**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, resident, and Physician interviews, the facility failed to notify the physician that the scheduled medication gabapentin, a medication ordered for nerve pain that is not to be stopped abruptly, was not administered. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24 and had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms and the physician was not notified of this. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The physician was not notified that Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, the facility failed to notify the physician that 14 doses of the antibiotic Amoxicillin 875 mg was administered to Resident #39 instead of the antibiotic Augmentin (Amoxicillin-Clavulanate 875 mg-125 mg) that was ordered by the physician on discharge from the hospital. This deficient practice affected 3 of 10 residents reviewed for notification. Immediate Jeopardy began for Resident #51 on 5/9/24 when the resident reported a pain scale of 10, had not been receiving gabapentin, and the physician was not notified, and on 5/12/24 for Resident #46 when the resident had increased pain, difficulty sleeping, had not been receiving gabapentin, and the physician was notified. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Example #3 was cited at scope and severity D. Findings included: 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. The May 2024 Medication Administration Record (MAR) indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. This MAR and the medication administration notes revealed Resident #51's gabapentin was not administered on 5/8/24 at 5:00 PM and 9:00 PM and on 5/9/24, 5/10/24, 5/11/24, 5/12/24 and 5/13/24 at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. A pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse #9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse #9 stated Resident #51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse #9 indicated Resident #51 refused her shower on 5/9/24 which was not normal for her, reporting she was in too much pain. Nurse #9 stated she was not aware that she should have notified the physician of Resident #51's increased pain and the ordered medication gabapentin that was not administered. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 indicated she did not notify the physician that Resident #51 had not received the scheduled gabapentin. Nurse #8 stated she did not realize that she should have notified the physician that the medication was not available and not administered as ordered. Nurse #8 stated she did not report Resident #51's increased pain to the physician. A nursing progress note by Nurse #13 on 5/10/24 at 3:24 AM stated Resident #51 reported her legs were numb. The note stated the nurse informed Resident #51 there were no interventions for that and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room. Attempts were made to interview Nurse #13 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not notify the physician that the medication gabapentin was not available and not administered and had increased pain. Unit Manager #1 was unable to explain why she did not notify the physician that the ordered medication gabapentin was not administered to Resident #51. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room. Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated due to acute pain and received gabapentin. The discharge instructions were to take prescription medications as ordered including gabapentin 800 mg 4 times per day and to not stop taking prescription medication for pain suddenly. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM and was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider of the resident's change in condition and requested to be sent to the hospital. Resident #51 was sent to the hospital per her request. Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. Nurse #14 worked at the facility through an agency. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room. Resident #51 returned to the facility having received Gabapentin at the emergency room. Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. An ED Summary dated 5/13/24 indicated Resident #51 was evaluated due to acute pain. Resident #51 received gabapentin in the emergency room and the emergency room physician sent a new prescription for gabapentin to the pharmacy. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51 and why the physician was not notified. The DON stated she expected the nurses to notify the physician when medications were not available for administration. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be available and administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identify that a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated she was in the position at the facility since 6/7/24. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered and if the ordered medication was not obtained the physician should be notified. Attempts were made via phone to interview the previous physician with messages left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. Resident #46's May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR revealed on 5/10/24 at 9:00 PM, and on 5/11/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24 and 5/17/24 at 9:00 AM and 9:00 PM, the nursing staff documented the gabapentin was not administered. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin the medication was not administered due to it being unavailable. Nurse #3 stated she did not notify the physician that she had not administered the prescribed medication gabapentin and was unaware that she should have done this. An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that worked at the facility for several months. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart and she did not notify the physician that the gabapentin was not administered. Nurse #6 stated she was not aware that she was supposed to notify the physician. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse #17 indicated she was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #17 stated she did not notify the physician that she did not administer the scheduled gabapentin on 5/13/24, 5/14/24 and 5/15/24. Nurse #17 did not have an explanation why she did not notify the physician. An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 was unable to explain why she had not notified the physician of Resident #46's medication gabapentin not administered and resident's increased pain. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident had increased pain and she did not notify the physician. An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM. Nurse #5 stated she did not notify the physician the medication was unavailable or of the missed doses. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and she did not notify the physician. Attempted to interview Nurse #11, nurse assigned to Resident #46 on 5/16/24 7:00 PM to 7:00 AM. Messages were left on 6/11/24 and 6/12/24 with no return call received. An interview was conducted with Resident #46 on 6/13/24 at 9:30 AM. Resident #46 stated she had gone without gabapentin for days at a time on several occasions. Resident #46 reported staff stated the medication was coming from the pharmacy and then it didn't come in. Resident indicated she was familiar with her medications and gabapentin was prescribed for nerve pain. Resident #46 stated she had increased pain, trouble sleeping, was anxious, irritable, nauseous and unable to get up out of bed or complete her usual routine during the time when she did not receive her gabapentin. Resident #46 stated it was horrible and the staff told her she would just have to wait it out until the medication came in. Resident #46 stated she was not aware if the physician was notified of her medication not being administered as ordered. An in-person interview with the Director of Nursing (DON) on 6/12/24 at 4:15 PM revealed the nurses on the medication cart were expected to notify the physician when a medication was not available and administered as ordered. The DON stated she started at the facility at the end of March 2024. The DON stated she was not aware the physician was not notified. The DON expected the nurses to notify the physician of changes in condition including uncontrolled pain, medications not administered, and residents transferred to the hospital for evaluation. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected the physician to be notified when medications were not available and administered as ordered. The Administrator stated nursing staff did not understand what to do when they identified a medication was not available for administration and this included notification of the physician for further orders. An interview was conducted by phone with the Physician on 6/18/24 at 1:20 PM. The Physician stated she had been in the position since 6/7/24. The Physician indicated the dose of gabapentin ordered, 800 mg twice per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the risk of withdrawal and increased pain. Withdrawal symptoms can occur within 12 hours and can be severe. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered. She stated it was the responsibility of the facility to notify the physician when a scheduled medication was not available. Attempts were made via phone to interview the previous physician with messages left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received. The Administrator was notified of Immediate Jeopardy on 6/13/24 at 2:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to notify the provider when two residents (Resident #51 and Resident #46) were not administered their ordered gabapentin for multiple doses. Resident #51 was not administered her routine order for gabapentin 800 mg 4 times a day from 05/08/2024 - 05/13/2024. A licensed nurse stated she did not notify the physician when the medication was not available. The nurse stated that if medication was not available for a few days, then she would call the pharmacy. The facility Unit Manager #1 was aware of the gabapentin not being available but did not recall what happened or what she did about obtaining the medication. The documentation in the electronic health record (EHR) showed no evidence that the physician was notified. On 05/09/2024 Resident #51 refused a shower due to too much pain. On 05/10/2024 Resident #51 complained of her legs feeling numb. On 05/12/2024 Resident #51 complained of pain and spasming in which Resident #51 requested to go to the emergency room (ER). Resident #51 returned from the ER where the resident was treated for acute pain and received gabapentin at the hospital. In the evening on 05/12/2024 Resident #51 complained of agitation and anxiety due to not receiving gabapentin and requested to go to the ER. Resident #51 received gabapentin in the ER. The physician in the ER sent a new prescription for gabapentin to the pharmacy. Resident #46 was not administered her routine order for gabapentin 800 mg 2 times a day from 05/10/2024 - 05/17/2024. Unit Manager #2 stated there had been delays in receiving refills of gabapentin and resident had been without the ordered gabapentin. She stated she did not notify the physician. Resident #46 had a pain level of 8 or 9 constantly during the time the facility failed to obtain and administer the medication. Resident #46 complained of not receiving pain medication which caused her more pain and made it hard to sleep. Resident #46 complained of irritability, being anxious, and nausea. Resident #46 had not felt well and had not been able to get out of bed to participate in activities and perform a daily routine due to pain in her legs. Residents with missed medications, changes in conditions, and residents who have had a documented risk management report are at a greater risk of the physician not being notified. Therefore, effective 06/13/2024, the Administrator, Director of Nursing, and Unit Managers (UMs) completed an audit for the past 90 days of all residents in the facility who had missed medications, changes in conditions, and/or a documented risk management report to ensure the physician had been notified. On 06/15/2024 it was determined by this audit that the physician had not been notified of every missed medication, change in condition, and documented risk management report. The concerns were identified and reported to the physician to ensure the notification of change. A documented risk management report is a report that a nurse completes to document resident incidents such as medication errors, falls, skin tears, pressure ulcers, etc. Any resident incident that occurs in the facility is documented in the electronic health record. It includes general details of the incident, a description of the incident, any statements from the resident or witnesses and any follow-up action to be taken by the nursing staff. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be complete: On 06/13/2024 the Director of Nursing educated Floor Nurses and Unit Managers (UMs) on the process to notify the physician when there are missed medications, changes in conditions, and/or a resident who has a documented risk management report. Nurses will notify the physician immediately via phone call to the on-call service provider that is posted at each nursing station. This process will happen if the nurse is working in the facility and witnesses a missed medication, change in condition, and/or if the nurse completes a documented risk management report on any resident. The Director of Nursing and Unit Managers (UMs) will begin in person education on 06/13/2024 with all nurses and medication aides which will include all full-time, part-time, as needed, and agency staff. This education will be on the importance of notifying the physician of any missed medications, changes in conditions, and documented risk management reports. No nurses or medication aides will work after 06/13/2024 until they have received the above noted education. The Director of Nursing will be responsible for keeping up with those nurses and medication aides who have and have not been educated. The Director of Nursing is responsible for completing the education or assigning the UM to complete the education for any staff who has not been educated by 06/13/2024. The UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure staff notify the provider when there are missed medications, changes in conditions, and/or if a resident has a documented risk management report. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. On 06/14/2024 the Director of Nursing and provider reviewed the facility provider communication log. Effective 06/13/2024 the Director of Nursing will provide education to ensure all nurses and medication aides (full-time, part-time, as needed, and agency) have comprehensive knowledge of how to utilize the provider communication log. The provider communication log is located in a white binder at each nursing station in the facility. The Floor Nurses and UMs will utilize this provider communication log daily to document any reason for why the provider should see a resident such as for a sick visit, readmission, new admission, orders to be signed, at the resident's request, at the resident's families request, medication refills, changes in conditions, and/or documented risk management reports. Effective as of 06/13/2024 Floor Nurses and UMs will be responsible for ensuring this provider communication log is updated daily. The Floor Nurses and UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure staff notify the provider when there are missed medications, changes in conditions, and/or a resident who has a documented risk management report. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. All newly hired nurses and medication aides, (full-time, part-time, as needed, and agency) will be educated as noted above. This will be completed by the Director of Nursing. The Director of Nursing will be responsible for keeping up with new hires who have and have not been educated. The Director of Nursing is responsible for completing the education with new hires. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. Alleged date of immediate jeopardy removal: 6/16/24 The removal plan of the Immediate Jeopardy was validated on 06/19/24. The audit conducted for all residents who had missed medications, changes in conditions, and/or a documented risk management report to ensure the physician had been notified was verified and confirmed any identified concerns were reported to the physician. A sample of staff including the Administrator, Unit Manager, nurses and medication aides were interviewed regarding in services they received related to the deficient practice. All staff interviewed stated they had been in serviced regarding the process of notifying the physician when there are missed medications or changes in condition. The IJ removal date of 06/16/24 was validated. 3. Resident #39 was admitted to the facility on [DATE] with a diagnosis of a urinary tract infection (UTI). The hospital Discharge summary dated [DATE] revealed the following physician order: Amoxicillin-Clavulanate 875 mg-125 mg tablet oral every 12 hours for 7 days, (Augmentin). Amoxicillin-Clavulanate is a combination penicillin-type antibiotic used to treat a wide variety of bacterial infections. The facility MAR (Medication Administration Record) for May 2024 revealed Resident #39 was administered Amoxicillin 875 mg-give 1 tablet by mouth every 12 hours for a UTI x 7 days. He received the Amoxicillin 875 mg on the following dates for a total of 14 doses: 05/03/24, 05/04/24, 05/05/24, 05/06/24, 05/07/24, 05/08/24, 05/09/24, and 05/10/24. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. He had an indwelling urinary catheter. He had undergone recent genitourinary surgery (refers to the urinary organs of the body) that required skilled nursing care. He was administered antibiotic medication. Review of the Consultant Pharmacist ' s Medication Regimen Review dated 05/27/24 revealed the following recommendation: This resident was admitted with an order for Amoxicillin/Clavulanate 875 MG BID (twice a day) for 7 days. This was entered into the computer as Amoxicillin 875 MG. This is what the pharmacy sent. Please notify the provider of the medication error to clarify if any additional treatment is needed. Please review with the nurses to ensure they read orders carefully and double check entries. In an interview with the Consultant Pharmacist on 6/12/24 at 9:50 AM she stated the difference between Amoxicillin and Amoxicillin-Clavulanate was that the Clavulanate drug helped the Amoxicillin work better and more types of bacteria were affected by the addition of Clavulanate. She would have expected the provider to be notified to report the medication error and determine if additional treatment was necessary. In an interview with the Director of Nursing (DON) on 06/12/24 at 4:40 PM she stated she had not followed up on the pharmacy recommendation and had not notified the provider that the wrong antibiotic had been administered to Resident #39 to determine if further treatment was necessary. In an interview with the facility physician on 06/19/24 at 9:30 AM she stated she had not been notified that Resident #39 was given the wrong antibiotic. She noted she started at the facility last week and was not his doctor when this occurred. However, she reported she had seen Resident #39 yesterday and he was not having any symptoms of a UTI at this time. She did not feel any further intervention was required. She stated she would expect to be notified whenever there was a pharmacy recommendation or a medication error so that it could be addressed when it occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Psychiatrist, Physician, and Wound Clinic Physician, the facility failed to protect the residents' right to be free of neglect when the facility failed to obtain significant medications (Resident #51, Resident #46, and Resident #8), administer significant medications (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8), notify the physician that scheduled medication for nerve pain that was not to be stopped abruptly was not administered (Resident #51 and Resident #46), and provide effective pain management (Resident #51 and Resident #46). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51's scheduled gabapentin was not obtained and administered for 21 doses resulting in ineffective pain management as evidenced by complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. The physician was not notified. Resident #51 was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46's scheduled gabapentin was not obtained and administered for 14 doses resulting in ineffective pain management as evidenced by increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. The physician was not notified. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized and the discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). This deficient practice affected 9 of 10 residents reviewed for neglect. Immediate Jeopardy began on 3/14/24 when the facility neglected to administer Resident #269's haloperidol and carvedilol as ordered and the resident required ED evaluation due to shortness of breath and an elevated pulse. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Residents #8, #10, #32, #39, and #50 were cited at scope and severity E. The findings included: This tag is cross referenced to: F580: Based on record review, and staff, resident, and Physician interviews, the facility failed to notify the physician that the scheduled medication gabapentin, a medication ordered for nerve pain that is not to be stopped abruptly, was not administered. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24 and had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms and the physician was not notified of this. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The physician was not notified that Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, the facility failed to notify the physician that 14 doses of the antibiotic Amoxicillin 875 mg was administered to Resident #39 instead of the antibiotic Augmentin (Amoxicillin-Clavulanate 875 mg-125 mg) that was ordered by the physician on discharge from the hospital. This deficient practice affected 3 of 10 residents reviewed for notification. F697: Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. F755: Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Physician interview, the facility failed to ensure scheduled medication was obtained and available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication. She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication. F760: Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant). An interview was conducted via phone with the Physician on 6/18/24 at 1:20 pm. The Physician indicated it was the facility's responsibility to provide the services necessary for the residents. An interview was conducted in person with the Director of Nursing (DON) on 6/14/24 at 4:10 PM. The DON indicated that staff not providing services needed to the resident was a form of neglect. She indicated education was provided to nursing staff to educate them on providing services the residents required. The Administrator was notified of immediate jeopardy on 6/13/24 at 5:00 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to protect Residents #46, #51, #269, and #419 from neglect as evidenced by the following deficient practices: 580: The facility failed to notify the physician when two residents (Resident #51 and #46) were not administered their ordered gabapentin for multiple doses. 697: The facility failed to effectively manage Resident #51's and Resident #46's pain. 755: The facility failed to ensure routine pain medication was obtained and available for administration for Resident #51 and Resident #46. 760: The facility failed to prevent significant medication errors for Resident #269, Resident #419, Resident #51, and Resident #46. The facility became aware of this neglect allegation for Resident #51 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #46 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #269 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #419 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The Administrator and Director of Nursing identified that all current residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be complete: On 06/13/2024 the Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) began educating all staff on the facility abuse and neglect policy. This education will be on the importance of staff understanding that all residents have a right to be free of neglect and that failing to provide the necessary care and services to residents constitutes neglect. All staff will have a comprehensive understanding that the following are necessary care and services: obtaining and administering medications as ordered by provider, effectively managing pain, and notifying the physician of significant changes to include any issues with administering significant medications as ordered. The Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) will begin in person education on 06/13/2024 with all staff which will include all full-time, part-time, as needed, contract staffing departments, and agency staff. No staff member will work after 06/13/2024 until they have received the education. The Social Worker and Director of Nursing will be responsible for keeping up with staff who have and have not been educated. The Social Worker, the Director of Nursing, and UMs are responsible for completing the education with all staff including any staff who have not been educated by 06/13/2024. The UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Social Worker and the Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure the facility implements effective systems so that residents receive the necessary care and services that are needed. The Social Worker and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator. All newly hired staff (full-time, part-time, as needed, contract staffing departments and agency) will be educated as noted above. This will be completed by the Social Worker, Human Resources Coordinator, and/or Director of Nursing. The Social Worker, Human Resources Coordinator, and the Director of Nursing will be responsible for keeping up with new hires who have and have not been educated. The Social Worker, Human Resources Coordinator, and the Director of Nursing are responsible for completing the education with new hires. The Social Worker, Human Resources Coordinator, and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator. Alleged date of immediate jeopardy removal: 6/16/24 The removal plan of the Immediate Jeopardy was validated on 06/19/24. A sample of staff including the Administrator, Unit Manager, nurses and medication aides were interviewed regarding in-services they received related to the deficient practice. All staff interviewed stated they had been in-serviced regarding the importance of staff understanding that all residents have a right to be free of neglect and understood that failing to provide the necessary care and services to residents constitutes neglect such as obtaining and administering medications as ordered, managing pain, and notifying the physician of significant changes. The IJ removal date of 6/16/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Immediate Jeopardy began when the facility failed to provide effective pain management for Resident #51 on 5/9/24 resulting in a pain level of 10 out of 10, and for Resident #46 on 5/12/24 when the resident had increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Findings included: Gabapentin is an anticonvulsant medication prescribed for seizures and nerve pain. Manufacturer instructions indicated gabapentin caused physical dependence and stopping the medication results in withdrawal symptoms. Within 12 hours after stopping gabapentin, withdrawal symptoms may start and may be severe. Withdrawal symptoms include nausea, insomnia, anxiety, tremors, body aches, increased pain, hallucinations and seizures. 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's physician orders revealed an order dated 4/10/24 for methadone 5 mg 2 times per day for pain and an order dated 4/18/24 for baclofen 20 mg 3 times per day for muscle spasms. Review of Resident #51's care plan revealed a focus dated 11/7/23 of pain due to chronic back pain. The goal indicated resident's pain will be relieved with use of pain medications. Interventions included provide/ administer pain medications as ordered, monitor for complaint of pain and report the need for further interventions. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated the 92 gabapentin pills from the 4/25/24 supply for Resident #51 were returned to the pharmacy while Resident #51 was in the hospital from [DATE] through 5/8/24. The hospital Discharge summary dated [DATE] indicated Resident #51 was hospitalized from [DATE] through the morning of 5/8/24. The hospital discharge summary indicated the order for gabapentin for Resident #51 was unchanged when she returned on 5/8/24. The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and the documentation of a 9 indicated to see the nursing notes. This MAR did not include routine monitoring of pain using a 0-10 pain scale rating. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. A pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse # 8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 reported increased pain when she did not receive her gabapentin. Nurse # 8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as order. Nurse #8 stated she did not report Resident #51's concerns about not receiving the medication gabapentin to administration and did not have an explanation for why she did not report the concerns. A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the writer (Nurse #8) informed Resident #51 there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. An interview was conducted via phone with Nurse # 9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51 and the resident reported pain in her legs. Nurse #9 indicated it was normal for Resident #51 to refuse her shower. An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 revealed she was assigned to Resident #51 on 5/10/24 from 7:00 PM to 7:00 AM. Nurse #13 indicated the ordered medication gabapentin 800 mg was unavailable for the scheduled dose at 9:00 PM. Nurse #13 recalled that Resident #51 normally did not complain of pain other than discomfort from her suprapubic catheter (a tube inserted through the abdomen to drain urine from the bladder). The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51 and did not assess Resident #51 for pain. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks and prior to that she worked the 7:00 PM to 7:00 AM shift. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall any further details of the situation. Unit Manager #1 stated she did not recall if she had been involved in obtaining the medication gabapentin for Resident #51. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to the emergency room. Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on 5/12/24 at 6:11 AM. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM. Nurse #2 stated she was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital during the night on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Nurse #2 stated it looked like Resident #51 was exhibiting withdrawal symptoms. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility, and she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available. A progress note written by Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51's gabapentin was not available in the facility and the resident was sent to the emergency room during the night on 5/12/24 to obtain it. The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM). Attempts were made via phone to interview Nurse #14, a nurse that worked through an agency as needed. Messages left on 6/13/24 and 6/14/24 with no return call received. An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on 5/12/24 at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room. Resident #51 returned to the facility having received Gabapentin at the emergency room. Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. The emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/13/24 - The MAR for 9:00 AM indicated Nurse # 15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 12:00 PM indicated Nurse # 15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 5:00 PM indicated Nurse # 15 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24. A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 reported pain due to not receiving gabapentin but stated gabapentin was ordered for pain so running out of the medication would cause increased pain. An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated she was familiar with Resident #51. NA #1 stated Resident #51 complained of pain at times, but this was not common for her. An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident #51 complained of leg pain at times. A follow up interview was conducted via phone with Nurse #8 on 6/27/24 at 6:15 PM. Nurse #8 stated she was aware of the potential for withdrawal and adverse effects that Resident #51 may sustain because of not receiving the ordered doses of gabapentin. Nurse #8 stated muscle aches and spasms were signs of withdrawal. An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51 resulting in missed doses of the medication ordered for pain. The DON indicated there was confusion regarding the requirements to order and reorder gabapentin and she did not understand the requirements herself. The DON revealed the Consultant Pharmacist had informed her of the problem with gabapentin running out but being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills, especially medications for pain. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected pain medication to be administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identified a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications, especially pain medications, so they could be administered as ordered. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident reported no pain in the previous 5 days. A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8. Gabapentin 800 mg was administered twice per day from 5/1/24 through 5/9/24. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked through an agency and was assigned to work at the facility on 5/6/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this. An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident # 46. Nurse #2 recalled the gabapentin was delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Resident #46 would do it. The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication: 5/10/24 - The MAR for 9:00 PM indicated Nurse # 3 documented a 9 and there was no corresponding nursing note. - The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain. Nurse #3 documented the PRN dose was effective. 5/11/24 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 7. Nurse #3 documented the PRN dose was effective. 5/12/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 9. Nurse #3 documented the PRN dose was effective. 5/13/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9. A pain level of 8 was recorded at 10:50 PM. The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy. - The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for pain. Nurse #17 documented the PRN dose was effective. 5/14/24 - The MAR for 9:00 AM indicated Nurse # 7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:25 PM Nurse # 17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen. Nurse #17 documented the PRN dose was effective. 5/15/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. 5/16/24 - The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 AM indicated waiting for delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse # 11 documented a 9. The corresponding nursing note on 5/17/24 at 12:40 AM indicated awaiting medication delivery from pharmacy. 5/17/24 - The MAR for 9:00 AM indicated Nurse #5 documented a 9. An administration note dated 5/17/24 at 10:09 AM indicated awaiting medication delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:04 PM. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented 9 on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin and indicated the medication was not administered due to it being unavailable. Nurse #3 stated Resident #46 had pain and was unable to sleep when she did not receive the medication gabapentin. Nurse #3 reported she did not relay Resident #46's reports of increased pain to the physician. An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that had worked at the facility for several months. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart. Nurse #6 indicated Resident #46 was upset about not receiving her scheduled gabapentin due to having increased pain. Nurse #6 did not report the resident's concerns about pain and did not have an explanation for why. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse # 17 stated she was assigned to Resident #46 from 7:00 PM to 7:00 AM shift on 5/13/24, 5/14/24, and 5/15/24. Nurse # 17 stated she looked for the medication on the medication cart and when she did not see it, she documented it 9, not available. Nurse #17 indicated medications were frequently missing and ran out from the medication cart. Nurse #17 revealed gabapentin was prescribed for pain and Resident #46 exhibited increased pain, irritability and anxiety from not receiving the medication. Nurse #17 did not report Resident #46's symptoms to the physician or administration and did not have an explanation for why. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #16. Nurse #16 was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #16 stated she worked at the facility through an agency for about 6 weeks. Nurse #16 stated 9 on the electronic MAR indicated the medication was not available. Nurse #16 indicated she documented 9 for unavailable on Resident #46's MAR on 5/13/24, 5/14/24 and 5/15/24 at 9:00 PM for the scheduled doses of gabapentin. Nurse #16 stated gabapentin was prescribed for pain and Resident #46 reported increased pain and inability to sleep from not receiving her scheduled pain medication. An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 stated she signed for the dose on the electronic MAR on 5/15/24 at 9:00 AM in error. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not attempt to obtain it or notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 stated she was aware that gabapentin was prescribed for nerve pain and not receiving the medication would cause the resident to have increased pain. Nurse #7 was unable to explain why she did not report Resident #46's increased pain from not receiving the scheduled doses of gabapentin. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident reported increased pain. Unit Manager #2 stated she did nothing about Resident #46's medication not being available and did not have an explanation for why. An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated there was a problem with running out of medications and administration was aware of the problem with medication not coming in from pharmacy. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM and did not call the pharmacy to obtain it. Nurse #5 stated Resident #46 reported increased pain. Nurse #5 stated she the medication was on order, so she did not attempt to obtain it. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and the resident reported pain. Nurse #2 stated she did not call the pharmacy to obtain the prescribed gabapentin for Resident #46. Nurse #2 stated medications were frequently unavailable, and she was informed by other nurses, although she did not recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done. Attempted to interview Nurse #11, nurse assigned to Resident #46 on 5/16/24 7:00 PM to 7:00 AM. Messages were left on 6/11/24 and 6/12/24 with no return call received. An interview was conducted with Resident #46 on 6/13/24 at 9:30 AM. Resident #46 stated the facility frequently had trouble obtaining medications. Resident #46 stated she had gone without medications for days at a time on several occasions. Resident #46 reported staff would state the medication was coming from the pharmacy and then it didn't come in. Resident indicated she was familiar with her medications and gabapentin was prescribed for nerve pain. Resident #46 stated she had increased pain, trouble sleeping, was anxious, irritable, nauseous and unable to get up out of bed or complete her usual routine during the time when she did not receive her gabapentin. Resident #46 stated it was horrible and the staff told her she would just have to wait it out until the medication came in. An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated she was familiar with Resident #46. NA #1 stated Resident #46 complained of pain at times, but this was not common for her. An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident # 46 was pleasant, quiet and did not usually complain of pain. NA #9 stated Resident #46's normal routine was to get up out of bed to the wheelchair and attend activities daily. An interview was conducted via phone with Nurse #5 on 6/27/24 at 6:44 PM. Nurse #5 stated she was aware that suddenly stopping gabapentin could lead to withdrawal symptoms including insomnia, nausea, tremors and anxiety. Nurse #5 stated the symptoms Resident #46 reported could have been withdrawal symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #8 was admitted to the facility on [DATE] with diagnoses which included chronic atrial fibrillation, Type 2 Diabetes Mellitus, and arthritis pain. Review of the Resident #8's physician orders revealed an 2/28/24 order for Oxycodone/Acetaminophen 10/325 milligrams (mg) - 1 tablet by mouth two times a day at 8:00 am and 8:00 pm for pain, Oxycodone/Acetaminophen 5/325 mg - 1 tablet by mouth once a day at 2:00 pm for pain, and Bio Freeze Professional External Gel 5% topical analgesic apply to area every 6 hours as needed for pain (PRN). A review of the pharmacy records indicated 30 tablets of Oxycodone/Acetaminophen 10/325 mg was delivered to the facility on 3/28/24 and signed by Nurse #10 and Nurse #18. The April 2024 Medication Administration Record (MAR) indicated Resident #8's Oxycodone/Acetaminophen 10/325 mg was scheduled to be administered at 8:00 am and 8:00 pm and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #8's Oxycodone/Acetaminophen: 4/16/24 - The MAR for 8:00 pm indicated Nurse #2 documented a 9 and there was no corresponding nursing note. 4/18/24 - The MAR for 8:00 am indicated Nurse #6 documented a 9 and the corresponding record note at 9:06 am indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. - The MAR for 8:00 pm indicated Nurse #9 documented a 9 and the corresponding record note at 9:36 pm indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. 4/19/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and the corresponding record note at 12:53 pm indicated Resident #8 was out of the facility with spouse and friend for lunch. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:42 pm indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. 4/20/24 - The MAR for 8:00 am indicated MA# 5 documented a 9 and there was no corresponding nursing note. 4/21/24 - The MAR for 8:00 am indicated MA# 5 documented a 9 and there was no corresponding nursing note. 4/22/24 - The MAR for 8:00 am indicated Nurse #6 documented a 9 and the corresponding record note at 9:34 am indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:53 pm indicated the medication was on order. 4/23/24 - The MAR for 8:00 am indicated Nurse #19 documented a 9 and the corresponding record note at 9:46 am indicated the medication was not on hand and had been ordered. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:38 pm indicated the medication was on order from the pharmacy. 4/24/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and there was no corresponding nursing note. A review of the facility's narcotic count sheet (a document used to document and track the administration of controlled substances) for Resident #8's Oxycodone/Acetaminophen 10/325 mg revealed no nurse signatures for the following: - 4/16/24 8:00 pm Nurse #2 - 4/18/24 8:00 am Nurse #6 - 4/18/24 8:00 pm Nurse #8 - 4/19/24 8:00 am Nurse #9 - 4/19/24 8:00 pm Nurse #8 - 4/20/24 8:00 am MA #5 - 4/21/24 8:00 am MA# 5 - 4/22/24 8:00 am Nurse #6 - 4/22/24 8:00 pm Nurse #8 - 4/23/24 8:00 am Nurse #19 - 4/23/24 8:00 pm Nurse #8 - 4/24/24 8:00 am Nurse #9 Attempts were made to interview Nurse #9 via phone with messages left on 6/28/24 with no return call received. Nurse #9 no longer worked at the facility. Attempts were made to interview Nurse #2 by phone with messages left on 6/28/24 with no return call received. Nurse #2 worked at the facility through an agency. Attempts were made to interview Medication Aide #5 (MA #5) by phone with messages left on 6/28/24 with no return call received. During a phone interview on 7/1/24 at 11:51 am with Nurse #8, she indicated Resident #8 did not have her scheduled 8:00 pm Oxycodone 10/325 mg available on 4/19/24 and 4/23/24. She indicated in her nursing documentation she was awaiting delivery from the pharmacy. She stated she did not know which nurse ordered the Oxycodone 10/325 mg. During a phone interview with Pharmacy Tech #1on 7/1/24 at 3:32 pm she stated the pharmacy sent the narcotics (Oxycodone/Acetaminophen) on 3/28/24. The Pharmacy Tech #1 indicated not enough Oxycodone/Acetaminophen was sent for Resident #8. She further stated the facility did not request a refill for the medication after 3/28/24 and prior to 4/25/24. Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Physician interview, the facility failed to ensure scheduled medication was obtained and available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication. She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication. Immediate Jeopardy began on 5/9/24 for Resident #51 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in a reported pain scale of 10 out of 10. Immediate Jeopardy began on 5/12/24 for Resident #46 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Example #3 was cited at scope and severity E. Findings included: 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The pharmacy records indicated a supply of 120 gabapentin 800 mg pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated 92 gabapentin pills from the 4/25/24 supply for Resident #51 were returned to the pharmacy while Resident #51 was in the hospital from [DATE] through 5/8/24. The hospital Discharge summary dated [DATE] indicated Resident #51 was hospitalized from [DATE] through the morning of 5/8/24. The hospital indicated the order for gabapentin for Resident #51 was unchanged when she was discharged on 5/8/24. A nursing progress note written by Nurse #8 on 5/8/24 at 4:22 PM revealed Resident #51 returned to the facility from the hospital on 5/8/24 at 2:40 PM. Resident #51's May 2024 Medication Administration Record (MAR) indicated there was no routine pain monitoring. The May 2024 MAR indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. Following readmission to the facility on 5/8/24, a pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 indicated she did not know the process for obtaining medications from the pharmacy and had been informed by other nurses, although she did not recall which nurses, that if a medication was not available, they just had to wait for it to come in. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse # 8 stated frequently medications were not available. Nurse #8 stated a written or electronic prescription was not required to reorder gabapentin. Nurse # 8 stated Resident #51 was frustrated about not receiving the medication gabapentin as order. A nursing progress note by Nurse #13 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed Resident #51 there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from pharmacy. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse #9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse #9 stated Resident #51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse #9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse #9 indicated Resident #51 refused her shower on 5/9/24 which was not normal for her, reporting she was in too much pain. Nurse #9 stated the facility frequently ran out of medications and did not receive medications on time. Nurse #9 stated she did not attempt to obtain medication for Resident #51 and did not know the process for obtaining gabapentin. Attempts were made to interview Nurse #13 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51. She stated she was unclear the requirements for reordering gabapentin and did not assess Resident #51 for pain. Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room. Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on 5/12/24 at 6:11 AM. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM and was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility. Nurse #2 stated she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available. A progress note written by Agency Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51 had not received her medications from the pharmacy. Unit Manager #1 wrote down the medication that was needed from the pharmacy. The resident was sent to the emergency room last night to obtain gabapentin. The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM). Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. Nurse #14 worked at the facility through an agency. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room. Resident #51 returned to the facility having received Gabapentin at the emergency room. Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on 5/12/24 at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/13/24 - The MAR for 9:00 AM indicated Nurse #15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 12:00 PM indicated Nurse #15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 5:00 PM indicated Nurse #15 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24. A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks. Unit Manager #1 stated she thought gabapentin required a written or electronic prescription to be refilled but it had been a while since she ordered it so she was not sure. Unit Manager #1 stated she knew gabapentin had to be kept in the narcotic locked box and signed for. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall when or how she became aware. Unit Manager #1 indicated she did not recall if she had been involved in obtaining the medication gabapentin for Resident #51. An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated she thought a written or electronic prescription was required to obtain a refill of gabapentin, but she was not sure. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 had pain due to not receiving gabapentin. Unit Manager #2 stated she had not contacted the pharmacy to obtain the ordered medication gabapentin for Resident #51. An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated there was a system process problem with the facility and the ordering and reordering of medications, including gabapentin. The Consultant Pharmacist stated there was confusion in the facility regarding the requirements for ordering and reordering gabapentin and this placed the residents at risk of adverse effects. The Consultant Pharmacist stated she discussed the problems with obtaining medications for administration when the current Director of Nursing (DON) came into the position at the facility (DON started position in the end of March) and made her aware of the concerns. Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. The Consultant Pharmacist indicated the pharmacy considered gabapentin a controlled medication for storage and accounting purposes but did not require a written or electronic prescription for refills. An interview was conducted by phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Pharmacy Quality Assurance Specialist indicated the pharmacy treated gabapentin as a controlled medication in terms in the storage and accounting for it. She stated a written or electronic prescription was not required to obtain the medication from the pharmacy. The Pharmacy Assurance Specialist stated the process for obtaining a refill of the medication gabapentin was the facility sent the refill sticker via fax or completed a refill request in the computer. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51. The DON indicated there was confusion regarding the requirements to order and reorder gabapentin and she did not understand the requirements herself. The DON revealed the Consultant Pharmacist had informed her when she started at the facility at the end of March of the problem with gabapentin not being available. Being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be available and administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identify that a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact with no behaviors. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident had no pain in the previous 5 days. A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain. A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM and was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this. An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident #46. Nurse #2 recalled the gabapentin was delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Resident #46 would do it. Review of a Controlled Drug Record for Resident #46 revealed the last dose from the supply of gabapentin delivered on 4/8/24 was signed out by Nurse #7 on 5/10/24 at 8:00 AM bringing the count to 0 pills remaining. Resident #46's May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR further indicated there was no routine monitoring of Resident #46's pain level. The May 2024 MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication: 5/10/24 - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain. 5/11/24 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:43 PM. - The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen. 5/12/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A pain level of 9 was recorded at 9:37 PM. - The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen. 5/13/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #17 documented a 9. A pain level of 8 was recorded at 10:50 PM. The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy. - The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for pain. 5/14/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:25 PM Nurse #17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen. 5/15/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #17 documented a 9 and there was no corresponding nursing note. 5/16/24 - The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 AM indicated waiting for delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nur[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident #8 was admitted to the facility on [DATE] with diagnoses which included chronic atrial fibrillation, Type 2 Diabetes Mellitus, and pain. Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact. a. Physician's orders for Resident #8 dated 2/28/24 indicated: - Oxycodone/Acetaminophen 10/325 mg - 1 tablet by mouth two times a day for pain. - Oxycodone/Acetaminophen 5/325 mg - 1 tablet by mouth one time a day for pain Resident #8's physician's orders did not include an order for routine pain monitoring. Resident #8's MAR from 2/28/24 through 6/12/24 revealed the resident received Oxycodone/Acetaminophen 5/325 mg as ordered by physician. A Nurse Practitioner note (NP) dated 4/16/24 at 8:00 am indicated Resident #8 had concerns about her pain medication refills. The note further indicated the NP explained and showed to the primary nurse an order from pharmacy indicating the medication was dispensed. An attempt was made to interview NP via phone with messages left on 7/1/24 at 3:45 pm with no return call received. The April 2024 MAR indicated Resident #8's Oxycodone/Acetaminophen 10/325 mg was scheduled to be administered at 8:00 am and 8:00 pm. This MAR and the medication administration notes revealed the following related to Resident #8's Oxycodone/Acetaminophen 10/325 mg: The Medication Administration Record (MAR) specified the documentation of a 9 indicated to see the nursing notes. 4/16/24 - The MAR for 8:00 pm indicated Nurse #2 documented a 9 and there was no corresponding nursing note. 4/18/24 - The MAR for 8:00 am indicated Nurse #6 documented a 9 and the corresponding record note at 9:06 am indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. - The MAR for 8:00 pm indicated Nurse #9 documented a 9 and the corresponding record note at 9:36 pm indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy 4/19/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and the corresponding record note at 12:53 pm indicated Resident #8 was out of the facility with her husband and friend for lunch. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:42 pm indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. 4/20/24 - The MAR for 8:00 am indicated Medication Aide (MA #5) documented a 9 and there was no corresponding nursing note. 4/21/24 - The MAR for 8:00 am indicated MA #5 documented a 9 and there was no corresponding nursing note. 4/22/24 - The MAR for 8:00 am indicated Nurse #6 documented a 9 and the corresponding record note at 9:34 am indicated the facility was awaiting the arrival of Oxycodone/Acetaminophen 10/325 mg from the pharmacy. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:53 pm indicated the medication was on order. 4/23/24 - The MAR for 8:00 am indicated Nurse #19 documented a 9 and the corresponding record note at 9:46 am indicated the medication was not on hand and had been ordered. - The MAR for 8:00 pm indicated Nurse #8 documented a 9 and the corresponding record note at 8:38 pm indicated the medication was on order from the pharmacy. 4/24/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and there was no corresponding nursing note. During a phone interview on 7/1/24 at 11:51 am with Nurse #8, she indicated Resident #8 did not have her scheduled 8:00 pm Oxycodone 10/325 mg available on 4/19/24 and 4/23/24. She indicated in her nursing documentation she was awaiting delivery from the pharmacy. She further stated Resident #8 did not voice any complaints of pain. During an interview with Nurse #19 on 6/28/24 at 12:00 pm, she explained Resident #8's medication was not available on the medication cart. She indicated the medication had been ordered. She further stated Resident #8 did not voice any complaints of pain. Attempts were made to interview Nurse #9 via phone with messages left on 6/28/24 with no return call received. Nurse #9 no longer worked at the facility. Attempts were made to interview Nurse #2 by phone with messages left on 6/28/24 with no return call received. Attempts were made to interview MA #5 by phone with messages left on 6/28/24 with no return call received. The June 2024 MAR and the medication administration notes revealed the following related to Resident #8's Oxycodone/Acetaminophen 10/325 mg: 6/2/24 - The MAR for 8:00 am indicated Medication Aide (MA #3) documented a 9 and the corresponding administration record note at 12:39 pm indicated the medication was not on hand and had been ordered. During a phone interview with MA #3 on 6/28/24 at 12:21 pm she indicated the medication was not available in the narcotic drawer on the medication cart on 6/2/24 and she documented she was waiting for the medication to be delivered from the pharmacy. Resident #8 did not voice any complaints of pain. Resident #8 was interviewed on 6/12/24 at 8:30 am, she indicated she was unable to recall when she spoke to the DON regarding not receiving her pain medication. She stated she spoke to the previous NP on 4/16/24 regarding not receiving her pain medication. She indicated the previous NP explained the medication had been dispensed by the pharmacy. In an interview with the Director of Nursing (DON) on 6/12/24 at 11:00 am, she indicated she was aware of Resident #8's concerns related to not receiving her pain medication. She further stated there was a problem with the medications not being available. She indicated she expected the nurses to administer the pain medications as ordered by the physician. During a phone interview with the Administrator on 6/28/24 at 4:10 pm, she stated she expected pain medication to be administered as ordered by the physician. b. A physician's order for Resident #8 dated 9/22/23 indicated Ozempic 0.25 or 0.5 milligrams (mg) - inject 1 mg subcutaneously (under the skin) one time a day every Friday for type 2 Diabetes Mellitus. The April 2024 Medication Administration Record (MAR) indicated Resident #8's Ozempic was scheduled to be administered at 8:00 am every Friday. This MAR and the medication administration notes revealed the following related to Resident #8's Ozempic: 4/5/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and the corresponding administration record note at 10:56 am indicated the medication had been ordered. 4/19/24 - The MAR for 8:00 am indicated Nurse #9 documented a 9 and the corresponding administration record note at 7:53 am did not indicate why the medication was not given. Attempts were made to interview Nurse #9 via phone with messages left on 6/28/24 with no return call received. Nurse #9 no longer worked at the facility. The May 2024 MAR and the medication administration notes revealed the following related to Resident #8's Ozempic: 5/17/24 - The MAR for 8:00 am indicated Nurse #7 documented a 9 and the corresponding administration record note at 9:17 am indicated the medication was on order. An interview with Nurse #7 on 6/12/24 at 2:50 pm revealed she ordered the Ozempic on 5/17/24 and was told it would be delivered to the facility that night. She further revealed she passed this information in report to the on-coming night nurse but was unsure if the injection was given by the night nurse. e. A physician's order for Resident #8 dated 8/19/23 indicated Rivaroxaban (anticoagulant)15 mg - 1 tablet by mouth in the evening for atrial fibrillation. The May 2024 MAR and the medication administration notes revealed on 5/30/24 MA#5 documented a 9 and there was no corresponding administration record note. Attempts were made to interview MA #5 by phone with messages left on 6/28/24 with no return call received. e. A physician's order for Resident #8 dated 8/19/23 indicated Glipizide 10 mg - 1 tablet by mouth two times a day for type 2 Diabetes Mellitus. The May 2024 MAR and the medication administration notes for 5/19/24 for Resident #8's 8:00 am dose of Glipizide indicated Unit Manager #2 documented a 9 and the corresponding administration record note at 10:41 am indicated the facility was awaiting the arrival of Glipizide 10 mg from the pharmacy. In an interview with the Director of Nursing (DON) on 6/12/24 at 11:00 am, she stated there was a problem with the medications not being available. She further stated she expected the nurses to administer all medications as ordered by the physician. A phone interview with the Medical Director on 6/17/24 at 11:21 am indicated missing diabetic medications was not optimal but had no serious adverse effects. She further stated missing anticoagulant medications adverse outcome would possibly be having a stroke. She also stated missing pain medication would possibly be having increased pain. Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant). Immediate Jeopardy began on: 3/14/24 for Resident #269 when haloperidol and carvedilol were not administered as ordered and the resident required ED evaluation due to shortness of breath and an elevated pulse; 5/9/24 for Resident #51 when gabapentin not being administered as ordered resulted in a 10 out of 10 pain scale; 5/12/14 for Resident #46 when gabapentin not being administered as ordered resulted in increased pain and difficulty sleeping, and on 3/15/24 for Resident #419 when the resident's IV dislodged (came out of her vein) and the nurse was unable to restart the IV to administer the ordered antibiotic. Immediate Jeopardy was removed on 6/15/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Examples #5, #6, #7, #8, and #9 were cited at scope and severity E. Findings included: 1. Review of Resident #269's hospital Discharge summary dated [DATE] indicated the resident was to receive haloperidol 2 tablets of 2 milligrams (mg) at bedtime for mood and carvedilol 12.5 mg twice per day. Resident #269 was admitted on [DATE] with diagnoses which included congestive heart failure, atrial fibrillation and toxic encephalopathy (a neurological disorder caused by exposure to toxic substances). Resident #269's admission physician orders entered on 3/7/24 included haloperidol 20 mg at bedtime for mood. The order was entered into the computer by the previous Director of Nursing (DON). Resident #269's admission physician orders entered on 3/7/24 did not include carvedilol 12.5 mg as indicated in his hospital discharge summary. Review of Resident #269's medical record revealed the admission assessment was completed by Nurse #9 on 3/7/24 at 3:22 PM. Review of Resident #269's March 2024 Medication Administration Record (MAR) revealed haloperidol 20 mg was scheduled to be administered at 8:00 PM. The MAR was blank on 3/7/24 for the scheduled 8:00 PM dose. The MAR revealed the medication was electronically signed as administered on 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/13/24. The MAR further revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily from admission on [DATE] through the morning of 3/14/24 as indicated in the hospital discharge summary. This resulted in 14 missed doses of the medication from admission on [DATE] through the morning of 3/14/24. Resident #269's admission Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and received antipsychotic medication. Review of Resident #269's March 2024 MAR revealed vital signs were to be obtained every shift. On 3/14/24 day shift (7:00 AM to 3:00 PM) the following were recorded: Blood pressure 162/90 (elevated), pulse 113 (elevated), respirations 20 and temperature 97.0 degrees Fahrenheit. Review of Resident #269's electronic health record revealed a nursing progress note written by Nurse #9 dated 3/14/24 at 12:10 PM which indicated resident complained of shortness of breath and stated he did not feel right. Resident #269's vital signs were: blood pressure 136/90, pulse 113 (elevated), respirations 22, temperature 97.5 and oxygen saturation of 98% on 3 liters of oxygen. Resident #269 requested to go to the hospital. On 3/14/24 at 12:25 PM Resident #269 went out of the facility to the emergency department. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:00 PM. Nurse # 9 stated she was no longer employed at the facility. Nurse #9 stated she was assigned to Resident #269 on 3/14/24 when he requested to be sent to the emergency room for evaluation. Nurse #9 stated Resident #269 was not doing well that day. Nurse #9 further stated Resident #269 complained of not feeling well, stating he knew something was wrong, his pulse was elevated, he was short of breath and reported he did not feel good all over. Nurse #9 stated after she sent Resident #269 to the hospital, she reviewed his medications and saw the dose of haloperidol was 20 mg. Nurse #9 stated she did not administer Resident #269 haloperidol on her shift as it was ordered to be given on night shift. Nurse #9 indicated if she saw a dose of 20 mg of haloperidol on the MAR to be given, she would not have given it since it was a higher dose than normally ordered. Nurse #9 stated she would clarify a dose that was higher than normal with the doctor. An Emergency Department (ED) Provider Report dated 3/14/24 at 4:24 PM indicated Resident #269 was evaluated with a chief complaint of shortness of breath. Chest x ray and laboratory tests were obtained with no further treatment required. Vital signs upon discharge from the emergency department were blood pressure 138/88, respirations 18 and oxygen saturation 94 percent. The discharge medication list indicated Resident #269 was to receive in part the medication haloperidol 2 tablets of 2 mg at bedtime and carvedilol 12.5 mg twice per day. There was no indication in the ED report of the significant medication errors with haloperidol or carvedilol. Review of the electronic health record for Resident #269 revealed the resident returned to the facility on 3/14/24 at 6:44 PM. Review of Resident #269's physician orders revealed an order dated 3/14/24 for haloperidol 2 mg give 1 tablet at bedtime for mood. The order was entered by the previous DON and was discontinued on 3/15/24. Review of the March 2024 MAR for Resident #269 revealed haloperidol 2 mg give 1 tablet at bedtime on 3/14/24 at 8:00 PM was documented with a 9 indicating to see nurses notes. Review of Resident #269's nursing progress notes revealed there was no corresponding note on 3/14/24 at 8:00 PM. Review of Resident #269's physician orders revealed an order dated 3/15/24 for haloperidol 2 mg give 2 tablets at bedtime for mood. Review of Resident #269's electronic health record revealed an incident note written by Nurse #4 on 3/15/2024 at 3:58 PM. The note indicated Resident #269's order for haloperidol was transcribed in the computer incorrectly. The progress note indicated Resident #269 received the incorrect dose of haloperidol on 3/8, 3/9, 3/10, 3/11, 3/12, and 3/13/24. Attempts were made to interview Nurse #4 via phone with messages left on 6/11/24 and 6/12/24 with no return call received. Nurse #4 no longer worked at the facility. The order for carvedilol 12.5 mg indicated in the 3/14/24 ED discharge summary was not entered into Resident #269's physician orders when the resident returned to the facility. The March 2024 MAR revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily on the evening of 3/14/24 through the morning of 3/20/24 as indicated in the ED discharge summary. This resulted in 12 missed doses of the medication. A nursing progress note dated 3/20/24 at 11:50 AM written by Nurse #7 stated resident was discharged home. An interview was conducted with Nurse #13 via phone on 6/27/24 at 12:50 PM. Nurse #13 was assigned to Resident #269 on 3/8/24 from 7:00 PM to 7:00 AM and administered the haloperidol 20 mg on 3/8/24 at 9:00 PM. Nurse #13 stated she administered the medication as ordered and documented on the MAR. Nurse #13 did not recall any further information regarding the dose of haloperidol. An interview was conducted via phone with Nurse #8 on 6/13/24 at 5:12 PM. Nurse #8 confirmed she was assigned to Resident #269 from 7:00 PM to 7:00 AM on 3/9/24 and she administered haloperidol 20 mg according to the physician order and as documented on the MAR. Nurse #8 stated she did not think about it at the time to clarify or hold the haloperidol due to an excessive dose. An interview was conducted with Unit Manager #1 on 6/13/24 at 9:30 AM. Unit Manager #1 stated she was assigned to Resident #269 on 3/11/24, 3/12/24 and 3/13/24. Unit Manager stated she administered the ordered doses of haloperidol to Resident #269 at 9:00 PM on 3/11/24, 3/12/24 and 3/13/24. Unit Manager #1 stated she did not question the dose or obtain a clarification of the dose prior to administering it. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated normally, the floor nurses entered the orders in the computer without verifying the orders with the Physician when a resident was admitted . Unit Manager #2 stated she was not sure who was supposed to fax the orders from the hospital, that she did not do it and she thought it must be someone from administration. Unit Manager #2 confirmed she was assigned to Resident #269 on 3/10/24 and her electronic signature on the MAR indicated she administered the 9:00 PM dose of haloperidol 20 mg. Unit Manager #2 stated it did not occur to her to clarify the dose or hold the haloperidol due to the dose of 20 mg ordered being higher than a usual dose ordered. An interview was conducted via phone with the previous Director of Nursing (DON) on 6/13/24 at 1:20 PM. The previous DON stated she entered the orders into the computer for Resident #269 on 3/7/24 when he was admitted to the facility from the hospital. She stated she entered the order for haloperidol incorrectly. She indicated she did not know why she put the order in incorrectly and couldn't say what happened. The previous DON revealed she was not aware she omitted the order for carvedilol and she did not have an explanation for why other than human error. The previous DON indicated she did not recall if she sent the discharge summary to the pharmacy. The previous DON stated she recalled Resident #269 went to the emergency room but did not know why or the outcome. The previous DON stated she left the position at the facility shortly after the resident was sent to the hospital. An interview was conducted via phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Quality Assurance Specialist indicated the pharmacy dispensed 30 tablets of haloperidol 20 mg on 3/7/24 for Resident #269. The Quality Assurance Specialist indicated the pharmacy did not receive the hospital Discharge summary dated [DATE] for Resident #269. The Quality Assurance Specialist stated normally the pharmacist compared the discharge summary and the orders that were entered and would call the facility for clarification or to report discrepancies. The Quality Assurance Specialist indicated documentation in the pharmacy record indicated the pharmacy did not receive a discharge summary for Resident #269. The pharmacy record indicated the pharmacist called the facility on 3/7/24 and was informed by the previous Director of Nursing (DON) to send all Resident # 269's medications as they were entered into the computer. Precautions indicated to use haloperidol with extreme caution with residents with cardiac arrhythmia. The Quality Assurance Specialist stated there was no dosage warning in the computer for the haloperidol dosage. An interview was conducted via phone with the Consultant Pharmacist on 6/12/24 at 9:15 AM. The Consultant Pharmacist indicated haloperidol 20 mg was a high dose which was usually only prescribed in an acute setting with a major psychiatric diagnosis. The Consultant Pharmacist indicated the high dose of haloperidol had the potential for adverse effects including harm and receiving the medication at that dose for a sustained period increased the likelihood of effects. The Consultant Pharmacist stated adverse effects could include but were not limited to sedation, somnolence, movement disorders, drooling and severe respiratory difficulty. The Consultant Pharmacist stated the haloperidol error was a significant medication error. The Consultant Pharmacist reported the omission of carvedilol could result in harm due to potential for exacerbation of atrial fibrillation (irregular heart rate) and congestive heart failure. The Consultant Pharmacist indicated there was a systemic problem with medication administration in the facility for some time and she addressed this with the current DON when she started in March. The Consultant Pharmacist indicated the pharmacy was supposed to receive a copy of the discharge orders to reconcile that with what was entered into the computer by the facility. An interview was conducted via phone with the Physician on 6/11/24 at 1:00 PM. The Physician stated she was new to the facility having started on 6/7/24. The Physician stated in her career as a physician she had never prescribed a dose of 20 milligrams of haloperidol. The Physician indicated the recommended dose that she would prescribe was 2.5 milligrams to 5 milligrams as a one-time dose for an acute psychotic episode. The Physician further stated 6 doses of 20 mg of haloperidol had the potential for serious adverse effects such as sedation, increased tiredness, and respiratory difficulty. The Physician reported the omission of carvedilol from Resident #269's medication list from admission on [DATE] through discharge on [DATE] was concerning and had the potential for serious adverse effects including changes in blood pressure, heart rate, shortness of breath and worsening of congestive heart failure. An interview was conducted with the current Director of Nursing (DON) on 6/12/24 at 2:15 PM. The DON indicated the incorrect dose of haloperidol administered to Resident #269 was a significant medication error. The DON stated she was aware of the error with the transcription of Resident #269's orders and stated the error was made by the previous DON. The DON stated she did not recall how she was made aware of the error. The DON stated she expected orders to be transcribed correctly and the discharge summary to be faxed to the pharmacy by the floor nurse. An interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated it was her expectation that medications would be transcribed and administered correctly. She stated she was unaware of the error that occurred with the transcription of Resident #269's medications. 2. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The May 2024 Medication Administration Record (MAR) indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. Following readmission to the facility on 5/8/24, a pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/10/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse #8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as ordered. A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51. An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 stated Resident #51's gabapentin was unavailable, and she had not administered it. Nurse #13 stated she did not attempt to obtain the medication for Resident #51. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain t[TRUNCATED]