vital signs were taken again, and Resident #1 was kept comfortable. EMS (emergency medical services) was called with a detailed report. The incident report did not specify what medications were given to Resident #1. A phone interview with Nurse #1 on 4/9/24 at 11:44 AM revealed she couldn't remember all the details of how the medication error happened, but she was in the middle of the morning medication pass on 2/17/24. Nurse #1 stated she remembered both Resident #1 and Resident #2 came up to her medication cart at the same time and asked for their medications. Nurse #1 pulled Resident #2's medications and while Resident #1 asked about her medications, Nurse #1 got confused and accidentally gave her Resident #2's medications. Nurse #1 stated it was less than 10 minutes after she had administered the medications and when she started to document the medications in the medication administration record that she realized that she had made a medication error by administering Resident #2's medications to Resident #1. Nurse #1 stated she immediately notified the Unit Manager, the Director of Nursing (DON), and the Administrator. After obtaining Resident #1's vital signs and noting that her heart rate was elevated, Nurse #1 notified an on-call physician who gave her an order to send Resident #1 to the hospital. Nurse #1 stated it took her less than 45 minutes from the time she administered the wrong medications to Resident #1 to the time that she was sent to the ED. A progress note dated 2/17/24 at 10:54 AM by an on-call physician indicated she was contacted by Nurse #1 on 2/17/24 at 9:04 AM about a transfer notification due Resident #1 having received Risperidone 2 mg, Furosemide 40 mg, Lisinopril 20 mg and Amlodipine 10 mg in error and was sent to the emergency room (ER). Vital signs were heart rate 110 beats per minute (normal range 60 to 100), blood pressure 147/95 (normal is less than 120/80), respiratory rate 16 (normal range 12 to 16), temperature 98.1 (normal is around 98.6), and oxygen saturation 95% (normal range between 95% to 100%). This note was electronically signed by the on-call physician on 2/17/24 at 9:30 AM. An interview with Resident #1 on 4/9/24 at 9:48 AM revealed she remembered having received the wrong medications in February. Resident #1 stated it happened during the morning medication pass when the nurse put four pills in a cup, and she gave the cup to her. Resident #1 stated she later found out that three of the pills in the medication cup were blood pressure medications which were supposed to be for another resident. Resident #1 stated she knew something was wrong when the nurse went back after she had swallowed the medications to ask her whether she had already swallowed them, and after she told the nurse that she did, the nurse's face didn't look right. The nurse went down the hall, told someone, called EMS and they sent her to the hospital. Resident #1 further stated she remembered her heart was racing at that time and she stayed at the hospital for observation for two days. At the hospital, they gave her intravenous fluids and put her on a heart monitor. Resident #1 stated at one point while she was at the hospital, her blood pressure got too low, and the hospital doctor told her that one of the pills she accidentally took worked against her Parkinson's disease medications. The hospital records dated 2/17/24 indicated Resident #1 arrived at the Emergency Department (ED) at 10:22 AM and was evaluated after a medication mix-up where the resident got someone else's medications. She was hypotensive with systolic blood pressure in the 70s (normal range 110 to 119) and diastolic blood pressure in the 40s (normal range 60 to 90). She was having chest pain and felt weak. She was at her baseline with her Parkinson's. In the ED, electrocardiogram showed normal sinus rhythm with prolonged QT interval 5-7 seconds (irregular heart rhythm where it takes longer than usual for the heart to recharge between beats). She was given two liters of normal saline bolus and calcium gluconate (medication used to manage hypocalcemia or low calcium levels in the blood, cardiac arrest, and cardiotoxicity due to hyperkalemia or hypermagnesemia) on 2/17/24. Resident #1's laboratory tests indicated her potassium level was 3.7 millimoles per liter (normal value 3.6 to 5.2) and her magnesium level was 1.8 milligrams per deciliter (normal value 1.7 to 2.2). She was referred for admission due to the prolonged nature of antihypertensives and being hypotensive on presentation. It was documented that the hypotension secondary to the medication mix-up could have been an interaction between the agonist of the Risperidone and the antagonist of the Carbidopa-Levodopa. Her blood pressure improved, and Resident #1 was admitted for observation and monitoring after receiving fluids at the ED. Resident #1 was discharged back to the facility on 2/19/14 at her baseline with no new orders. An interview with the Unit Manager (UM) on 4/9/24 at 2:36 PM revealed she remembered being notified by Nurse #1 that she had accidentally administered Resident #2's medications to Resident #1 on 2/17/24. The UM stated they obtained Resident #1's vital signs which showed an elevated heart rate. Resident #1 also complained to them that she didn't feel right. They notified the on-call physician and received an order to send her out to the hospital. They called 911 and notified the Administrator and the DON. From what Nurse #1 reported to her, both Resident #2 and Resident #1 were at the medication cart at the same time. Resident #2 was upset and demanded for his medications while Resident #1 asked Nurse #1 about her medications as well. The UM stated there was a lot going on at the medication cart and Nurse #1 got turned around and accidentally gave the wrong medications to Resident #1. A phone interview with the Medical Director (MD) on 4/9/24 at 4:04 PM revealed Resident #1 receiving Resident #2's medications was a significant medication error because the medications were not ordered for her, and she did not have indications for them. The MD stated that the hypotension was caused by the antihypertensives that she received. He also stated that he wouldn't be as concerned with the interactions with her Parkinson's medications as much as the hypotension brought on by the antihypertensives. He further stated that this medication error should have been avoided and it was something they did not want to happen again. A phone interview with the former Director of Nursing (DON) on 4/9/24 at 4:29 PM revealed she received a phone call from Nurse #1 on 2/17/24 notifying her about a medication error involving Resident #1. The DON stated Nurse #1 told her that both Resident #1 and Resident #2 were at the medication cart. Resident #2 was becoming aggressive and demanded his medications while Resident #1 also wanted her medications at the same time. While holding the medication cup with Resident #2's medications and walking Resident #1 back to her room, Nurse #1 inadvertently gave the cup of Resident #2's medications to Resident #1. The DON stated that she instructed Nurse #1 to get a set of vital signs on Resident #1 and call 911. The DON stated she immediately started education on the rights of medication administration and on how to handle distractions during medication pass. The DON stated Nurse #1 should have stopped her medication pass with all the distractions at her medication cart at that time. She stated that Nurse #1 unfortunately made the medication error due to her being distracted. An interview with the Administrator on 4/10/24 at 10:18 AM revealed she was notified about the medication error involving Resident #1, but she couldn't recall a lot of the details because the incident was handled by the former DON. The Administrator was notified of immediate jeopardy (IJ) on 4/17/24 at 12:57 PM. The facility provided the following immediate jeopardy removal plan. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: On 2/17/24, the facility failed to prevent a significant medication error when Nurse #1 administered medications to Resident #1 prescribed for Resident #2 during the morning medication pass which included Risperidone (antipsychotic medication), Furosemide (a medication used to treat fluid retention and swelling), Lisinopril (a medication used to treat high blood pressure), and Amlodipine (a medication used to treat high blood pressure). On 2/17/24, the Director of Nursing (DON) received a call from Nurse #1 regarding giving the wrong medications to Resident #1. On-call physician was immediately notified and instructed Nurse #1 to assess vitals and mental status for changes in condition and send to hospital if observed. During the monitoring, Resident #1's heart rate had increased therefore Emergency Medical Services (EMS) was called and Resident #1was transferred to the hospital for evaluation. Resident #1 was sent to the emergency department (ED) for an evaluation. She was referred for admission due to the prolonged nature of antihypertensives and being hypotensive on presentation. It was documented that the hypotension secondary to the medication mix-up could have been an interaction between the agonist of the Risperidone and the antagonist of the Carbidopa-Levodopa. Her blood pressure improved, and Resident #1 was admitted for observation and monitoring after receiving fluids at the ED. Resident #1 returned to the facility on 2/19/24 with no new orders. Nurse #1 completed a medication error report on 2/17/24 for Resident #1 as appropriate. On 2/17/24, the DON discussed details of incident with Nurse #1 and immediately provided reeducation on the seven rights of medication administration and on strategies to avoid and/or respond to distractions during medication administration to prevent medication errors. All residents are at risk for a medication administration error. On 2/17/24, the DON and facility licensed nurses immediately assessed all current facility residents for changes in vital signs and/or altered mental status and no additional concerns were identified. On 2/17/24, the Regional Director of Clinical Services (RDCS) completed an audit per the electronic medical record (EMR) of the 1) Medication Administration Audit Report for all current facility resident's medication administration records (MARs) for 2/17/24 first shift (7am-3pm) to ensure medications were administered as ordered without omissions or documented Code 9 (other/see nurses notes) which could indicate an issue such as a medication error or giving a resident the wrong medication. No additional medication errors were identified, including residents being administered the wrong medication. An audit of medication error incident reports from 1/1/2024 - 2/17/2024 were also audited on 2/17/24 by the RDCS per the EMR Risk Management report and no additional incidences of residents being administered the wrong medications were identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 2/19/24, the Regional Director of Clinical Services (RDCS) completed an audit of all current resident orders and of medications on the medication on the carts and medication rooms to ensure that medications are available for administration as ordered by the physician. No concerns identified. On 2/17/24, the DON notified the Administrator, Staff Development Coordinator (SDC), Regional Director of Clinical Services (RDCS), [NAME] President of Operations (VPO), [NAME] President of Clinical and Quality (VPCQ) and Medical Director Resident #1's medication error. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was conducted via telephone to discuss the root cause of facilities failure to prevent a significant medication error. Root cause determined that Nurse #1 failed to effectively redirect another resident during medication administration which led to not confirming the right medications were given to the right resident per the seven (7) rights of medication administration leading to a significant medication error for Resident #1. Immediate corrective actions were discussed and established to ensure no other residents were at risk. Immediate corrective actions to ensure no other current facility residents were at risk for medication errors included full-house assessments for changes in vital signs and/or altered mental status, review of MARs to ensure medications were administered as ordered for all current residents and education to facility and agency licensed nurses and medication aides on the seven rights of medication administration and on strategies to avoid and/or respond to distractions during medication administration to prevent medication errors during medication administration. On 2/18/24, the DON and Staff Development Coordinator (SDC) provided education in person and verbally via telephone to facility and agency licensed nurses and medication aides on the seven rights of medication administration and on strategies to avoid and/or respond to distractions during medication administration to prevent medication errors during medication administration. Facility and agency licensed nurses and medication aides who did not receive education on 2/18/24 will receive education prior to administering medications. The DON and/or SDC will be responsible for monitoring the daily nursing schedule, notifying, and providing education in person or verbally via telephone prior to next shift worked for facility and agency licensed nurses and medication aides who did not receive education on 2/18/24 and for tracking completion of education utilizing the electronic Master Education Log. Effective 2/18/24, the facility updated the facility and agency orientation packet and checklist to include education on the seven (7) rights of medication administration to prevent medication errors and on redirecting other residents during medication administration to reduce distractions and medication errors. The facility orientation packet will continue to include medication skills competency for licensed nurses and medication aides upon hire, annually and as needed. The DON and/or SDC will be responsible for monitoring the completion of agency and facility education for licensed nurses and medication aides and will utilize the electronic Master Education Log to track compliance. On 2/19/24, the Administrator met with the Interdisciplinary Team (IDT) including but not limited to, the DON, Unit Managers, Social Services Director and Medical Director to discuss the medication error and root cause analysis of the facilities failure to prevent a significant medication error and to discuss any recommended changes to the corrective plan implemented on 2/17/24. No recommended changes were made. Effective 2/19/24, the Administrator will be ultimately responsible for ensuring implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: 2/20/2024 On 4/10/24 the facility provided a corrective action plan with a completion date of 2/19/24 for the significant medication error that occurred on 2/17/24. This was reviewed and it was determined the corrective action plan did not meet all the criteria for past noncompliance specifically in the area of audits/monitoring. The corrective action plan did not include observations nurses and medication aides during medication pass to ensure residents were administered medications per the 7 rights of medication administration. On 4/10/24, the facility's credible allegation of immediate jeopardy removal was validated on-site by record review, observations, and interviews with nursing staff. A medication administration observation was conducted on 4/9/24. No concerns related to the medication errors were identified. The observation consisted of 26 medications, 3 different residents and 1 nurse and 2 medication aides. The nurse and the medication aides were observed implementing the rights of medication administration, and deferring distractions and interruptions until they completed the medication pass. The medication records of sampled residents were reviewed with a focus on medication errors. No concerns were identified. Interviews with nurses and medication aides revealed they were required to complete an in-service related to medication errors. They confirmed they were educated in person on the 7 rights of medication administration and how to handle distractions and interruptions until the medication pass is completed. A review of the in-service records revealed the DON completed the in person in-services with the nurses and medication aides. All nurses and medication aides who had not worked prior to 2/19/24 or were newly employed were in-serviced before they were allowed to work. The immediate jeopardy removal date of 2/20/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident, staff, Psychiatric Nurse Practitioner, Nurse Practitioner and Medical Doctor interviews, the facility failed to protect a resident-to-resident injury for 1 of 3 sampled residents reviewed for abuse (Resident #1). On 6/7/23, Resident #1 was punched in the face by Resident #2 causing multiple facial fractures and experiencing increased pain. After the incident Resident #1 was found curled up and crying, and stated he was afraid. Resident #1 was transported to the hospital for evaluation and was diagnosed with right zygomatic arch (bone that is on the outer part of the eye closest to the cheek), lateral (side) orbital wall (eye socket), and anterior (front) maxillary sinus (near the cheeks) fractures and returned to the facility on [DATE]. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included a disabling disease of the brain and spinal cord (central nervous system), cognitive communication deficit, Alzheimer's disease with late onset, dementia with other behavior disturbance. Review of Resident #1's behavioral care plan dated 04/28/23 revealed he had behaviors related to aggression in the past. Interventions included behavioral outbursts would be minimized and or managed through the next review. The resident or staff would not be injured through the next review. The staff should try to determine the reason for the exacerbation of the Resident #1's behavior if possible and to adjust their approach as appropriate. The staff would remove the resident from other residents as needed. The staff would set and enforce limits on Resident #1's behavior when appropriate. The staff would assist the resident to avoid situations that may cause anger or increased anxiety. The staff would notify the physician and implement orders as appropriate. The quarterly Minimum Data Set (MDS) dated [DATE] revealed the Resident #1 was severely cognitively impaired and had no behaviors during the assessment period. Resident #1 needed extensive assistance with bed mobility and transfers and total assistance with eating and toileting. A review of Resident #1's nursing note dated 6/7/2023 at 6:52 PM revealed the resident was sent out to the Emergency Department (ED) at 5:45 PM after being struck in the face by another resident. His nose was actively bleeding, and his right eye was puffy and beginning to bruise. Resident #1 returned from the ED at 3:56 AM. On report that was called to the facility from the hospital revealed the ED Doctor stated to follow up with Ear, Nose, and Throat (ENT). A Computed Tomography (CT) without contrast scan (an x-ray machine that takes several images of bones, blood vessels, and soft tissues that a computer makes into a digital image) completed at the hospital on 6/7/23 revealed Resident #1 had several facial fractures that did not require surgery for repair. Record review of Resident #1's hospital Discharge summary dated [DATE] revealed Resident #1 was transported to the hospital for evaluation after being hit in the face by his roommate. Resident #1 diagnosed with a right zygomatic arch, lateral orbital wall, and anterior maxillary sinus fractures and returned to the facility on [DATE]. Resident #1 was unable to be interviewed due to his cognition. An attempt was made to interview Resident #1 on 7/12/13 at 1:15 PM but he was unable to participate due to his severely impaired cognition. Resident #2 was admitted to the facility 3/26/22 with diagnosis that included other frontotemporal neurocognitive disorder (The result of damage to neurons in the frontal and temporal lobes of the brain), vascular dementia with other behavioral disturbances, unspecified mental disorder due to known physiological condition, and anxiety disorder. Review of the behavioral care plan dated 3/16/23 revealed Resident #2 had behaviors related to him being incarcerated which caused insecurities, hoarding, trust problems, as well as anger and aggression. The goals included Resident #2's behavioral outburst will be minimized and or managed through the next review. The resident or staff will not be injured through the next review. The interventions included staff trying to determine the reason for Resident #2's exacerbation of behavior if possible and adjust as appropriate. The staff will remove Resident #2 from other residents as needed. The staff will set and enforce limits on Resident #2' behavior when appropriate. The staff will assist Resident #2 to avoid situations that may cause anger or increase anxiety. The quarterly MDS dated [DATE] revealed Resident #2 was severely cognitively impaired and had no behaviors during the assessment period. He needed supervision only for bed mobility and transferring. He was coded as receiving an antidepressant 7 of 7 days during the assessment period, and he was ambulatory with the use of a cane. Resident #2 discharged from the facility on 06/07/23 and was unable to be interviewed. A review of Resident #2's change in condition form dated 6/7/23 revealed in part: Send to ED for evaluation. A review of Resident #2's hospital admission summary dated [DATE] revealed in part: Resident #2 was admitted with a history of major neurocognitive disorder followed by Neurology, who presented to the ED with a several week history of increased aggression. A Nurse Practitioner progress note dated 6/8/23 revealed in part Resident #1 was seen for an acute visit regarding a complaint of acute pain and noted in part, Resident #1 was reportedly attacked by his roommate yesterday (Resident #2) evening (06/07/23) resulting in multiple facial and nasal fractures. Resident #1 was evaluated in the emergency room (ER) and discharged back to the facility. He was started on Tylenol and Oxycodone (pain medication) with a referral to an Ear, Nose & Throat (ENT) Specialist for further evaluation and management of fractures. An interview on 7/11/23 at 1:51 PM with Nurse Aide (NA) #1 who was present and responsible for the room of Resident #1 and Resident #2 on 6/7/23 revealed when she walked in with the dinner tray, she saw Resident #1 lying in bed and Resident #2 was standing next to him between both beds. She noticed some blood from Resident #1's nose and reported this to Nurse #1 who went in to assess Resident #1. NA #1 stated she never saw the altercation between Resident #1 and Resident #2. NA #1 stated she had no concerns about behaviors from Resident #1. A phone interview on 7/12/23 at 10:10 AM with Nurse #1 who was Resident #1's Nurse on 6/7/23 revealed NA #1 told her she thought Resident #2 had hit Resident #1 because Resident #1 had a nosebleed. Nurse #1 assessed Resident #1 and he had a little bit of a nosebleed. She recalled another Nurse brought her an ice pack and a washcloth for Resident #1's face. The curtain between Resident #1 and Resident #2 was drawn, and Resident #2 started rambling like you know you deserved it. Nurse #1 had staff at the desk get the Unit Manger. Upon assessment, Nurse #1 stated there was no redness present upon her initial assessment of Resident #1. Resident #1 was whimpering and holding his face, but couldn't tell her what happened. The Unit Manager and the Social Worker took care of removing Resident #2 from the room and calling Adult Protective Services (APS), the Police and both Resident's Responsible Parties. Nurse #1 stated she had not worked with Resident #2 often but there were no concerns regarding aggression when she worked with him that day. Nurse #1 stated she had no concerns about Resident #1's behavior but, Resident #1 had attempted to get out of the bed even though he was unable to do so without assistance. An interview on 7/12/23 at 9:45 AM with the Unit Manager revealed on 06/07/23 he was in his office and staff came to him and stated they thought Resident #2 hit Resident #1 because his nose was bleeding. The Unit Manager went into the room and asked Resident #2 about the incident and saw Resident #1's face was swollen. Resident #2 told him he did hit Resident #1. Resident #1 was curled up and crying and stated he was afraid. The ambulance came to the facility and transported both Resident #1 and Resident #2 to the hospital, Resident #2 for a psychiatric assessment and Resident #1 for treatment. The Unit Manager stated Resident #2 was discharged from the hospital and admitted to a new facility with a locked dementia unit. There were no concerns about Resident #2 prior to this event and no indicators of different behavior that day. The Unit Manager revealed he had no concerns about Resident #1's behavior. An interview with the Director of Social Services on 7/12/23 at 12:12 PM revealed on 06/07/23 she came around to do her daily room checks and saw the nurses were assessing Resident #1 and he was in the bed moaning. She stated you could tell he was in pain. She and the Unit Manger took Resident #2 to the administrator's office and Resident #2 went willingly. The Social Worker was unaware of any concerns about Resident #2's behavior prior to this incident. She had no concerns about the behavior of Resident #1 and Resident #1 rarely spoke. An interview on 7/11/23 at 2:33 PM with the Administrator revealed prior to the incident on 06/07/23 she did not have any concerns that would have led her to believe Resident #2 would have acted out physically to another resident. She recalled Resident #2 was very protective of Resident #1 checking on him throughout the day. The Administrator explained Resident #2 would have verbal tiffs with other residents, but nothing that had ever resulted in injury and Resident #2 had no physical altercations or behaviors that would have led the staff to believe he would hurt someone else. Upon his discharge from the hospital, Resident #2 was moved to their sister facility where there were individual rooms and a locked dementia unit. She further stated she had no concerns regarding any behaviors from Resident #1. On 7/11/23 at 12:12 PM an interview with the Psychiatric Mental Health Nurse Practitioner revealed Resident #2 would not be competent enough to explain why the incident with Resident #1 happened. He recalled, when Resident #2 got agitated one time before and brushed someone with a cane, he stated to Psychiatry Staff that he did not hit anyone and was just moving them out of his way. He further stated Resident #2 was intentional with hitting Resident #1; however, Resident #2 was not mentally competent to recall his actions or the consequences of them. Resident #2 was usually calm, and the facility gave him a greeter job and he spent a lot of time with the Administrator. An interview on 7/12/23 at 2:36 PM with the Nurse Practitioner (NP) revealed she was informed about the incident on 06/07/23 between Resident #2 and Resident #1 and saw Resident #1 on 6/8/23. The NP stated in her medical opinion this incident had caused Resident #1 harm. She stated there were no indications that Resident #2 would be physically aggressive with anyone, this was the first incident she was aware of. The only behavior Resident #1 displayed was a lack of safety awareness. Resident #1 was bed bound and significantly cognitively impaired. An interview on 7/12/23 at 3:48 PM with the Medical Director (MD) revealed he was informed about the incident on 06/07/23 between Resident #1 and Resident #2 and saw Resident #1 after his return from the hospital on 6/8/23. The MD stated in his medical opinion the incident had caused harm to Resident #1. He stated he wasn't aware of any behavior and never would have expected Resident #2 to become physically violent with anyone prior to that day. The MD further stated he never saw Resident #1 agitated only laying in the bed or in the chair in the hall sleeping. He stated he never saw Resident #1 get up or really move or do anything. The Administrator was notified of the Immediate Jeopardy on 7/25/23 at 11:19 AM. The facility provided the following Corrective Action Plan with a completion date of 6/8/23. 1) On 6/7/23, Resident #2 was observed by a staff member standing over his roommate Resident #1 who was lying in bed on his left side, with both fists out. Staff immediately removed Resident #2 from roommate, Resident #1, and placed on 1:1 staff supervision. Nurse was alerted and completed resident assessment and first aid to roommate and notification to MD with orders to send Resident #2 to ER for psych evaluation related to danger to others. Administration notified and made appropriate calls to police, resident representatives, APS and 2-hour NC State report submitted, and investigation initiated to include staff and resident interviews. Resident #2 is a long-term care resident who was admitted to the facility on [DATE] with the primary diagnosis of frontotemporal neurocognitive disorder and secondary diagnosis of vascular dementia with behavioral disturbances and unspecified mental disorder due to known physiological condition. On 5/4/23 his BIM score was a 4 (severely impaired). He receives ongoing psych services and was last seen on 5/23/23 for a medication review in which no changes were made and remains on Aricept for dementia, Trazadone for agitation and Keppra for seizure disorder. Resident has a history of verbal and physical aggression towards others and care plan includes interventions; allowing resident to express concerns and provide follow-up to resolve issues, try to determine reason for exacerbation of behavior if possible and adjust as appropriate, remove residents from other residents as needed, set and enforce limits on behaviors when appropriate, assist resident to avoid situations that may cause anger or increased anxiety, administer medications as ordered, evaluate effectiveness of medications and side effects, do not argue with resident, give praise and/or positive feedback for attempts of socially acceptable/adaptive behaviors, notify physician and implement orders as appropriate, notify family as appropriate and psych services as appropriate. 2) Because all residents are at risk from being physically abused by other residents, the following plan has been formulated to address this issue: On 6/7/23 at 6:30 PM, Resident #2 was placed on 1:1 staff supervision and assessment completed by the licensed nurses with no apparent injuries until transferred to the ER at 7:15 PM for psych evaluation. On 6/7/23, the Administrator and Director of Nursing (DON) notified the [NAME] President (VP) of Clinical Services and VP of Operations to discuss incident, investigative protocol and corrective action to address incident and prevent any further incidence to other residents at risk. A follow-up call was held the following morning on 6/8/23 at 10:00AM to further discuss investigation, root cause analysis and corrective plan. On 6/8/23, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by facility Interdisciplinary Team (IDT) including the Medical Director, VP of Clinical & QAPI and VP of Operations to review the behavioral management policy to ensure the policy was followed and that it included appropriate strategies to identify and manage residents' with behaviors toward others. A review of the Abuse Policy and of the facilities previous F600 Abuse citations and corrective action plans were also reviewed for the 2/25/22 complaint survey and 6/1/22 recertification survey and it was determined that the facility followed the corrective plans and that the 6/7/23 incident would require additional action plans based on different root cause of a resident-to-resident abuse incident. The QAPI committee thoroughly discussed the incident on 6/7/23 and developed an immediate action plan based upon root cause analysis to address and remove immediate and future risk potential. Based upon root cause analysis the IDT determined that the Behavior Management Policy and Abuse Policy was followed and Resident #2's behavior was unpredictable and likely associated with his medical diagnosis of frontotemporal neurocognitive disorder, vascular dementia with behavioral disturbances and unspecified mental disorder due to known physiological condition and furthermore, unavoidable. Resident #2's care plan was also thoroughly reviewed and determined appropriate. 3) On 6/8/23, the Administrator and Director of Nursing were educated by the VP of Clinical & QAPI on the Behavior Management policy and prevention and response to residents with aggressive behaviors and emergency situations such as physical abuse of residents. Education included strategies for prevention of resident abuse and identifying the likelihood based upon resident assessments, any exhibited behaviors, triggering and alleviating factors. Beginning 6/8/23, current facility and agency staff on each shift, including Nursing, Activities, Social Work, Dietary, housekeeping and maintenance, were educated by the DON on F600 and the Prevention of Abuse or/and Neglect. The education will be communicated verbally and telephonically by the DON or SDC. Written education will be available for review prior to the staff member working their assigned shift. The Staff Development Coordinator (SDC) will utilize a master employee list to track 100% completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. Beginning 6/8/23, all current facility and agency staff will be educated by the DON on the facility behavioral management policy to include managing resident behaviors and prevention of resident-to-resident altercations. This will include identifying contributing factors such as situational, physical environment, and organizational factors. An emphasis will be placed upon ensuring supervision of residents to aid in preventing physical assault between residents. If the resident is displaying aggressive behaviors towards others, the resident will be monitored closely which will include 1 to 1 observation if the resident continues to have behaviors. If the resident continues to have aggressive behaviors towards others despite facility interventions, the facility will transfer the resident to the hospital for an immediate psychological evaluation to protect risk to others. The education will be communicated verbally and telephonically by the DON or SDC. Written education will be available for review prior to the staff member working their assigned shift. The SDC will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. On 6/8/23, the Director of Nursing completed an audit for F600 via abuse questionnaire with cognitively intact residents and the Licensed Nurses completed body audits on cognitively impaired residents to ensure other residents are free from abuse, including resident-to-resident. No additional concerns identified. On 6/8/23, the IDT reviewed current facility residents with aggressive behaviors or a risk for aggressive behaviors towards others to ensure appropriate care plans are in place and that they are not placed together as roommates. This review included residents with risks for poor impulse control and/or a history of aggression towards others and of residents involved in resident-to-resident altercations, all current residents with traumatic neurological disorders. All identified residents care plans were reviewed and determined appropriate. 4) Effective 6/8/23, the IDT will complete ongoing weekly risk meeting to discuss residents with aggressive behaviors to ensure the effectiveness of the residents' plan of care to prevent resident abuse. Effective 6/8/23, the facility Administrator, Director of Nursing, Social Worker or SDC will perform facility tours (including off shifts and weekends) 5 times weekly to observe any residents with behaviors and appropriate staff supervision and response to any behaviors. Additionally, the Administrator and Director of Nursing will monitor daily staffing levels to ensure adequate supervision to prevent resident abuse. Effective 6/8/23, the facility Administrator or DON will conduct questionnaires weekly with a minimum of 5 Licensed Staff and Nurse Aides to validate understanding of how to appropriately identify, prevent and respond to residents with physical behaviors. Effective 6/8/23, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this corrective plan. Date of Completion: 6/9/2023 The Corrective Action plan was validated on 07/12/23 and concluded the facility had implemented an acceptable corrective action plan on 06/09/23. Interviews with staff members over various shifts and positions revealed they were educated on abuse regarding what abuse looks like, who to call, and what interventions should be in place, such as separate the residents, don't leave them alone, and call for help. Review of the audits and monitoring tools revealed they were completed as outlined in the corrective action plan with no concerns identified.