**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, family member, Medical Director and Adult Protective Services (APS) Social Worker (SW) interviews, the facility failed to provide a safe and orderly discharge for 1 of 3 residents reviewed for discharge (Resident #88). Resident #88 was being treated in the facility with Chlordiazepoxide HCl (a medication used to treat the symptoms of alcohol withdrawal also known as Librium) for a known history of alcohol abuse and received a dose a short time before exiting the facility on 5/18/25 at approximately 10:51 AM. The Medical Director wrote orders for Resident #88 to be monitored every shift for symptoms of alcohol withdrawal syndrome, such as tremors, shaking, anxiety, nausea, vomiting, headaches, elevated heart rate, sweating, irritability, confusion, insomnia, nightmares and high blood pressure the same day the Chlordiazepoxide HCl was initiated. Consuming alcohol while taking Chlordiazepoxide HCL could cause nausea and/or vomiting. When Resident #88 returned to the facility on 5/18/25 he begged staff to let him back in but, he was not allowed to re-enter the facility. There were no documented assessments of Resident #88 when he returned to the facility. Unit Manager #1 offered Resident #88 his belongings and medications to include the remaining Chlordiazepoxide HCL and Metoprolol (a medication used to lower blood pressure), which he refused except for his cigarettes. Resident #88 also refused to sign the Against Medical Advice (AMA) document. Unit Manager #1 failed to notify Emergency Medical Services (EMS) or have Resident #88 transferred to a higher level of care for ongoing monitoring when notified he had exited the facility or when he returned. Unit Manager #1 called law enforcement at 12:08 PM because staff wanted Resident #88 banned from the facility. Resident #88 did not have a planned discharge location, and no ongoing monitoring arranged. He was seen at the local convenience store, homeless, by staff members on 5/19/25 and 5/20/25 and no staff members offered assistance to Resident #88. In addition, Resident #88 was an amputee, mobile in a wheelchair, had no other source of money or resources, and did not have supplies for urinary incontinence. Resident #88 was found intoxicated by the APS SW at the convenience store on 5/20/25 and was taken to the hospital for chest pain and palpitations as well as left lower extremity pain due to a fall from his wheelchair. Resident #88 remailed homeless and a second hospitalization occurred on 5/29/25 and Resident #88 received intravenous antibiotics in the emergency department (ED) for left leg cellulitis (a bacterial infection involving the inner layers of the skin) and was discharged on 5/30/25 with a prescription for oral antibiotics. The third hospitalization was on 6/4/25 and Resident #88 presented with complaints of worsening left lower leg pain with erythema (redness) and edema (swelling) times one week. He was admitted to the hospital and treated with intravenous antibiotics for cellulitis for a wound on his left leg and monitored for alcohol withdrawal. Resident #88 declined placement in a skilled nursing facility and discharged AMA on 6/16/25 stating he was going to the street. Immediate jeopardy began on 5/18/25 when Resident #88 was not permitted to return to the facility after a brief leave of absence. Immediate jeopardy was removed on 6/27/25 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 completion of education.Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses which included hypokalemia, protein-calorie malnutrition, anxiety, depression, alcohol dependence with unspecified alcohol-induced disorder, and absence of right leg below the knee. Resident #88 and discharged on 5/18/25. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was cognitively intact and was independent with Activities of Daily Living (ADLs) but needed supervision assistance with shower transfers. Resident #88 was not coded for any behaviors. The MDS further revealed he utilized a prosthetic limb for a below the knee amputation of his right leg and had occasional urinary incontinence. The MDS indicated he was not coded for any discharge planning to the community.A review of Resident #88's care plan last reviewed on 2/27/25 revealed he was non-compliant with the facility's rules on alcohol and management routinely confiscated alcohol from him. Interventions included not allowing Resident #88 to bring alcoholic beverages into the facility, encouraging peer bonds, and monitoring for symptoms of alcohol use. In addition, Resident #88's care plan indicated he had a history of alcohol and substance abuse, and staff reported the presence of alcohol intoxication and illegal substances at the facility. Interventions included educating Resident #88 on facility policies on consumption of alcohol, explaining the facility's responsibility for all resident's safety, and reporting any occurrences or suspicions to facility administration. Resident #88's care plan also indicated he wished to remain a long-term resident at the facility. Interventions included evaluating his motivation to return to the community, encouraging him to discuss feelings and concerns with impending discharge, and monitoring for and address episodes of anxiety, fear, distress. The care plan further revealed Resident #88 had occasional bladder incontinence due to impaired mobility. Interventions included cleaning peri-area with each incontinence episode, using disposable briefs per manufacturer's recommendation and have staff check and change during care rounds and as needed, and monitoring and documenting for signs and symptoms of a urinary tract infection.A review of Resident #88's Electronic Medical Record (EMR) was conducted. It revealed Resident #88 was given a 30-day discharge notice signed by the Administrator on 3/25/25. The reason for discharge was selected as your health has improved sufficiently so that you no longer need the services provided by the facility. The discharge location was to a lower level of care in an adult care home.An interview with the Social Worker (SW) on 6/19/25 at 2:45 PM revealed she originally gave Resident #88 a 30-day discharge notice to an adult care home on 3/25/25, but he did not qualify due to his payor source and so the discharge could not take place. The SW stated the Administrator spoke to Resident #88 and his family member regarding not coming back to the facility if he went out to drink alcohol. A review of a Social Work Progress note written by the SW on 4/10/25 indicated she had a conversation with Resident #88 about three programs for alcohol detoxification. Resident #88 refused to participate, and SW informed him that if he didn't go to a detoxification program, then he would be discharged to a homeless shelter.No further formal discharge planning was noted in Resident #88's EMR after 4/10/25. An interview with the SW occurred on 6/20/25 at 1:40 PM. She stated the facility did not pursue any discharge planning to a homeless shelter after the discharge notice to an adult care home failed. She stated Resident #88 did not want to go to a homeless shelter and he wanted to stay at the facility. The SW stated she told him that he could not stay at the facility and continue drinking alcohol. A review of a Psychiatric-Mental Health Nurse Practitioner (NP) progress note dated 4/8/25 revealed, in part, reports of Resident #88's alcohol confiscation in the past were noted. Despite this, Resident #88 denies any sleep disturbances and was on melatonin. During the visit, the Psychiatric-Mental Health NP expressed concern about the risk of withdrawal, but no tremors, diaphoresis, or agitation were observed during the visit. Recommended nursing staff to use the Clinical Institute Withdrawal Assessment for Alcohol (instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal) to assess for withdrawal symptoms every four to six hours and continue to monitor closely for any signs of alcohol withdrawal. Staff was educated on the risks of withdrawal and the importance of monitoring symptoms. Consider referral to supportive therapy if Resident #88 declined formal rehab.A review of a nursing progress note written by Nurse #3 on 4/26/25 revealed, in part, Resident #88 was observed seated in the smoking courtyard and drinking a beer. Resident #88 was approached and made aware of the facility alcohol policy and that his room and backpack needed to be searched and he began to get agitated, and said, leave me alone. Resident #88 wheeled himself to his room and upon searching, nine cans of beer were taken from his backpack, and five empty cans from his bedside drawer. Resident #88 also had a strong smell of alcohol on his breath.A review of a Licensed Clinical Social Worker's (LCSW) note dated 5/1/25 revealed Resident #88 was being seen for the first time to assess possible psychotherapeutic need due to disturbances of potential alcohol abuse and mental health concerns by staff. The LCSW's note read in part that Resident #88 was not a danger to himself or others and that he was self-medicating with alcohol. Resident #88 agreed to psychotherapy sessions and will focus most sessions on rapport building until Resident #88 felt more comfortable to communicate his needs in an effective manner. A review of a nursing progress note written by Nurse #3 on 5/5/2025 revealed Resident #88 returned from leave of absence (LOA) and a smell of alcohol was noticed. Resident #88 was made aware of the facility alcohol policy. His backpack was searched, and several cans of beer were taken away.A review of a nursing progress note written by Nurse #12 on 5/8/2025 revealed, in part, Resident #88 was able to make needs known to staff. Resident #88 was noted with a can of beer and the smell of alcohol on his breath. Resident #88 was educated on facility protocol on having alcohol in his personal possession and was educated on the need to confiscate his beverage. He became upset stating, I can have that. You can't tell me what to do. Resident #88 was encouraged to speak with management on protocol and showed signs of intoxication. The Director of Nursing (DON) was made aware.A review of a Medical Director progress note dated 5/14/25 revealed Resident #88 was seen for alcohol use. The note indicated he left the facility to consume alcohol, which was against the protocol of the facility and Resident #88 agreed on 5/14/25 to be treated within the facility for his alcohol withdrawal symptoms. An additional review of Resident #88's physician's orders included an order written on 5/14/25 revoking Resident #88's leave of absence (LOA) privileges due to poor safety awareness and risk of injury associated with ongoing behaviors due to alcohol dependency. A review of a social work progress note written on 5/14/25 by the SW revealed, in part, she spoke with Resident #88 and his family member regarding his alcohol use in the facility and when he left the facility. Resident #88 and his family member were made aware that this behavior would no longer be tolerated at the facility. He was informed that an order was written by the Medical Director that Resident #88 was no longer allowed to leave the facility due to excessive drinking and coming back intoxicated. The note further revealed that if Resident #88 left the facility it would be considered Against Medical Advice (AMA), and he would be discharged . Resident #88 and his family member understood. A review of Resident #88's physician's orders dated 5/14/25 revealed an order for chlordiazepoxide HCl to be given in a tapered dose over the course of five days. Day one (5/15/25) dose was two 25 milligram (mg) capsules to be given every six hours, day two dose (5/16/25) was two 25mg capsules every eight hours, day three dose (5/17/25) was two 25mg capsules every 12 hours, and day four and five dose on 5/18/25 and 5/19/25 was for two 25mg capsules one time a day for two days. A review of Resident #88's May Medication Administration Record (MAR) from 5/1/25 until 5/18/25 revealed Resident #88 received Chlordiazepoxide HCl on 5/15/25 two 25 milligram (mg) capsules every six hours, on 5/16/25 two 25mg capsules every eight hours, on 5/17/25 two 25mg capsules every 12 hours, and on 5/18/25 two 25mg capsules at 9:00 AM. A physician's order dated 5/14/25 to monitor resident every shift for signs and symptoms of alcohol withdrawal syndrome .tremors, shaking, anxiety, nausea, vomiting, headaches, elevated heart rate, sweating, irritability, confusion, insomnia, nightmares and high blood pressure. Notify MD if/when observed every shift for AWS (alcohol withdrawal symptoms). If aggression or violent behavior observed call 911.A review of Resident #88's May MAR from 5/15/25 to 5/17/25 revealed Resident #88's vital signs were documented every shift and were all within normal limits. A nursing progress note written by Unit Manager #1 on 5/18/25 revealed, in part, she was notified by the facility Receptionist that Resident #88 left the facility AMA, and he was observed leaving facility grounds and headed towards a main road. The note further revealed Resident #88 and his emergency contact (Family Member #1) were previously notified that his LOA was revoked due to unsafe health practices and poor safety awareness. Should resident leave facility grounds it would be against medical advice. It was a discharge from the facility against medical advice. Resident #88 repeatedly violated facility policies related to consuming alcohol on facility property and sneaking alcohol into his room and management repeatedly confiscated the alcohol. An interview with Unit Manager #1 on 6/19/25 at 1:48 PM revealed she was working on 5/18/25 when Resident #88 left the facility. She stated he and Family Member #1 understood after a meeting with administration 5/14/25 that he was not allowed to leave the facility due to his alcohol use. She stated she was alerted by the Receptionist on 5/18/25 that Resident #88 left the facility and she reminded him when he came back that he would be leaving AMA and not allowed to come back into the facility. Unit Manager #1 stated she called Resident #88's family member (Family Member #1) after she was notified Resident #88 left by the Receptionist to let her know he had left the facility, and he was not allowed back in. She asked Family Member #1 to come get his belongings. Unit Manager #1 stated she called APS and law enforcement when he returned but did not call an ambulance for evaluation. The Unit Manager #1 did not state if Resident #88 was assessed when he returned to the facility.A second interview with Unit Manager #1 on 6/20/25 at 12:35 PM revealed Resident #88 did not immediately come back after leaving the facility on 5/18/25. She stated she called his family member (Family Member #1) and asked if she could come gather his belongings. Unit Manager #1 stated Family Member #1 called Resident #88 and he returned to the facility. She stated Resident #88 had already violated the agreement, and she would not let Resident #88 back into the facility. She stated Resident #88 begged to come back and stated he did not have anything to drink while he was gone. Unit Manger #1 stated she called law enforcement when he returned to the facility, and they arrived and found Resident #88 sitting on the porch at the facility. She stated law enforcement let him know he was not allowed back on the property as it would be considered trespassing. Unit Manager #1 stated she was instructed on what to do if Resident #88 left on a weekend by the Administrator and the DON. Unit Manager #1 indicated she saw Resident #88 on 5/19/25 and 5/20/25 at the convenience store but did not stop and check on him and added multiple staff members also reported seeing him in the convenience store parking lot. Unit Manager #1 stated she did not call an ambulance when Resident #88 returned to the facility because he would have refused to get in an ambulance. A review of the facility's sign-in and out logbook at the receptionist desk revealed Resident #88 was signed out by the receptionist on 5/18/25 at 10:51 AM.An interview with the Receptionist on 7/3/25 at 11:17 AM revealed she was informed by Unit Manager #1 on 5/16/25 about the agreement the facility made with Resident #88 about not leaving the facility. The Receptionist stated Resident #88 was in the front lobby of the facility on 5/18/25 as another resident's family member was moving items out of the facility. She stated she reminded Resident #88 of the agreement he had with the facility, and he stated he wanted to go out to the store and not to put a hand on him. The Receptionist stated she told Resident #88 she would never do that to him and when the other resident's family member went out the front door, Resident #88 followed him out. She stated she immediately called Unit Manager #1 and signed Resident #88 out on the facility sign in and out logbook at 10:51 AM. The Receptionist stated she got in her car and followed him to the main road, and he was at the bus stop. The Receptionist indicated that while she was in her car she asked Resident #88 to come back to the facility. She stated Resident #88's phone rang a few minutes later and he started back to the facility. The Receptionist stated when she returned to the building, Unit Manager #1 asked where she found Resident #88. She stated Resident #88 made it to the bus stop across the street on the main road, not too far from the facility. The Receptionist stated she was unsure of the time she got back to the facility, but by the time she returned and used the restroom, Resident #88 was outside on the porch and Unit Manager #1 was speaking to him. She stated residents could sign out in a logbook at the nurse's desk, but she did not always know if they did sign out, so she signed the book at the receptionist desk to keep track of all the residents coming and going. She stated that is why she signed Resident #88 out on 5/18/25 and put removed in the return time slot as he did not come back inside the facility.An additional review of Resident #88's EMR revealed no documented vital signs or any assessment of Resident #88 by nursing staff before he exited the facility on 5/18/25 or after he returned to the facility on 5/18/25.A review of Resident #88's AMA form in the EMR dated 5/18/25 revealed no signature. The signature line where Resident #88 would have signed was filled in by Unit Manger #1 with the statement Resident refused to sign. The AMA form included the signatures of Unit Manager #1 and another nurse.A review of a police report dated 5/18/25 was reviewed and revealed law enforcement arrived at the facility at 12:36 PM for a disturbance with a suspect on scene and indicated Resident #88 was at the front door of the facility. In addition, the report revealed facility staff wanted Resident #88 banned from the property. An interview with the SW on 6/19/25 at 11:34 AM revealed Resident #88 would often go off campus and buy 12 to 24 cans of beer and drink them. She stated the facility staff started finding empty beer cans in his room as he drank alcohol on facility grounds and off campus. The SW stated she investigated detoxification programs for Resident #88 and initially he was willing to participate. She stated when a detoxification program came to evaluate him at the facility, he refused to participate in the program. She further explained the Administrator eventually told Resident #88 he was not allowed to leave the facility and if he did, he could not return. The SW explained on 5/18/25, Resident #88 followed a visitor out the front door and when he came back later, the weekend staff would not allow him to come back into the facility. The SW stated an APS SW was working with Resident #88 after his discharge from the facility for placement and resources. An interview with Resident #88's Family Member #1 occurred on 6/19/25 at 9:29 AM. She stated Resident #88 left the faciity on 5/18/25 and when he came back, the staff would not let Resident #88 back in the facility. The Family Member stated Resident #88 did not have access to his belongings, medicine, or anything. She explained that after Resident #88 was not allowed back into the facility, he became homeless and had been in and out of the hospital for several weeks. The Family Member explained that an APS Social Worker found Resident #88 on the streets and was working with him to locate a new facility. Additional interviews with Family Member #1 were attempted on 6/23/25 at 3:10 PM and 6/24/25 at 11:12 AM but were unsuccessful. A telephone interview with Resident #88 on 6/24/25 at 11:17 AM revealed he tried to get back into the building after leaving on 5/18/25. He stated the facility staff called law enforcement on him for trespassing while he was sitting on the porch in front of the facility. Resident #88 stated he did not sign anything agreeing to the medication they put him on or not leaving the facility and didn't recall agreeing to the treatment. He stated he hung out at the convenience store until the APS SW found him a few days later and did not recall going anywhere else after the discharge from the facility. Resident #88 stated, When they told me I couldn't leave it made me feel like I was in jail. Them not letting me back in made me mad. It was a f---ing G-- D--- joke that they left me out on the porch. I was only gone 30 minutes-not enough time to do anything. Resident #88 also stated Family Member #1 paid for him to have a phone, but he had no other source of money or resources. An interview with the Medical Director on 6/19/25 at 12:46 PM revealed that Resident #88 posed a threat to other residents and staff and was combative towards employees and other residents in the building. He stated Resident #88 was using alcohol in and out of the facility and it was decided he was no longer allowed to leave the facility on 5/14/25 during a meeting with Resident #88, Family Member #1 (over the phone), and the DON. The Medical Director stated he worked closely with a pharmacist to initiate a course of chlordiazepoxide HCl as it was not a medication used often in long term care. He stated this medication acted as a central nervous system depressant and helped with the symptoms of alcohol withdrawal. The Medical Director stated the medication required constant monitoring during the five-day course of medication. He stated Resident #88 was ultimately a threat to himself and would have had the expectation for the facility staff to call Emergency Management Services (EMS) and have him sent to the hospital for evaluation if he came back to the facility in an unsafe manner such as being intoxicated. The Medical Director stated the facility did not dump him out of the facility; they attempted to treat his alcohol detoxification as it was their medical responsibility. A second telephone interview with the Medical Director occurred on 6/24/25 at 11:43 AM. He explained that Chlordiazepoxide HCl blocked side effects of alcohol detoxification. He explained if someone undergoing Chlordiazepoxide HCl treatment started drinking, it would make them physically sick-throwing up and nauseated. The Medical Director explained the combination of drinking alcohol on Chlordiazepoxide HCl would not make a person confused, the alcohol itself could cause confusion. He stressed the importance of vital sign monitoring during Chlordiazepoxide HCl treatment and looking for any symptoms such as sweating, nervousness, or shaking. The Medical Director stated when Resident #88 was not allowed back into the facility, there would be no way monitoring could occur without hospitalization. A third telephone interview with the Medical Director occurred on 7/3/25 at 3:02 PM. He stated he educated Resident #88 in person with Family Member #1 over the phone on all side effects of Chlordiazepoxide HCl on 5/14/25. He discussed the possible side effects of Chlordiazepoxide HCl and the possible side effects of taking Chlordiazepoxide HCl and drinking alcohol. The Medical Director stated Resident #88 agreed to the treatment plan because of the severity of the situation and the consequences of bringing alcohol in the facility and endangering himself and others. An interview with the APS SW on 6/20/25 at 9:27 AM revealed she was assisting Resident #88 with ongoing services since his discharge from the facility on 5/18/25. She stated Resident #88 was currently homeless and had been hospitalized three times on 5/20/25, 5/29/25, and 6/4/25. The APS SW stated the facility called on 5/18/25 and filed a report. She stated she called the facility on 5/19/25 and 5/20/25 multiple times to ask staff additional questions about Resident #88's discharge from the facility with no response. She stated she drove to the facility on 5/20/25 to get clarification on Resident #88's appearance as the person she saw at the convenience store had a darker skin tone and it was reported to her that Resident #88 was Caucasian. The APS SW stated she met with the DON and the Administrator when she arrived at the facility, and they explained multiple staff members and the Administrator had seen Resident #88 at the convenience store when they were driving to work on 5/20/25. The APS SW stated Resident #88 was hanging out at the convenience store since his discharge on [DATE] until 5/20/25 when she found him intoxicated and dirty in the convenience store parking lot without any medications, supplies, or his belongings. She stated he was hospitalized for an abrasion on his leg and discharged the following day on 5/21/25. The APS SW explained that after his discharge from the second hospitalization on 5/30/25, she found him at another convenience store further up the road, still homeless and without resources. The APS SW stated Resident #88 did not have the money to pay for the antibiotic he was prescribed for cellulitis in his leg. The APS SW stated he was admitted to another hospital on 6/4/25 and was admitted for a significant wound infection in his leg. A review of the hospital records dated 5/20/25 revealed Resident #88 arrived at the emergency department (ED) via emergency medical services (EMS) complaining of chest pain and palpitations as well as left lower extremity pain. EMS stated he fell out of his wheelchair and sustained an abrasion to his left lower extremity. A fresh abrasion was noted to the anterior left shin. Resident #88 did undergo an extensive workup for his complaint of his leg pain and chest pain and no abnormalities warranting a hospital admission were noted. The record indicated Resident #88 was homeless with a history of alcohol dependence and chronic alcohol use disorder. Resident #88 had a below the knee amputation with a history of hypertension and chronic osteomyelitis. Additionally, the note revealed Resident #88 stated he was not in a shelter. The Physician documented Resident #88 was found to be mildly hyponatremic (low sodium) and hypokalemic (low potassium). It was noted the hyponatremia was likely secondary to beer ingestion and Resident #88 was given oral potassium as well as a multivitamin. The note further indicated Resident #88 reported he had been living in a nursing home for about one year and they kicked me out on Sunday. Patient was obviously intoxicated and slurring his words and was a very poor historian. In addition, Resident #88's hospital records revealed his blood ethanol level was 128mg/dl (an ethanol level of 50mg/dl or above was considered intoxicated). The Physician further documented because Resident #88 was homeless and intoxicated, he was not discharged on 5/20/25 but kept in the ED and allowed him to metabolize the alcohol and see clinical case management in the morning to get resources to a homeless shelter and a bus pass to facilitate transportation to the shelter. Resident #88 was discharged the following day on 5/21/25 with no prescriptions. A review of the hospital records dated 5/29/25 indicated Resident #88 presented to the ED with a chief complaint of left lower extremity swelling and reported redness and swelling to his left lower extremity for several days. Resident #88 denied a fever, chills, dyspnea, abdominal pain, nausea or vomiting. The ED Physician documented Resident #88 had a previous right lower extremity amputation and prosthesis. The ED Physician noted Resident #88 had a few abrasions to his left knee and lateral leg from where he fell from his wheelchair several days ago. Pitting edema of the left lower leg was observed as well as poor hygiene. Resident #88 stated he had been drinking beer today. Resident #88's blood ethanol level was not obtained. Resident #88 received intravenous antibiotics for left leg cellulitis and was discharged on 5/30/25 with an order for 500mg of Cephalexin (antibiotic), one capsule to be taken four times a day for seven days for cellulitis of left lower extremity. Review of ED provider notes dated 6/4/25 indicated Resident #88 presented complaining of worsening left lower leg pain with erythema (redness) and edema (swelling) times one week. Pulses were intact and range of motion was normal. Resident #88's blood ethanol level was 93mg/dl. Resident #88 was admitted to the hospital and treated with intravenous antibiotics for cellulitis for a wound on his left leg and monitored for alcohol withdrawal. The history and physical documented on 6/5/25 noted Resident #88 had a past medical history significant for essential hypertension, history of chronic alcohol dependence, ongoing alcohol and tobacco use, status post right BKA, homelessness, and mild protein calorie malnutrition. Resident #88 had been doing quite very well until about a week ago when he started noticing increasing redness and pain in the left leg area. The Physician documented Resident #88 denied having any injury, but he had some scabs which he tried to remove at which time he started having the redness. Resident #88 denied having any chest pain or shortness of breath or nausea or vomiting or abdominal pain. He has been having throbbing kind of pain in the left leg which he ranks as a 7-8/10 intensity. The doppler ultrasound of the legs did not show any evidence of deep vein thrombosis but significant erythema was observed. He was recently seen in the emergency room on 5/29/2025 at which time he was prescribed Keflex, but he has not been taking the medications. On 6/16/25 Resident #88 met with the hospital Case Manager and stated he no longer wanted to go to a long-term care facility and requested to be discharged . Resident #88 confirmed he planned to return to the street. The Case Manager was able to provide a medication voucher for a one-month supply and noted the APS SW was made aware of Resident #88's decision. Resident #88 discharged AMA from the hospital on 6/16/25 and was known to be homeless. An interview with the DON occurred on 6/20/25 at 10:35 AM and revealed Resident #88 had a history of drinking alcohol outside of the facility for quite some time but he started to bring the alcohol on campus. She stated staff found beer in the courtyard and in his room. The DON explained the facility tried to discharge him to an adult care home and tried to get him into an alcohol detoxification program, but he refused. She stated the Medical Director started him on medication to curb his withdrawal symptoms and his leave of absence privileges from the facility were revoked on 5/14/25. The DON stated she was not at the facility on 5/18/25 when Resident #88 left but stated Unit Manager #1 called and explained on 5/18/25 he signed out of the facility and left the campus even though he had physician's orders to stay at the facility. She stated he knew that if he left, it would be AMA. She stated Unit Manager #1 tried to give Resident #88 his belongings, but he only took his cigarettes and refused to sign the AMA form. The DON stated she could not recall if Resident #88 signed any document agreeing to the plan but knew he had been educated because she was part of the meeting. The DON stated she did not have the expectation that Unit Manager #1 should have called an ambulance on 5/18/25 because she knew Resident #88 would refuse treatment and he was not in any acute distress to her knowle

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and responsible party, staff, and Medical Director interviews, the facility failed to notify Resident #1's responsible party (RP) that Resident #1 had low blood sugar levels from insulin administration and the insulin was discontinued on 07/21/23. The insulin was prescribed for Person #2 (potential new admission from the same skilled nursing facility with same first and last name as Resident #1). Resident #1's RP stated if he had been notified in July about the administration of the insulin he would have asked to speak to the Administrator and the Medical Director and informed them Resident #1 did not have a diagnosis of diabetes. Had Resident's #1's RP been notified there was the high likelihood further significant medication errors would not have occurred until September. This deficient practice occurred for 1 of 2 residents reviewed for notification of change. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses according to his correct FL-2 form (state form that describes a patient's medical condition and the amount of care needed when placed in a facility) signed by the medical doctor at the discharging skilled nursing facility and dated 07/05/23 included progressive neurological condition, dementia with behavioral disturbance, non-Alzheimer's dementia, malnutrition, stage IV pressure ulcer and long-term drug therapy. Person #2's medication orders which were entered for Resident #1 on 07/17/23 included in part: 1. Aspirin oral tablet chewable 81 milligram (mg) tablet - give 1 tablet by mouth daily for hypertension. 2. Eliquis oral tablet 5 mg - give 1 tablet by mouth two times a day for aphasia. 3. Furosemide oral tablet 40 mg - give 1 tablet by mouth one time a day for hypertension. 4. Lantus (long-acting insulin) Subcutaneous Solution 100 units/millimeter (insulin Glargine) inject 55 units subcutaneously two times a day for diabetes mellitus. 5. Synthroid oral tablet 50 micrograms (mcg) (Levothyroxine Sodium) - give 1 tablet by mouth in the morning for thyroid. Resident #1's medication orders effective 09/16/23 included in part: 1. Brimonidine Tartrate Ophthalmic Solution 0.2% - instill 1 drop in both eyes three times a day. 2. Dorzolamide HCl Ophthalmic Solution 2% - instill 1 drop in left eye two times a day. 3. Flomax Oral Capsule 0.4 mg - give 1 capsule by mouth at bedtime for BPH. 4. Folic Acid Oral Tablet - give 1 tablet by mouth one time a day for malnutrition/weight loss. 5. Melatonin Oral Tablet - give 1 tablet by mouth at bedtime for insomnia. 6. Vitamin B-1 Tablet 100 mg - give 1 tablet by mouth one time a day for risk for malnutrition/weight loss. 7. Vitamin B-12 ER Oral Tablet Extended Release 1000 mcg - give 1 tablet by mouth one time a day for risk for malnutrition/weight loss. Resident #1's admission nursing assessment dated [DATE] revealed he was alert and oriented to person only and unable to verbalize needs but was listed as his own responsible party. Review of Resident #1's progress notes and Medication Administration Record revealed the following: On 07/19/23 an order was written by the Medical Director (MD) to check blood sugar levels before meals and at bedtime for hypoglycemia to begin at 6:00 PM on 07/19/23. On 07/19/23 at 11:02 AM Resident #1 had a blood sugar level of 65 and his insulin was held. The Nurse Practitioner was made aware. Resident was alert and had no signs or symptoms of distress noted. Resident #1 was given orange juice and a snack. At 11:30 AM Resident #1's blood sugar level went up to 104 documented by Nurse #2. On 07/20/23 at 5:55 AM Resident #1 had a blood sugar level of 64. He was given a 120 ml health shake to drink. There was no documentation that anyone was notified of the blood sugar level of 64 by Nurse #4 in the progress notes. Review of a lab report revealed on 07/20/23 at 6:53 AM a lab drawn blood glucose level revealed a blood sugar level of less than 40. There was no indication on the lab that the results had been reviewed by staff. There was no documentation in the nursing progress notes by Nurse #4 who was assigned to the resident that anyone was notified of the lab. Several attempts were made to contact Nurse #4 who frequently cared for Resident #1 on the 7:00 PM to 7:00 AM shift without success. On 07/20/23 at 9:00 AM according to the MAR Resident #1 had Lantus insulin held by Nurse #2 due to low blood sugar level at 5:55 AM of 64. His blood sugar level on 07/20/23 at 10:24 AM was 91. A telephone interview on 12/07/23 at 12:57 PM with Nurse #2 revealed he remembered Resident #1 and taking care of him and said he was usually the nurse on that hall on the 7:00 AM to 7:00 PM shift. He confirmed he had taken care of the resident on 07/20/23 based on his initials being documented on the MAR for that shift. He stated Resident #1 would not have been able to tell you he was not diabetic and should not have been on insulin. Nurse #2 stated he couldn't remember if Resident #1 had low blood sugar levels or not but said the parameters for notifying the physician were usually on the orders for low and high blood sugar levels. He further stated for a blood sugar level of less than 40 he would have called the provider for further orders but did not recall knowing Resident #1 had a blood sugar level of less than 40. Nurse #2 indicated he could not remember if he called Resident #1's responsible party (RP) to notify him of the low blood sugar levels on any of the days it was low but said if he had he would have documented it in the nursing progress notes and if there was not a note, he must not have contacted the RP. On 07/21/23 at 6:03 AM Nurse #4 documented Resident #1 had a blood sugar level of 71. There was no documentation in the nursing progress notes that the MD or NP was notified but a note was placed in the MD communication book and a voicemail was left for the responsible party (RP) for Resident #1. Several attempts were made to contact Nurse #4 who frequently cared for Resident #1 on the 7:00 PM to 7:00 AM shift without success. On 07/21/23 at 1:29 PM the Lantus insulin order was discontinued for Resident #1 by the Medical Director (MD) but the before meals and at bedtime blood sugars continued until 09/15/23. Review of Resident #1's nursing progress notes revealed no indication his responsible party (RP) had been notified of his low and critically low blood sugar levels on 07/20/23 at 5:44 AM which was 64, on 07/20/23 at 6:53 lab drawn blood sugar level which was less than 40 (critically low) or his low blood sugar level on 07/21/23 at 6:03 AM which was 71. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, non-verbal, and required extensive assistance of 1-2 staff members with all activities of daily living. An interview on 12/06/23 at 11:47 AM with the Social Worker revealed she and the Unit Manager had attempted to interview the resident for his care plan meeting on 07/19/23 and it became apparent to them during the meeting the resident was alert and oriented to person only and was unable to talk with them. She stated after the meeting she had called the SW at the discharging skilled nursing facility and obtained the responsible party name and telephone number and had updated the resident's medical record with the information obtained. The SW stated she notified the Admissions Coordinator #1 and the Business Office Manager of the updated information on Resident #1's responsible party that had been entered in the resident's electronic medical record. She further stated Admissions Coordinator #1 called the responsible party (RP) until she finally reached him on 07/24/23 and he came into the facility on [DATE] to sign Resident #1's admission paperwork. The SW explained sometime in September it was brought to her attention the facility had the wrong date of birth , diagnoses, and medication orders for Resident #1, so she called the discharging skilled nursing facility and obtained the correct information from the Social Worker at that facility and said the Marketing Director obtained hard copies of the correct information from the discharging skilled nursing facility. An interview on 12/06/23 at 3:14 PM with the Medical Director (MD) revealed she was familiar with Resident #1 and remembered that somewhere along the course of his stay they had discovered they had the incorrect demographic information on him which resulted in him not being on the correct medications or having the right diagnoses documented at the facility. She stated he was administered insulin, but it was discontinued on 7/21/23 when she realized his blood sugar levels were not consistent with needing insulin. The facility obtained Resident #1's correct demographics, diagnoses, and orders from the discharging skilled nursing facility on 09/15/23. The MD further stated she began calling Resident #1's responsible party on 09/16/23 but was unable to leave a message due to his mailbox being full but said she finally reached him by telephone on 09/19/23 to inform him of the mix-up with his diagnoses, orders, and medications initially received from the discharging skilled nursing facility. A telephone interview on 12/07/23 at 12:09 PM with Resident #1's RP revealed he had not been notified by anyone at the facility that Resident #1 had received the wrong medications for 2 months of his stay at the facility. He stated no one from the facility had called him on 07/21/23 and told him they had stopped giving Resident #1 insulin and said if they had he would have told them, he needed to meet with the facility director and the medical director because Resident #1 had never been a diabetic a day in his life. The RP further stated they had not notified him of the insulin or the low blood sugar levels when he had visited Resident #1 on 07/24/23 and signed his admission paperwork. The RP also stated he was not told about other medications Resident #1 had received and had not had diagnoses for receiving the medications. The RP was not aware the facility had the wrong date of birth for Resident #1 until Hospice had asked about his date of birth on 09/15/23 during a telephone conversation. He said he was not aware Resident #1 had received the wrong medications for 2 months and had only been told by the Medical Director that they were adjusting his medications. The RP indicated he assumed it was because Resident #1 had been placed on Hospice, they were adjusting medications. An interview on 12/07/23 at 11:34 AM with the Assistant Director of Nursing (ADON) revealed she had served as the Unit Manager for North for about 6 weeks from 06/20/23 through 07/31/23. The ADON indicated she did not remember Resident #1's low and critically low blood sugar levels but said their normal process would have been to notify the Medical Director (MD) or Nurse Practitioner (NP) about the low blood sugar levels, document the notification and contact the resident's guardian, responsible party or family and notify them of the low blood sugar levels and the holding of his insulin and document the notification. The ADON said if it was not documented in the nursing progress notes she would have to assume Resident #1's RP had not been notified of the low blood sugar levels and could not explain why he had not been notified. An interview on 12/06/23 at 5:00 PM with the Director of Nursing (DON) and the Nurse Consultant revealed the nurses would not have had the correct contact information for Resident #1's RP to notify him of the insulin being discontinued or that he had low blood sugar levels. They both explained Person #2's information listed him as his own responsible party with no telephone number. The DON nor the Nurse Consultant could answer why Resident #1's RP had not been notified of the insulin and low blood sugar levels after the facility had obtained the RP's name and telephone number from the discharging skilled nursing facility on 07/19/23 or why he was not informed when he had visited Resident #1 on 07/24/23 and signed his admission paperwork. A follow up interview on 12/07/23 at 4:45 PM with the Director of Nursing (DON), and Nurse Consultant with the Administrator present revealed the DON, Administrator nor Nurse Consultant knew why Resident #1's RP had not been notified of the low blood sugar levels or the insulin being discontinued on 07/21/23 when he had visited Resident #1 on 07/24/23 and signed his admission paperwork. The DON and Nurse Consultant stated the nurse assigned to the resident or the Unit Manager should have told the RP about the insulin and low blood sugar levels on 07/24/23 and it should have been documented. The DON stated the expectation with notification was for the resident (if they are their own responsible party), family, guardian, or Power of Attorney to be notified within 24 hours of any changes with a resident. The DON and Nurse Consultant further stated the RP had been notified on 09/19/23 by the Medical Director of the mix-up with his medications and said the MD stated the RP had no concerns regarding the information. They said there was a delay in notifying Resident #1's RP because the MD had tried to contact the son for several days and finally got to speak with him on 09/19/23. The Administrator was notified of immediate jeopardy on 12/07/23 at 5:15 PM. The facility provided the following corrective action plan with a completion date of 09/29/23: As a result of the deficient practice of not securing accurate patient information, Resident #1 received medications prescribed to Resident #2. Medications included 3 doses of Lantus (Long Acting) insulin. Resident #1 was not a diabetic and had not been prescribed insulin. Resident #1's responsible party was not notified that Resident #1 had three critical low blood sugar readings as a result of receiving insulin and the insulin being discontinued on 7/21/23. At the time of the occurrence Resident #1 was listed as his own responsible party based on information received from the discharging facility that belonged to Resident #2. At the time, the facility had not yet discovered Resident #1 had been receiving medications prescribed to Resident #2. After realizing Resident #1's cognitive impairment, and several attempts were made to the contact number listed on Resident #2's admission Record, the Director of Admissions reached back out to the discharging facility's Social Worker on 7/19/23. The discharging facility's Social Worker provided new contact information for Resident #1. The Director of Admissions made several attempts using the new number with no success. Contact was not made until the morning of 7/24/23 by the Admissions Director. The admission agreement was completed by the Director of Admissions in the afternoon on 7/24/23 with Resident #1's responsible party. Resident #1's responsible party was not informed of the low blood sugars or insulin being discontinued on 7/24/23. All residents residing in the facility have the potential to be affected by the deficient practice. On 9/28/23, the Admissions Director and Admissions Coordinator completed a review of current resident records to verify dates of birth and responsible party/emergency contact information was accurate. Any discrepancies identified were corrected. On 9/21/23, a Root Cause Analysis was completed by the Director of Nursing and Executive Director related to notification. It was determined Resident #1's responsible party was not notified of critical low blood sugars and insulin being discontinued as result of not having the correct information for Resident #1's responsible party. On 9/21/23, the Executive Director educated the Admissions Director and Admissions Coordinator on ensuring responsible party/emergency contact information for newly admitted residents is entered into the electronic medical record and is accurate. Prior to admission The Director of Admissions or Admissions Coordinator will validate contact information for residents, responsible parties and/or emergency contact through verbal authentication. The newly hired Admissions Director or Admissions Coordinator will be educated during the Orientation process by the Executive Director, going forward. The Executive Director has been notified of this responsibility. On 9/21/23, the Director of Nursing initiated education to licensed nurses related to change in condition/notification to include: Family/Responsible Party Notification Physician Notification Physician order (if indicated) Appropriate documentation If more than 3 attempts are made to notify the responsible party the nurses must notify the Director of Nursing/and or Unit Manager. Reviewed situations that would require notification to include: o an accident involving the resident which results in injury and has the potential for requiring physician intervention. o a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. o A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. After 9/21/23 nurses not educated will receive this education prior to working their next scheduled shift), regarding change in condition/notification to include notifying responsible party and notification to Director of Nursing when the contact information is not present/no longer accurate or responsible party is not able to be reached after 3 attempts. The Director of Nursing will be responsible for tracking nurses not educated on 9/21/23. In the event the facility must use contract nursing, the contracted nurse will be educated by the Director of Nursing prior to the start of their assignment. On 9/21/23, the Director of Nursing assigned a designee from the Nursing Administrative Team to ensure evening and weekend Licensed Nurses were educated prior to the start of their shift. Newly hired Licensed Nurses and will be educated during the Orientation process by the Director of Nursing, going forward. The Director of Nursing has been notified of this responsibility. Starting on 9/28/23 the Executive Director and/or designee to complete Quality Improvement monitoring for Notification of Changes to MD/NP/Responsible Party and to ensure newly residents have emergency contact/responsible party listed with correct telephone number to be completed weekly for twelve weeks to be completed by 12/21/23 and monthly for 3 months to be completed by 3/21/24. The Director of Nursing and Executive Director introduced the plan of correction to the Quality Assurance Performance Improvement Committee on 9/28/23. The Director of Nursing is responsible for implementing this plan. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, CNA, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. Compliance date: 09/29/23 The facility's corrective action plan was validated by the following: On 12/13/23 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to the admissions staff and business office staff on the admissions policy, verifying demographic information, and how to verify correct information by reviewing two forms of identification of residents, one including a photograph. Review of the monitoring audits revealed no concerns identified. Interviews conducted with the Business Office Manager and the Assistant Business Office Manager and Admissions staff revealed they had received education on the admissions policy and the importance of confirming each resident's correct information prior to the resident being admitted to the facility. Record review of sampled residents recently admitted revealed no concerns. In addition, the plan of correction was validated upon review of the sign-in sheets for in-service education provided to all licensed nurses on notification of change in condition policy, admissions policy, discharge policy, medication errors and change in condition notification and documentation of notification in the electronic medical record (EMR) on 09/21/23. Review of the monitoring audits revealed there were no concerns identified. Interviews conducted with the licensed nursing staff revealed they had received education on notification and documentation of the notification for any change condition or treatment for residents. Record review of sampled residents who recently had changes in condition or treatment revealed no concerns. The facility's compliance date of 9/29/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to implement their Admissions Policy and Procedure and verify the identity of a cognitively impaired resident when he was admitted to the facility with paperwork from the discharging skilled nursing facility for Person #2 (potential new admission with same first and last name as Resident #1). As a result, Resident #1, who did not have a diagnosis of diabetes, was administered 3 doses of long-acting insulin, and experienced 3 three low blood sugar levels before the insulin was discontinued. In addition, Resident #1 received an anticoagulant, aspirin, a diuretic, and a medication used to treat hypothyroidism from 07/17/23 until 09/15/23 prescribed for Person #2. This deficient practice occurred for 1 of 2 residents reviewed for medication errors and had a high likelihood of serious harm (Resident #1). The findings included: The Admissions Policy and Procedure for the facility dated 08/19/2018, under Procedure read in part: The Marketing Coordinator or Admissions Coordinator will: - Copy all insurance, Medicare, and Medicaid cards, and attach copies of all applicable payor verification, i.e.: Medicare eligibility verification, Medicaid eligibility, etc. When documents are obtained, copies MUST be scanned into the electronic medical record. There must be 3 attempts to obtain these copies documented on the admission checklist before this can be turned over to the Business Office Manager. - Complete all documents listed on Admissions Checklist including any State specific forms not listed. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses according to his correct FL-2 form (state form that describes a patient's medical condition and the amount of care needed when placed in a facility) signed by the medical doctor at the discharging skilled nursing facility and dated 07/05/23 included progressive neurological condition, dementia with behavioral disturbance, non-Alzheimer's dementia, malnutrition, stage IV pressure ulcer and long-term drug therapy. Resident #1's admission nursing assessment dated [DATE] revealed he was alert and oriented to person only and unable to verbalize needs but was listed as his own responsible party. This assessment was entered by Nurse #3. Several attempts were made to contact Nurse #3 who was the admitting nurse for Resident #1 without success. Person #2's medication orders which were entered for Resident #1 on 07/17/23 by Admissions Coordinator #1 included: 1. Aspirin oral tablet chewable 81 milligrams (mg) tablet - give 1 tablet by mouth daily for hypertension. 2. Eliquis oral tablet 5 mg - give 1 tablet by mouth two times a day for aphasia. 3. Furosemide (diuretic) oral tablet 40 mg - give 1 tablet by mouth one time a day for hypertension. 4. Lantus (long-acting insulin) subcutaneous solution 100 units/millimeter (insulin Glargine) inject 55 units subcutaneously two times a day for diabetes mellitus. There were no orders to check blood sugar included in these orders. 5. Synthroid oral tablet 50 micrograms (mcg) (Levothyroxine Sodium) - give 1 tablet by mouth in the morning for thyroid. Review of Resident #1's correct medication orders received from the discharging skilled nursing facility on 09/15/23 and verified by the Medical Director at the facility on 09/16/23 included the following: 1. Brimonidine Tartrate Ophthalmic Solution 0.2% - instill 1 drop in both eyes three times a day for glaucoma. 2. Dorzolamide HCl Ophthalmic Solution 2% - instill 1 drop in left eye two times a day for glaucoma. 3. Flomax Oral Capsule 0.4 mg - give 1 capsule by mouth at bedtime for BPH. 4. Folic Acid Oral Tablet 1 mg - give 1 tablet by mouth one time a day for malnutrition/weight loss. 5. Vitamin B-1 Tablet 100 mg - give 1 tablet by mouth one time a day for malnutrition/weight loss. 6. Vitamin B-12 ER Oral Tablet Extended Release 1000 micrograms (mcg) - give 1 tablet by mouth one time a day for risk for malnutrition/weight loss. An interview on 12/06/23 at 11:47 AM with the Social Worker revealed she and the Unit Manager had attempted to interview the resident for his care plan meeting on 07/19/23 and it became apparent to them during the meeting the resident was alert and oriented to person only and was unable to talk with them. She stated after the meeting she had called the SW at the discharging facility and obtained the responsible party name and telephone number and had updated the resident's medical record with the information obtained. The SW stated she notified the Admissions Coordinator #1 and the Business Office Manager of the updated information on Resident #1's responsible party that had been entered in the resident's medical record. She further stated the Admissions Coordinator #1 called the responsible party (RP) until she finally reached him on 07/24/23 and he came into the facility on [DATE] to sign Resident #1's admission paperwork. The SW explained sometime in September it was brought to her attention the facility had the wrong date of birth , diagnoses, and medications for Resident #1, so she called the discharging skilled nursing facility and obtained the correct information from the Social Worker at that facility and said the Marketing Director obtained hard copies of the correct information from the discharging skilled nursing facility. An interview on 12/06/23 at 11:55 AM with the Business Office Manager, revealed on 09/15/23 she received a telephone call from the Hospice Nurse who informed her the facility had the wrong date of birth for Resident #1 according to the responsible party (RP) who was a family member. The Hospice Nurse reported to the Business Office Manager the correct date of birth for Resident #1 and the Business Office Manager notified the facility Social Worker of the error with Resident #1's date of birth . The facility Social Worker reached out by telephone to the SW at the discharging skilled nursing facility and obtained the correct information and Resident #1's correct FL-2 (state form that describes a patient's medical condition and the amount of care needed when placed in a facility) and medication orders. An interview on 12/06/23 at 5:20 PM with the Marketing Coordinator revealed she received referrals and goes to hospitals and facilities to evaluate residents for possible transfer and admission to the facility. She stated she had received a telephone call from the discharging skilled nursing facility and went to the facility to evaluate Resident #1 (could not remember the exact date) for possible admission to the facility. She further stated she could not remember if she had interviewed Resident #1 but said she had seen him and looked over his paperwork provided and agreed to take him. The Marketing Coordinator said the Social Worker at the discharging skilled nursing facility had printed out information and given to her in an envelope on that day (could not remember what day) and she had no reason to believe it wasn't the correct information for Resident #1 that they were admitting to the facility. She indicated they had received the right resident that she had evaluated for admission but had received the wrong information packet with the wrong medication orders. According to the Marketing Coordinator, because the wrong information was received from the discharging skilled nursing facility when she had evaluated Resident #1, the wrong information had been uploaded by Admissions Coordinator #1 to his computer profile at the facility. The Marketing Coordinator said at the time she evaluated Resident #1 she was not aware there were two residents with the same first and last names at the discharging skilled nursing facility but later learned there were, and she had been given the wrong information for the resident. She said the typical packet consisted of an FL-2 form, face sheet, discharge summary and order summary, none of which had pictures of the resident on them. The Marketing Coordinator stated she couldn't remember if she reviewed the information prior to it being entered into the system but had no reason to believe it was not the correct information for Resident #1. The Marketing Coordinator indicated Admissions Coordinator #1 would have been responsible for verifying Resident #1's information through various computer portals. Once the documents were received by Admissions Coordinator #1, she entered the information into the resident's electronic medical profile. According to the Marketing Coordinator, since the issue with Resident #1 being admitted from another facility with the information, orders, and medication orders for Person #2 (who had the same first and last name as Resident #1), the facility had changed their process. The Marketing Coordinator stated they now make copies of insurance card, photo identification, Medicare card, and social security card and scan them into the electronic medical record. If the admitting resident was unable to complete the admission packet with the Admissions Coordinator, then the responsible party was contacted to complete the process. She stated when she was initially trained for her position, she was not trained to obtain copies of cards and relied on portals for the information but said now they obtain copies of the cards prior to the resident being admitted and prior to admission now resident's or their responsible party, guardian, or power of attorney must provide two forms of identification of which one must include a photograph of the resident. Admissions Coordinator #1 was not available for interview. Admissions Coordinator #2 was not employed by the facility at the time of the error. An interview on 12/07/23 at 4:45 PM with the Director of Nursing (DON), Administrator, and Nurse Consultant revealed they were aware Resident #1 had been administered medications for which he didn't have diagnoses but said they were following the orders provided by the discharging skilled nursing facility. They all said they were not aware of any issues with Resident #1 and his orders until they were notified by Hospice on 09/15/23 that the date of birth they had for the resident was not correct. The Nurse Consultant stated once they learned the date of birth was incorrect, they called the discharging skilled nursing facility and obtained the correct information and the correct medication orders and had the Medical Director review the information, and evaluate Resident #1. Labs were ordered and they initiated new orders for medications and treatments for the resident. The Nurse Consultant and DON stated the original resident profile (face sheet) created on admission for Resident #1 could not be reviewed because instead of creating a new profile for Resident #1 they had corrected the current profile for the resident and the old information had been erased as a result. The Nurse Consultant further stated they should have created a new profile for the resident instead of correcting the old profile so that both profiles would be visible but said that was not what the Admissions Coordinator #1 had done with Resident #1's information. An interview on 12/11/23 at 10:46 AM was conducted with Social Worker (SW) #2 from the discharging skilled nursing facility. The interview revealed the Marketing Coordinator from the admitting facility came and assessed both Resident #1 and Person #2 (who had the same first and last name) on 07/12/23 and was handed both residents discharge packets in two different envelopes with the face sheet, discharge summary, MAR, and FL-2 for each resident in the envelope. SW #2 further stated after the Marketing Coordinator left the facility Person #2 decided he didn't want to discharge so she let the Marketing Coordinator know on 07/14/23 that Resident #1 would be coming; however, Person #2 had decided to remain at their facility and not discharge. The interview further revealed at discharge on [DATE] Resident #1 was sent to the receiving facility with a second discharge packet which included his medications, face sheet, nursing progress notes, history and physical, order summary and dietary considerations. SW #2 stated after the discharge she was contacted by the Marketing Coordinator from the admitting facility stating they had mixed up the residents and needed Resident #1's records again. SW #2 stated the Marketing Coordinator came to the discharging skilled nursing facility and was handed the information in person. She stated the Marketing Coordinator acknowledged she had been given both Resident #1's and Person #2's packets when she completed the assessments at the discharging skilled nursing facility. The Administrator was notified of immediate jeopardy on 12/07/23 at 5:15 PM. The facility provided the following corrective action plan with a completion date of 09/29/23: The facility failed to ensure Resident #1 was free from a significant medication error when Resident #1 was administered medications prescribed for Person #2. Resident #1 received the following medications: Lantus Eliquis Synthroid Lasix Aspirin Prior to Resident #1's admission to our facility, the Director of Admissions conducted a bedside assessment. When leaving the discharging skilled nursing facility, the discharging facility's Social Worker provided physical copies of the Person #2's North Carolina Long Term Care Form (FL-2) with a date of birth of [DATE] and medication list for Resident #2. Resident #1 was also admitted to the facility with Person #2's date of birth (DOB: [DATE]), medical information, and medication orders on 7/17/23. Upon arrival on 7/17/23, Resident #1 was alert to person with confusion and memory impairment. The FL2 received provided no relative or contact information. Person #2's admission record from the discharging facility listed the resident as his own responsible party. On 7/19/23 a care conference meeting was held with Resident #1 led by the Social Services Director. During the care conference, Resident #1 was observed to have notable cognitive impairment, congruent with the signs and symptoms of possible dementia. Resident #1 was listed as his own responsible party. Resident #1 was unable to actively participate. After realizing Resident #1's cognitive impairment, and several attempts were made to the contact number listed on Resident #2's admission Record, the Director of Admissions reached back out to the discharging facility's Social Worker on 7/19/23. The discharging facility's Social Worker provided new contact information for Resident #1. The Director of Admissions made several attempts using the new number with no success. Contact was not made until the morning of 7/24/23 by the Admissions Director. The admission agreement was completed by the Director of Admissions in the afternoon on 7/24/23 with Resident #1's responsible party. On 9/15/23, during a phone conversation between the Resident #1 responsible party and our hospice partner, and while verifying information via telephone, it was discovered that the date of birth we were provided by the discharging facility did not match Resident #1. Upon further investigation, it was also discovered that the initial information received from the discharging facility was that of Person #2 who was also a resident of the discharging facility with the same name as Resident #1. On 9/15/23 the correct information, including medication orders for Resident #1 was obtained. Resident #1 was evaluated by the facility Medical Director. Upon review of Resident #1 medications and orders, all unnecessary medications were discontinued. On 9/15/23 the Director of Nursing completed a medication error report for Resident #1. The medication error report was completed for the medications received in error by Resident #1. Critical medications received in error were Insulin, Eliquis and Synthroid, Lasix and Aspirin. The insulin had previously been discontinued on 7/21/23, prior to this discovery due to low blood sugar levels. The Eliquis, Synthroid, Aspirin, and Lasix were discontinued on Friday, 9/15/23. Labs ordered were Thyroid Stimulating Hormone (TSH), Complete Metabolic Panel (CBP), Complete Blood Count (CBC) with differential. On 9/22/23 and 9/25/23 lab results (TSH, CBC with diff, and CMP) were reviewed by the Medical Director and determined there were no adverse reactions suffered, and Resident #1 was not at risk for any other adverse reactions because of this incident. Resident #1 was also seen and monitored throughout the weekend by the facility Nurse Practitioner. The facility's Medical Director made multiple attempts to reach Resident #1's responsible party by phone starting on 9/15/23 but was unable to leave a message due to full voice mailbox. The Medical Director spoke with the Resident #1's responsible party on 9/21/23 and advised him of the incident. Resident #1's responsible party understood and had no adverse response to the incident. To help ensure the deficient practice does not reoccur, a chart audit of all residents admitted since 5/17/2023 was conducted by Business Office Manager and Admissions Coordinator on 9/28/23 to ensure information filed in the residents' medical record was accurate and belonged to the residing resident. This audit included verifying the resident information on the demographic sheet, the resident's photograph, and financial information was accurate. Any discrepancies were corrected. On 9/21/23, a Root Cause Analysis was completed by the Director of Nursing and Executive Director. In conclusion, the facility failed to validate Resident #1 medical information upon admission on [DATE]. The Executive Director completed education on 9/21/23 with the facility's admissions team, which includes the Director of Admissions, admission Coordinator, Business Office Manager and Assistant Business Office Manager to ensure accurate documentation for admitting residents had been obtained prior to entering the facility. Accurate information would include demographic information, financial information, and a photograph. The admissions team was also reeducated to ensure required information, including but not limited to, clinical documentation, medication list, and FL-2s received from a discharging facility were accurate and belonged to the admitting resident. Authentication will be verified by the discharging facility's appointed representative. The facility Business Office Manager and Assistant Business Office Manager were also educated by the Executive Director on ensuring required information, which includes the residents' Social Security Number, date of birth , insurance card information and policy information belong to the admitting resident. The Director of Admissions and Admissions and/or Coordinator will validate the newly admitted residents' identity by verbal authentication. Authentication will require the newly admitted resident to verbally provide information, including, but not limited to their name, date of birth , and social security number. If the resident is unable to provide this information, the Director of Admissions and/or Admissions Coordinator will have the resident's guardian, power of attorney or appointed person verbally authenticate the newly admitted resident's identity. Authentication will require the newly admitted resident's guardian, power of attorney or appointed person to verbally provide information, including, but not limited to the resident's name, date of birth , and social security number. Prior to admission, newly admitted residents or their responsible party will be required to provide two forms of identification, of which one must include a photograph. Copy all insurance cards to include Medicare and Medicaid if available. When documents are obtained, copies must be scanned into the resident's electronic medical record. There must be 3 attempts to obtain these copies documented on the admission checklist before turning them over to the Business Office Manager. Newly hired Admissions or Business Office personnel will be educated on this process during new hire orientation. Starting on 9/28/23 the Executive Director and/or designee to complete Quality Improvement monitoring for admission Process to include two forms of identification, of which one must include a photograph, copy of insurance cards, and review admission packet to be completed weekly for twelve weeks and monthly for 3 months. Weekly monitoring will be completed by 12/21/23. Monthly monitoring will be completed by 3/21/24. The Director of Nursing and Executive Director introduced the plan of correction to the Quality Assurance Performance Improvement Committee on 9/28/23. The Executive Director is responsible for implementing this plan. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, CNA, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. Completion date: 09/29/2023. The facility's corrective action plan was validated by the following: On 12/13/23 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to the admissions staff and business office staff on the admissions policy, verifying demographic information, and how to verify correct information by reviewing two forms of identification of residents, one including a photograph. Review of the monitoring audits revealed no concerns identified. Interviews conducted with the Business Office Manager and the Assistant Business Office Manager and Admissions staff revealed they had received education on the admissions policy and the importance of confirming each resident's correct information prior to the resident being admitted to the facility. Record review of sampled residents recently admitted revealed no concerns. The facility's completion date of 9/29/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and family member, staff, Nurse Practitioner and Medical Director interviews, the facility failed to prevent significant medication errors when a. Resident #1 was administered medications prescribed for Person #2 (potential new admission with same first and last name as Resident #1). Person #2's information and medication orders were entered for Resident #1 in error on 7/17/23 and this was not discovered until 9/15/23. Resident #1 did not have a diagnosis of diabetes and was administered 3 doses of long-acting insulin and had three low blood sugar levels before the insulin was discontinued on 07/21/23. In addition, Resident #1 was administered an anticoagulant, aspirin, diuretic, and a medication used to treat hypothyroidism for which he had no diagnoses to treat. b. In addition, Resident #1 did not receive two eye drops prescribed for his diagnosis of glaucoma from 07/17/23 through 09/15/23. This deficient practice occurred for 1 of 2 residents reviewed for medication errors and had a high likelihood for serious harm. Example b. was cited at a lower scope and severity of D. The findings included: 1. a. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses according to his correct FL-2 form (state form that describes a patient's medical condition and the amount of care needed when placed in a facility) signed by the medical doctor at the discharging skilled nursing facility and dated 07/05/23 included progressive neurological condition, dementia with behavioral disturbance, non-Alzheimer's dementia, malnutrition, stage IV pressure ulcer and long-term drug therapy. Resident #1's admission nursing assessment dated [DATE] revealed he was alert and oriented to person only and unable to verbalize needs but was listed as his own responsible party. The resident's vital signs on admission were stable and there were no abnormalities noted by Nurse #3 for the resident. Several attempts were made to contact Nurse #3 who was the admitting nurse for Resident #1 without success. Person #2's medication orders which were entered for Resident #1 on 07/17/23 by the Admissions Coordinator #1 and included: 1. Aspirin oral tablet chewable 81 milligrams (mg) tablet - give 1 tablet by mouth daily for hypertension. 2. Eliquis oral tablet 5 mg - give 1 tablet by mouth two times a day for aphasia. 3. Furosemide (diuretic) oral tablet 40 mg - give 1 tablet by mouth one time a day for hypertension. 4. Lantus (long-acting insulin) subcutaneous solution 100 units/millimeter (insulin Glargine) inject 55 units subcutaneously two times a day for diabetes mellitus. There were no orders to check blood sugar included in these orders. 5. Synthroid oral tablet 50 micrograms (mcg) (Levothyroxine Sodium) - give 1 tablet by mouth in the morning for thyroid. Review of the Medication Administration Records (MAR) for Resident #1 revealed he received the following medications prescribed for Person #2 from 07/17/23 to 09/15/23. There was a picture of Resident #1 on the MAR: 1. Aspirin 58 doses 2. Eliquis 117 doses 3. Furosemide 58 doses 4. Lantus insulin 3 doses (discontinued on 07/21/23) 5. Synthroid 60 doses Review of Resident #1's corrected medication orders received from the discharging facility on 09/15/23 and verified by the Medical Director at the facility on 09/16/23 included the following: 1. Brimonodine Tartrate Ophthalmic Solution 0.2% - instill 1 drop in both eyes three times a day for glaucoma. 2. Dorzolamide HCl Ophthalmic Solution 2% - instill 1 drop in left eye two times a day for glaucoma. 3. Flomax Oral Capsule 0.4 mg - give 1 capsule by mouth at bedtime for BPH. 4. Folic Acid Oral Tablet 1 mg - give 1 tablet by mouth one time a day for malnutrition/weight loss. 5. Vitamin B-1 Tablet 100 mg - give 1 tablet by mouth one time a day for malnutrition/weight loss. 6. Vitamin B-12 ER Oral Tablet Extended Release 1000 micrograms (mcg) - give 1 tablet by mouth one time a day for risk for malnutrition/weight loss. Review of Resident #1's progress notes and Medication Administration Record revealed the following: On 07/18/23 at 9:00 AM Resident #1 received Lantus insulin 55 units subcutaneously administered by Nurse #1 as prescribed on the MAR. On 07/18/23 at 9:00 PM Resident #1 did not receive Lantus insulin as prescribed and it was documented as refused on the MAR. On 07/19/23 an order was written to check blood sugars before meals and at bedtime for hypoglycemia to begin at 6:00 PM according to the MAR On 07/19/23 at 9:00 PM Resident #1 received Lantus insulin 55 units subcutaneously administered by Nurse #2 on the MAR. On 07/20/23 at 5:55 AM Resident #1 had a blood sugar reading of 64. He was given orange juice and a snack documented by Nurse #4 in the nursing progress notes. On 07/20/23 at 6:53 AM a lab drawn blood glucose reading revealed a blood sugar reading of less than 40 according to the lab. On 07/20/23 at 9:00 AM Resident #1 had Lantus insulin held due to low blood sugar level at 5:55 AM of 64. The blood sugar was rechecked at 10:24 AM and it was 91 documented by Nurse #2. On 07/21/23 at 6:03 AM Resident #1 had a blood sugar reading of 71. He was given orange juice and a snack documented by Nurse #4. On 07/21/23 at 9:00 AM Resident #1 received Lantus insulin 55 units subcutaneously administered by Nurse #2 according to the MAR. On 07/21/23 at 1:29 PM the Lantus insulin order was discontinued for Resident #1 but the before meals and at bedtime blood sugars continued until they were discontinued on 09/15/23 according to the MAR. Several attempts were made to contact Nurse #4 by telephone without success. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, non-verbal, and required extensive assistance of 1-2 staff for all activities of daily living (ADL). A telephone interview on 12/07/23 at 11:39 AM with Nurse #1 revealed she remembered Resident #1 and vaguely remembered taking care of him but not any details. She stated he was non-verbal and would not have been able to verbalize to them he was not diabetic and not on insulin. She further stated he was only able to let them know if he was hungry, thirsty or in pain. She said if her initials were in the block on the Medication Administration Record with a check mark, she would have given the resident his insulin as prescribed and said she would have had no way of knowing the resident should not receive insulin or any of the medications he was ordered if it was in his physician orders, transcribed on the MAR and he matched the picture of the resident on the MAR. Nurse #1 stated she cared for the resident a few times but couldn't remember exactly what days before being reassigned to the other unit at the facility. She stated if the picture of the resident on the MAR matched the resident in the bed, they gave the medications as ordered by the physician. A telephone interview on 12/07/23 at 12:57 PM with Nurse #2 revealed he remembered Resident #1 and taking care of him and said he was usually the nurse on that hall. He stated Resident #1 would not have been able to tell you he was not diabetic and should not have been getting insulin. Nurse #2 stated he couldn't remember if Resident #1 had low blood sugar levels or not but said the parameters for notifying the physician were usually on the orders for low and high blood sugar levels. He further stated he had taken care of the resident a lot until he was moved to another room on another hall and said he always checked to be sure the resident matched the picture of the resident on the MAR before giving medications. A physician order was written on 09/13/23 to consult Hospice due to a decline in Resident #1's condition (advancement of dementia and intermittent refusal to eat and drink). An interview on 12/06/23 at 11:55 AM with the Business Office Manager, revealed on 09/15/23 she received a telephone call from the Hospice Nurse who informed her the facility had the wrong date of birth for Resident #1 according to the responsible party (RP) who was a family member. The Hospice Nurse reported to the Business Office Manager the correct date of birth for Resident #1 and the Business Office Manager notified the facility Social Worker of the error with Resident #1's date of birth . The facility Social Worker reached out by telephone to the SW at the discharging facility and obtained the correct information and Resident #1's correct FL-2 (state form that describes a patient's medical condition and the amount of care needed when placed in a facility) and medication orders. A review of Resident #1's progress notes revealed a note written on 09/15/23 at 9:28 PM by the Director of Nursing (DON) that read: Resident #1 admitted to the facility from another facility on 07/17/23. It was discovered today that the orders received at the time of admission were for another resident - Person #2 with the same name residing at the transferring facility. The Medical Director was made aware of the situation, order received and carried out to discontinue all medications until correct orders are received. Once correct orders were received, they were reviewed with and verified by the Medical Director. An interview on 12/06/23 at 3:14 PM with the Medical Director (MD) revealed she was familiar with Resident #1 and remembered that somewhere along the course of his stay they had discovered they had the incorrect demographic information on him which resulted in him not being on the correct medications or having the right diagnoses documented at the facility. She stated he was administered insulin, but it was stopped on 07/21/23 when she realized his blood sugars were not consistent with needing insulin, so it was discontinued but the resident had continued with blood sugars before meals and at bedtime. The MD further stated she couldn't recall all the medications he had been administered in error but said they were all discontinued on 09/15/23 when the facility had obtained his correct demographics, diagnoses, and orders from the discharging facility. She indicated Resident #1 was very frail and his underlying comorbidities had not been revealed on admission and they didn't have a true picture of his medical history until they had received updated and correct information on him on 09/15/23. The MD further indicated that while it was not beneficial that Resident #1 received the wrong medications for 2 months, they had not seen any adverse effects of the resident from the wrong medications being administered. She said she had ordered labs including a complete blood count (CBC), complete metabolic panel (CMP), and thyroid stimulating hormone (TSH) level and the labs were all within normal limits for the resident. An interview on 12/06/23 at 5:00 PM with the Director of Nursing (DON) and the Nurse Consultant revealed Resident #1 was discharged from another skilled nursing facility on 7/17/23 and they had received the demographic information, orders, and medication orders for Person #2. The DON stated it was not until Hospice notified them on 09/15/23 that they were aware there was a problem with Resident #1's date of birth . She further stated it wasn't until they reached the discharging facility on 09/15/23 that they discovered they also had incorrect diagnoses and medications for Resident #1. She explained their normal admitting procedure was for the admission Coordinator and the Business Office Manager or Assistant to verify insurance through the various computer portals. Once the information was verified the orders and medications were passed to the admitting nurse or Unit Manager and they verified the information for medications and orders was entered correctly once they received the orders. The DON further explained the nurses would have no way of knowing the information they received regarding diagnoses, orders, and medications was not correct for Resident #1 since he could not verify any information himself. She continued to explain that once his blood sugar levels appeared to remain low, the Medical Director (MD) discontinued the insulin so he only received 3 doses but said they had continued with blood sugar readings before meals and at bedtime since they thought he was diabetic. The DON stated once they discovered the error on 09/15/23 all orders for Resident #1 were discontinued and the Marketing Coordinator obtained the correct information for Resident #1. He was seen by the MD and new orders were written for the right medications to be given. She further stated Resident #1 was evaluated by the MD once the new information was obtained and said the MD indicated there were no adverse effects from him receiving the wrong medications. The DON explained the nurses verified the picture of the resident on the MAR with the resident in the bed to be sure they are giving the right medications to the right resident. An interview on 12/07/23 at 11:26 AM with the Unit Manager for North which included 100, 200 and 300 halls revealed she had only been employed as the Unit Manager for 90 days. She stated she recalled hearing about Resident #1 and the mix-up with his medications but didn't know any of the details about the situation. She stated typically the Nurses verified the resident's name prior to giving medications but was not aware of them asking residents their date of birth before giving medications. The Unit Manager further stated there was really no way the Nurses would have known they were giving the wrong medications to Resident #1 because he was unable to verbalize and tell them he was not on those medications. She indicated to her knowledge he had not come in with a picture identification and so the Nurses were carrying out the orders prescribed by the Medical Director (MD) and had no way of knowing the medications were incorrect. The Unit Manager further indicated with residents with the same name there should be 2 identifiers such as name and date of birth with a picture to ensure the right resident was receiving the right medications. According to the Unit Manager all residents' pictures are taken upon admission to use as an identifier for the Nurses and staff at the facility. An interview on 12/07/23 at 11:34 AM with the Assistant Director of Nursing (ADON) revealed she had served as the Unit Manager for North for about 6 weeks from 06/20/23 through 07/31/23. She stated she remembered Resident #1 and the mix-up with his medications. The ADON further stated she remembered Resident #1 was alert but not oriented and was non-verbal. She said his dementia was advanced and he would not have been able to tell the Nurses he was not supposed to receive insulin, or any of the medications he was prescribed that should not have been prescribed for him. The ADON indicated he would not have been capable of validating his date of birth and could only respond to his name being called but was not reliable to answer questions about diagnoses or medications. A follow up telephone interview on 12/07/23 at 3:00 PM with the Marketing Coordinator revealed she had gone to the transferring facility on 09/15/23 and obtained information for Resident #1 which included his medications, face sheet, nursing progress notes, history and physical, order summary and dietary considerations as well as his FL-2. The Marketing Coordinator stated she handed the information to the Admissions Coordinator #1 who entered the information in the electronic medical record for Resident #1 because that was their process at the time. b. Resident #1 did not receive 2 eye drops to treat his glaucoma from 7/17/23 through 9/15/23. The eye drops were prescribed as follows: 1. Brimonidine Tartrate Ophthalmic Solution 0.2% - instill 1 drop in both eyes three times a day for glaucoma. 2. Dorzolamide HCl Ophthalmic Solution 2% - instill 1 drop in left eye two times a day for glaucoma. An interview on 12/06/23 at 3:14 PM with the Medical Director (MD) revealed she was familiar with Resident #1 and remembered that somewhere along the course of his stay they had discovered they had the incorrect demographic information on him which resulted in him not being on the correct medications or having the right diagnoses documented at the facility. She stated that while he should have received other medications for which he had diagnoses; she had not seen any adverse effects from his not receiving those medications particularly the eye drops for his glaucoma. The Administrator, DON, Nurse Consultant and Regional [NAME] President of Operations were notified of immediate jeopardy on 12/07/23 at 5:15 PM. The facility provided the following corrective action plan with a completion date of 09/29/23. The facility failed to ensure Resident #1 was free from a significant medication error when Resident #1 was administered medications prescribed for Person #2. Resident #1 received the following medications: Lantus Eliquis Synthroid Lasix Aspirin Prior to Resident #1's admission to our facility, the Director of Admissions conducted a bedside assessment. When leaving the discharging skilled nursing facility, the discharging facility's Social Worker provided physical copies of the Person #2's North Carolina Long Term Care Form (FL-2) with a date of birth of [DATE] and medication list for Person #2. Resident #1 was also admitted to the facility with Person #2's date of birth (DOB: [DATE]), medical information, and medication orders on 7/17/23. Upon arrival on 7/17/23, Resident #1 was alert to person with confusion and memory impairment. The FL2 received provided no relative or contact information. Person #2's admission record from the discharging facility listed the resident as his own responsible party. On 7/19/23 a care conference meeting was held with Resident #1 led by the Social Services Director. During the care conference, Resident #1 was observed to have notable cognitive impairment, congruent with the signs and symptoms of possible dementia. Resident #1 was listed as his own responsible party. Resident #1 was unable to actively participate. After realizing Resident #1's cognitive impairment, and several attempts were made to the contact number listed on Person #2's admission Record, the Director of Admissions reached back out to the discharging facility's Social Worker on 7/19/23. The discharging facility's Social Worker provided new contact information for Resident #1. The Director of Admissions made several attempts using the new number with no success. Contact was not made until the morning of 7/24/23 by the Admissions Director. The admission agreement was completed by the Director of Admissions in the afternoon on 7/24/23 with Resident #1's responsible party. On 9/15/23, during a phone conversation between the Resident #1 responsible party and our hospice partner, and while verifying information via telephone, it was discovered that the date of birth we were provided by the discharging facility did not match Resident #1. Upon further investigation, it was also discovered that the initial information received from the discharging facility was that of Person #2 who was also a resident of the discharging facility with the same name as Resident #1. On 9/15/23 the correct information, including medication orders for Resident #1 was obtained. Resident #1 was evaluated by the facility Medical Director. Upon review of Resident #1 medications and orders, all unnecessary medications were discontinued. On 9/15/23 the Director of Nursing completed a medication error report for Resident #1. The medication error report was completed for the medications received in error by Resident #1. Critical medications received in error were Insulin, Eliquis and Synthroid, Lasix and Aspirin. The insulin had previously been discontinued on 7/21/23, prior to this discovery due to low blood sugar levels. The Eliquis, Synthroid, Aspirin, and Lasix were discontinued on Friday, 9/15/23. Labs ordered were Thyroid Stimulating Hormone (TSH), Complete Metabolic Panel (CBP), Complete Blood Count (CBC) with differential. On 9/22/23 and 9/25/23 lab results (TSH, CBC with diff, and CMP) were reviewed by the Medical Director and determined there were no adverse reactions suffered, and Resident #1 was not at risk for any other adverse reactions because of this incident. Resident #1 was also seen and monitored throughout the weekend by the facility Nurse Practitioner. The facility's Medical Director made multiple attempts to reach Resident #1's responsible party by phone starting on 9/15/23 but was unable to leave a message due to full voice mailbox. The Medical Director spoke with the Resident #1's responsible party on 9/21/23 and advised him of the incident. Resident #1's responsible party understood and had no adverse response to the incident. To help ensure the deficient practice does not reoccur, a chart audit of all residents admitted since 5/17/2023 was conducted by Business Office Manager and Admissions Coordinator on 9/28/23 to ensure information filed in the residents' medical record was accurate and belonged to the residing resident. This audit included verifying the resident information on the demographic sheet, the resident's photograph, and financial information was accurate. Any discrepancies were corrected. On 9/21/23, a Root Cause Analysis was completed by the Director of Nursing and Executive Director. In conclusion, the facility failed to validate Resident #1 medical information upon admission on [DATE]. The Executive Director completed education on 9/21/23 with the facility's admissions team, which includes the Director of Admissions, admission Coordinator, Business Office Manager and Assistant Business Office Manager to ensure accurate documentation for admitting residents had been obtained prior to entering the facility. Accurate information would include demographic information, financial information, and a photograph. The admissions team was also reeducated to ensure required information, including but not limited to, clinical documentation, medication list, and FL-2s received from a discharging facility were accurate and belonged to the admitting resident. Authentication will be verified by the discharging facility's appointed representative. The facility Business Office Manager and Assistant Business Office Manager were also educated by the Executive Director on ensuring required information, which includes the residents' Social Security Number, date of birth , insurance card information and policy information belong to the admitting resident. The Director of Admissions and Admissions and/or Coordinator will validate the newly admitted residents' identity by verbal authentication. Authentication will require the newly admitted resident to verbally provide information, including, but not limited to their name, date of birth , and social security number. If the resident is unable to provide this information, the Director of Admissions and/or Admissions Coordinator will have the resident's guardian, power of attorney or appointed person verbally authenticate the newly admitted resident's identity. Authentication will require the newly admitted resident's guardian, power of attorney or appointed person to verbally provide information, including, but not limited to the resident's name, date of birth , and social security number. Prior to admission, newly admitted residents or their responsible party will be required to provide two forms of identification, of which one must include a photograph. Copy all insurance cards to include Medicare and Medicaid if available. When documents are obtained, copies must be scanned into the resident's electronic medical record. There must be 3 attempts to obtain these copies documented on the admission checklist before turning them over to the Business Office Manager. Newly hired Admissions or Business Office personnel will be educated on this process during new hire orientation. Starting on 9/28/23 the Executive Director and/or designee to complete Quality Improvement monitoring for admission Process to include two forms of identification, of which one must include a photograph, copy of insurance cards, and review admission packet to be completed weekly for twelve weeks and monthly for 3 months. Weekly monitoring will be completed by 12/21/23. Monthly monitoring will be completed by 3/21/24. The Director of Nursing and Executive Director introduced the plan of correction to the Quality Assurance Performance Improvement Committee on 9/28/23. The Executive Director is responsible for implementing this plan. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Executive Director, Director of Nursing, Assistant Director of Nursing, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, CNA, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. The Quality Assurance Performance Improvement Committee meets monthly and quarterly at a minimum. Completion date: 09/29/2023 The facility's corrective action plan was validated by the following: On 12/13/23 the facility's plan of correction was validated upon review of the sign-in sheets for in-service education provided to the admissions staff and business office staff on the admissions policy, verifying demographic information, and how to verify correct information by reviewing two forms of identification of residents, one including a photograph. Review of the monitoring audits revealed no concerns identified. Interviews conducted with the Business Office Manager and the Assistant Business Office Manager and Admissions staff revealed they had received education on the admissions policy and the importance of confirming each resident's correct information prior to the resident being admitted to the facility. Record review of sampled residents recently admitted revealed no concerns. The facility's completion date of 9/29/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Consultant Pharmacist, Nurse Practitioner, and Medical Director interviews the facility failed to monitor the use of Levemir with finger stick blood glucose levels as ordered by the physician for 1 of 3 residents reviewed for unnecessary medications (Resident #7). Levemir is a long-acting insulin injected under the skin. On 05/14/23 Resident #7's family identified a change in the Resident's condition and requested Nurse #2 check the resident's finger stick blood glucose level. Resident #7's finger stick blood glucose level reading was HI. The HI blood glucose reading indicated severe hyperglycemia (much higher than normal blood glucose levels). Resident #7 was transferred to the Emergency Department (ED) and admitted into the intensive care unit (ICU) diagnosed with diabetic ketoacidosis (DKA) a serious complication of diabetes that can be life threatening requiring an insulin intravenous (IV) drip. Immediate jeopardy began on 05/10/23 when Resident #7 was admitted to the facility and her discharge instructions were not implemented and her finger stick glucose checks were not obtained as ordered. Immediate jeopardy was removed on 05/25/23 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Review of the Manufacturer's instructions (revised 04/2021) for the Blood Glucose monitoring system used to check Resident #7's blood glucose on 05/14/23 read in part: the meter displays results between 20-600 milligrams/deciliter (mg/dl). HI appears when the blood glucose level is greater than 600 mg/dl and indicates severe hyperglycemia (much higher than normal glucose levels). Review of a discharge summary from the local ED dated 05/10/23 read in part, active problems: type one diabetes mellitus with hyperglycemia (high glucose level). Sugars are very labile (up/down), decrease Levemir to 10 units twice daily. Further review of the discharge summary revealed new medication (orders to be implemented upon discharge) read in part, Levemir 10 units under the skin two times a day. Test blood glucose level six times daily. Resident #7 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, end stage renal disease with hemodialysis, and adult failure to thrive. Review of Resident #7's physician orders dated 05/10/23 revealed the following: Levemir 10 units subcutaneously (under the skin) two times a day for diabetes. Further review of the physician orders revealed no order for blood glucose monitoring six times a day as stated in the discharge summary. The physician orders were entered by Nurse #1. Review of the Medication Administration Record (MAR) dated May 2023 revealed Resident #7 received Levemir insulin twice daily on 05/11/23 and 05/13/23. She received the Levemir insulin one time a day on 05/12/23 and 05/14/23 (day of discharge). Review of the MAR further revealed no glucose checks were scheduled to be completed. Further review of Resident 7's medical record revealed a blood glucose level obtained on 05/12/23 by Medication Aide #2 and the result was 102. Review of a history and physical dated 05/13/23 by Medical Director (MD) #2 read in part, past medical history included type one diabetes and end stage renal disease. The history and physical stated that MD #2 had reviewed the discharge summary. The plan was to monitor glucose checks and continue Levemir. Review of a Nurse's note dated 05/14/23 at 3:16 PM read in part, family at Resident's bedside all shift. Writer checked Resident's blood sugar per family request. Blood sugar elevated. Writer let family know that she would notify on-call Medical Doctor and family stated she would just have Resident sent to the ED for evaluation. Writer notified the Director of Nursing (DON). The note was electronically signed by Nurse #2. Resident #7 was transferred to the local ER on [DATE]. Review of Resident #7's hospital admission history and physical dated 05/14/23 read in part; assessment and plan: Diabetic Ketoacidosis initial glucose greater than 800 mg/dl. Received small fluid bolus however limited by congestive heart failure and end stage renal disease. Started on insulin drip. Awaiting available bed in the intensive care unit. Resident #7's insulin drip continued through 05/18/23. The history and physical further stated that Resident #7 would require a hospital stay with anticipated date of discharge of 05/18/23. Resident #7 remained hospitalized at time that the survey began on 05/23/23. Nurse #2 was interviewed via phone on 05/23/23 at 1:30 PM. Nurse #2 confirmed that she was caring for Resident #7 on 05/14/23. She stated she recalled the day; she stated that Resident #7's family had been at bedside all shift as it was Mother's Day. The family stated that Resident #7 was not acting like herself and questioned what her blood glucose level was. Nurse #2 stated that she checked Resident #7's physician orders and realized that there was no order to check blood glucose levels but stated she went ahead and checked the blood sugar as requested by the family and it was HI. Nurse #2 stated she told the family she was going to go and call the on-call provider and make them aware. She reported that Resident #7 had only been at the facility for a few days and she had not noted any change in her presentation verses her previous encounter with her. She added that she remained at her baseline condition throughout the shift and was alert and verbal. Nurse #2 stated before she could call the physician, Resident #7's family stated they would call Emergency Medical Services (EMS). Nurse #2 stated she called the DON and made her aware of what had occurred and was instructed to copy the appropriate paperwork and document in the medical record which she had done. She stated that EMS arrived at the facility and transported Resident #7 to the ED. Nurse #2 stated that it never dawned on her to question her blood glucose level when giving her insulin earlier in the shift. She assumed that Resident's #7's blood glucose level had been checked on third shift because they never gave insulin without checking a resident's finger stick blood glucose level. Nurse #1 was interviewed via phone on 05/24/23 at 10:40 AM. Nurse #1 confirmed that she was working on 05/10/23. She stated typically admissions were completed by the nurse on the hall but depending on staffing and what was going on in the facility she assisted with admissions as needed. Nurse #1 stated the discharge summary would be obtained from the hospital and then reviewed either in person or via phone with the Nurse Practitioner (NP) or MD. Once the orders had been approved by the medical provider the orders would be entered into the electronic health record. Nurse #1 stated that she vaguely recalled admitting Resident #7. She stated that if Resident #7's discharge summary indicated that her blood glucose levels were to be checked six times a day then she would have entered that order into the electronic health record. She stated that if she did not enter the order it had to be an honest mistake because I always check glucose level with residents who receive insulin An attempt to speak to MA #2 was made on 05/24/23 at 10:43 AM and was unsuccessful. The Wound Nurse was interviewed on 05/24/23 at 12:30 PM. He stated he could not recall If he gave Resident #7's insulin or not but if he did, he would have documented it in the medical record. The Wound Nurse stated he would not give insulin without knowing what the blood sugar was. He added that if the Medication Aide (MA) had reported that the Resident had no glucose checks ordered he would have questioned that and called the provider to get clarification. The Consultant Pharmacist was interviewed via phone on 05/24/23 at 12:53 PM and confirmed that she remotely reviewed Resident #7's Discharge summary dated [DATE] and she had no recommendations based off of her review. She stated that she did not catch that Resident #7 had no ordered glucose checks on her review. She added that when she read the discharge summary, she mistook the glucose checks as a supply order and not as an actual order to check Resident #7's glucose six times a day. The Consultant Pharmacist stated she would have definitely requested glucose checks for Resident #7 on her next review, but stated she wished there would have been some glucose checks obtained on Resident #7 during her stay in the facility. She added that there was a one glucose check completed on 05/12/23 that was 102 mg/dl. The Nurse Practitioner (NP) was interviewed via phone on 05/23/23 at 3:43 PM. The NP stated she reviewed new admissions before she left for the day and then in the morning if the admission came after she had left for the day. She stated that she approved the discharge summary orders and made any changes that were required. The NP stated she recalled verbally approving Resident #7's discharge summary from Nurse #1 and stated that she had not made any changes. She stated that if the discharge summary stated to check glucose levels six times a day that is what should have been entered and completed because she had not made any changes. MD #2 was interviewed via phone on 05/23/23 at 5:09 PM. MD #2 confirmed that he had evaluated Resident #7 on 05/13/23. He stated that he reviewed the discharge summary and assumed the staff were following the instructions that were entailed in the discharge summary. MD #2 stated that it was a problem that the staff were administering Levemir twice a day and not checking her sugars. He stated that glucose checks six times a day was a bit much and he would have possibly at some point reduced the glucose checks to four times a day. MD #2 stated I assume that if we had checked her sugars, we could have prevented her diabetic ketoacidosis and hospitalization. The DON was interviewed on 05/23/23 at 4:12 PM who stated that when a new admission arrived at the facility or even before sometimes, the facility would obtain the discharge summary and have the orders approved by the NP or MD. Then those orders would be entered into the electronic medical record for completion by the staff. She stated the day following the admission, during the clinical meeting they would review the new admission and ensure that the orders were entered correctly as stated on the discharge summary. She could not recall specifically if they had reviewed Resident #7's admission or not. The DON stated that if Resident #7's discharge summary indicated that her glucose levels should be checked six times a day then she would expect to see that in her medical record. The DON confirmed that there was no physician order entered for glucose levels to be obtained for Resident #7. A follow up interview was conducted with the DON on 05/24/23 at 11:07 AM. The DON stated after reviewing her notes from 05/11/23 (day after Resident #7 admission on [DATE]) she recalled that Resident #7's admission was not reviewed in the clinical morning meeting because the administrative staff were busy with other duties. MD #1 was interviewed via phone on 05/23/23 at 3:00 PM who stated that he had been visiting the facility for a couple of months. He explained that MD #2 was covering for him during the week that Resident #7 was admitted , and he had completed the admission history and physical as required. MD #1 stated that the facility took their initial orders from the discharge summary and those orders would be approved by one of the providers at the facility and any necessary changes made accordingly. He stated that if Resident #7's discharge summary indicated that she required glucose checks six times a day the facility should have implemented that upon admission. MD #1 stated that six times a day was a lot, and he would have eventually tried to decrease that to four times a day. For complex residents like Resident #7, MD #1 stated he would have continued glucose checks four times a day and added some sliding scale insulin to help control her glucose level. MD #1 explained that residents that received hemodialysis that were also diabetics had glucose levels that were very labile, meaning they go up and go down and they required a very sensitive scale of insulin and glucose checks to ensure their glucose levels were stable thus preventing diabetic ketoacidosis and/or hospitalization. The Administrator was notified of the immediate jeopardy (IJ) on 05/24/23 at 11:50 AM. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The facility failed to monitor Resident #7's glucose level as ordered upon admission to the facility while administering Levemir insulin twice a day as ordered. On 05/14/23 a family member asked the staff to check Resident #7's sugar and it measured HI (unable to record number). The family member called Emergency Medical Services and had Resident #7 transferred to the local Emergency Room. Resident #7 was started on intravenous insulin drip and admitted to the intensive care unit where she currently remains (05/23/23). On 5/23/23, current diabetic residents' physician orders were reviewed by the Director of Nursing and Unit Manager to ensure blood glucose monitoring orders were in place. A total of 29 residents were reviewed, physician orders were obtained for residents identified without a routine order for blood glucose monitoring. On 5/24/23 the Regional Director of Clinical Services reviewed admissions and readmissions since 5/10/23 to ensure physician orders were transcribed accurately from Discharge Summary into Electronic Medical Record. No corrections needed. 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 5/23/23, the Director of Nursing and Regional Director of Clinical Services initiated education to the Licensed Nurses, Medication Aides, and Unit Managers regarding blood glucose monitoring for diabetics, admission process, notification of a change of condition, and admission Checklist. Admissions Checklist (Admissions/Readmissions orders must be verified by a second nurse at the time of admission.) The admission Checklist assists/guides the nurses through the admission process. The nurses will utilize the admission checklist to ensure they complete all the necessary assessments and steps to include reviewing discharge summary and comparing it to orders in electronic medical record. Admission/readmission orders must first be verified by MD/NP. After entering orders into the Electronic Medical Record, all orders must be verified by a second nurse. Both nurses must sign the admission Checklist indicating that the orders have been verified. Each shift will be responsible for carrying out the tasks that have not been completed by previous shift until all tasks are completed. Blood Glucose Monitoring for diabetics- Diabetic residents must have routine blood sugar checks ordered. If controlled by oral hypoglycemic medication, checks should be performed at least weekly per physician order. If receiving insulin, checks should be performed as ordered or at least daily. Notification in change of condition- Monitor residents for changes in condition. Complete change in condition assessment (SBAR) and notify the MD/NP and RP. On 5/23/23 the Regional Director of Clinical Services reeducated the Interdisciplinary Team regarding Clinical Morning Meeting to include the Director of Nursing, Unit Manager, Wound Nurse, MDS, and Executive Director. Daily Clinical Morning Worksheet (Admissions/Readmissions will be reviewed during clinical morning meeting.) The Interdisciplinary Team will review New Admissions/Readmissions during clinical morning meeting to ensure completion and accuracy of orders. The team will compare discharge summary to orders in the electronic medical record. The Director of Nursing and/or Unit Manager will review on the weekends. After 5/23/23, Licensed Nurses and Medication Aides not educated will receive this education prior to working their next scheduled shift by the Director of Nursing or Unit Manager. Education is being provided in person and via telephone by the Director of Nursing or Unit Manager. The Director of Nursing is tracking who has received education. Newly Hired Licensed Nurses and Medication Aides will be educated during the Orientation process by the Director of Nursing, going forward. The Director of Nursing has been notified of this responsibility as of 5/24/23. On 5/24/2023 Ad hoc QAPI with Root cause analysis was conducted and Nurse suspended pending investigation. Date of IJ Removal: 05/25/23 The credible allegation of IJ removal for glucose monitoring was conducted on 05/24/23 and 05/25/23. The admission checklist was verified for the addition of the second nurse verification of orders. Staff interviews were conducted and revealed that they received education regarding glucose monitoring of residents, the signs, and symptoms of change in condition in relation to blood sugar changes and reporting those changes to the medical provider. Administration staff were able to verbalize the procedure for verifying physician orders and the need to have two nurses verify the orders. They were also able to verbalize the procedure for daily clinical meetings and the need for an afternoon clinical meeting if the administration staff were unable to attend the morning clinical meeting to ensure all new and readmissions were reviewed for accuracy and completeness. Staff interviews revealed they were aware that all residents who received insulin or oral diabetic agents for the treatment of diabetes mellitus required some frequency of glucose checks. They should implement orders dictated in the discharge summary or reach out to the provider for orders if there was any questions or concerns. The IJ removal date of 05/25/23 was validated.