**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff, Speech Therapist (ST), Physician Assistant (PA), and Medical Director, the facility failed to provide speech therapy evaluation and services to Resident #70 during his stay. Resident #70 was admitted to the facility from the hospital on [DATE] with a recent history of aspiration pneumonitis (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) and acute hypoxic respiratory failure (a medical condition where the body rapidly fails to adequately oxygenate the blood, leading to a severe lack of oxygen in the tissues). Resident #70 required a mechanical soft diet with nectar thickened liquids when he was admitted on [DATE]. On 12/18/24 Resident #70 was diagnosed with pneumonia at the facility and treated with a 7-day course of antibiotics. His diet was downgraded to puree with nectar thick liquids by Unit Manager (UM) #1 on 12/19/24. Resident #70 was not evaluated by speech therapy after his diet was downgraded. On 1/7/25 Resident #70 had a choking and aspiration episode at the facility and was sent to the emergency department. Resident #70 was admitted to the hospital and returned to the facility on 1/13/25. The hospital discharge summary indicated Resident #70 was to receive speech therapy and was diagnosed with esophageal dysphagia (difficulty swallowing), aspiration pneumonia, and acute hypoxic (low blood oxygen level) respiratory failure secondary to aspiration pneumonia. Speech therapy was not initiated upon readmission to the facility, and no one identified the absence of the service. This deficient practice occurred for 1 of 1 resident reviewed for rehabilitation services (Resident #70). Immediate jeopardy began on 12/19/24 when speech therapy did not evaluate Resident #70 after his diet had been downgraded by Unit Manager (UM) #1 due to staff reporting he had coughing when eating and was not doing well with his diet. Immediate jeopardy was removed on 2/5/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective and to address the deficient practice. The findings included: A hospital progress note dated 12/14/24 read in part under problem list: Aspiration event, currently consistent with aspiration pneumonitis, no evidence of subsequent pneumonia at this time but still early and could develop. Acute hypoxic respiratory failure, secondary to above. Under plan, the progress note indicated he was being treated with antibiotics and given the aspiration event would likely lean towards treating him with a 14-day course. The note indicated the 14-day course of antibiotics would be completed on 12/16/24. A review of the facility's hospital records for Resident #70 revealed a physician progress note dated 12/15/24 that read: Speech-language pathology following; International dysphagia diet standardization initiative (IDDSI) level 4 puréed food, level 3 moderately thick/honey thick liquids. A hospital discharge summary for Resident #70 dated 12/17/24 indicated his hospital course was complicated by aspiration resulting in significant episode of respiratory distress. The hospital discharge summary reported he had been followed closely by speech therapy and was able to start back on a restricted International dysphagia diet standardization initiative (IDDSI) diet (a system for describing food textures and drink thicknesses for people with swallowing difficulties. The IDDSI framework helps to prevent choking and improve safety when eating and drinking.). The hospital discharge summary did not indicate the type of IDDSI diet. The hospital discharge summary indicated he was seen by palliative care during his hospital stay and would be discharged to the skilled nursing facility (SNF) with hospice. Resident #70 was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (COPD), acute cholecystitis (inflammation of the gallbladder), acute metabolic encephalopathy (a brain condition that causes confusion), and muscle weakness. A review of the facility admission physician orders did not reveal any orders for hospice services. There was an active order dated 12/17/24 that read: speech therapy may evaluate and treat as indicated. A diet order dated 12/17/24 read, regular diet, mechanical soft texture, nectar thick liquids. Entered by Nurse #4. A baseline care plan completed by Nurse # dated 12/17/24 read under dietary: Diet order, regular mechanical soft thickened liquids. Under dietary risks, risk for swallowing problems was marked. Under the section entitled therapy, speech therapy was marked. A telephone interview was conducted on 1/24/25 at 5:37 PM with Nurse #4. She recalled completing Resident #70's admission on [DATE]. She stated she would not have entered a modified diet order for mechanical soft with nectar thick liquids, unless she had found it somewhere in Resident #70's admission paperwork. She did not recall specifically where she had found the diet in his paperwork. She did not recall taking report from the hospital for Resident #70. She was not sure who had taken the report. Nurse #4 reported that if a diet order was not present in a resident's admission paperwork, she would call the hospital to ask what the diet was and then call the facility provider to clarify if they wanted to continue that diet. Nurse #4 reported she did not remember calling the hospital and doing that for Resident #70's diet. She said she did not recall calling the provider about his diet. Nurse #4 explained she did not do a therapy communication on admission for Resident #70 because typically admissions were talked about in the management morning meetings with therapy. A progress note by the PA dated 12/18/24 indicated Resident #70 had been seen and evaluated for worsening cough and shortness of breath. The physical exam stated he had diffuse adventitious (abnormal lung sounds, like crackles or wheezes, can be heard widespread throughout a large area of the chest when listening with a stethoscope) breath sounds throughout the right side of his lungs. The note indicated a plan to obtain a chest x-ray due to right sided adventitious breath sounds and high risk for aspiration given swallowing dysfunction. A chest x-ray was completed on 12/18/24 and read: patchy opacity in right mid lung may represent pneumonia. A review of physician orders revealed the following antibiotic orders: -An order dated 12/18/24 for Doxycycline (antibiotic) 100 milligram (mg) oral tablet, give 100 mg by mouth every 12 hours for pneumonia for 14 doses. -An order dated 12/19/24 for Amoxicillin (antibiotic) extended release (ER) oral tablet 1,000-62.5 mg tablet, give 2 grams by mouth two times a day for pneumonia for 7 days. A progress note by the PA dated 12/19/24 indicated Resident #70 had been seen for follow up of his chest x-ray and cough. The note included a diagnosis of pneumonia, that he was high risk for aspiration pneumonia, and a plan for antibiotic treatment. The note read: high risk for aspiration pneumonia given swallowing dysfunction and also at risk for healthcare associated pneumonia given recent prolonged hospitalization and intubation. Currently on doxycycline 100 mg by mouth twice daily for 7 days. Given patient risk factors and significant comorbidities we will add additional coverage with Augmentin 2 grams by mouth two times daily in conjunction with his doxycycline for 7 days. The 12/17/24 regular diet, mechanical soft texture, nectar thick liquids order was discontinued on 12/19/24 by Unit Manager (UM) #1. A new diet order dated 12/19/24 read, regular diet, puree texture, nectar thick liquids. An interview was conducted on 1/24/25 at 1:01 PM with UM #1. She recalled downgrading Resident #70's diet to from mechanical soft texture to pureed texture because he had trouble with the mechanical soft diet. She said she had not completed a therapy referral communication form. UM #1 explained the order from 12/17/14 that read, speech therapy may evaluate as indicated was part of the facility's standard orders entered for all new admissions. A follow up interview was conducted on 2/7/25 at 1:03 PM with UM #1. UM #1 reported a Nurse or NA had told her Resident #70 was not doing well on the mechanical soft diet and was coughing when eating it. She did not remember who had reported it to her. She explained she had not observed Resident #70 eating or drinking. UM #1 recalled Resident #70 had an increased cough on 12/18/24 and a chest x-ray was performed that had shown pneumonia. UM #1 explained she had downgraded Resident #70's diet on 12/19/24 because it had been reported to her, he had coughing when eating the mechanical soft diet, and she had thought his pneumonia might possibly be related to aspiration. She said she had not completed a therapy referral communication form because all orders, including diet changes were discussed during the morning meeting that was attended by the Director of Rehab, who was also the ST. UM #1 explained she attended the morning meetings and thought she recalled Resident #70's diet downgrade from 12/19/24 being discussed in the morning meeting. UM #1 stated she had assumed the ST would look at him, but did not remember the ST saying specifically she would. UM #1 stated she thought she probably should have done a therapy communication form and that it would have helped cover that she had told the ST about Resident #70's diet downgrade. She reported she had trusted the ST would follow up but did not ask her specifically. UM #1 reported she did not follow up with the ST to see if she had seen Resident #70. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. The MDS documented he had no behavior or rejection of care. The MDS indicated Resident #70 required substantial/ maximal assistance from staff with eating. He was coded on the MDS as having a mechanically altered diet. He was not coded on the MDS for a swallowing disorder or receiving speech therapy. A physician's order was dated 12/30/24 for a chest x-ray for pneumonia follow up. The start date of the order was 1/3/25. The chest x-ray report dated 1/3/25 read: no acute process in the chest. A nursing note dated 1/7/25 by Nurse #6 indicated Resident #70 was sent to the emergency department for evaluation due to an aspiration/choking incident. A situation background assessment recommendation (SBAR) note dated 1/7/25 by Nurse #6 revealed Resident #70's had increased confusion, swallowing difficulty, shortness of breath, abnormal lung sounds (rales, rhonchi, wheezing), nausea/ vomiting, and abnormal pulse. The note stated Resident #70 appears to have aspirated on apple juice. He vomited up some of the fluid and is now in respiratory distress. The note indicated the provider was notified with recommendations to send him to the emergency department. Oxygen was listed under intervention orders. The SBAR note indicated Resident #70's heart rate was 130, respiration rate was 25, and his oxygen saturation level was 78% with oxygen in place via nasal cannula. A telephone interview was conducted on 1/22/25 at 6:38 PM with Nurse #6. She remembered being Resident #70's assigned nurse on 1/7/25 and recalled the choking and aspiration incident. Nurse #6 recalled after dinner an NA alerted her Resident #70 as not doing well. She did not remember the name of the NA. Nurse #6 explained she went to Resident #70's room to assess him. She stated he had thrown up after dinner. She said his dinner meal tray had already been removed from his room. She recalled Resident #70 had a cup of thickened apple juice beside him on his bedside table. Nurse #6 stated she had not seen him drink the apple juice, but said what he had thrown up was the same color as the apple juice. Nurse #6 indicated she had assumed the apple juice had been what Resident #6 had drunk and that he had aspirated on the apple juice or the vomit. A follow-up telephone interview was conducted with Nurse #6 on 2/7/25 at 11:37 PM. Nurse #6 recalled when she went to Resident #70's room to assess him he had not been doing well. She stated he was having difficulty breathing and was short of breath. She explained she checked his oxygen saturation level, and it was in the 70's. She recalled Resident #70 had already been wearing oxygen and she had turned the oxygen flow rate up, but she did not remember what she had turned it up to. Nurse #6 stated she had not seen his meal tray and that she did not remember what had been served for dinner that night. She stated Resident #70 was able to talk to her. She explained she could see inside his mouth when he was talking and there had not been anything in his mouth. Nurse #6 stated Resident #70 had not mentioned what he had been eating. She recalled his vomit had been yellowish in color with very small white pieces mixed in it. An interview was conducted with Nurse Aide (NA) #5 on 2/7/25 at 12:03 PM. NA #5 recalled the chocking and aspiration incident from 1/7/25 with Resident #70. She reported she had been assisting him in his room with his dinner meal at the time of the incident. She recalled the only thing he had wanted to eat had been the puree fruit from his meal tray. She stated he did not have any coughing or issues when he ate the puree fruit. She did not remember what else had been served for dinner or was on his meal tray, but did recall he had puree food on his meal tray. NA #5 said she remembered Resident #70 had wanted something to drink and she gave him thickened apple juice. She reported that the apple juice had been nectar thick. NA #5 stated when she gave Resident #70 the thickened apple juice and he drank it he choked and started coughing. She reported he had been positioned sitting upright in bed. She said the first time she gave him the apple juice to drink he was able to cough and clear it. NA #5 reported he had wanted more juice and when she gave him the apple juice to drink the second time he started coughing and choking more, turned red in the face, and was unable to clear it. She remembered Resident #70 was able to talk and had said I'm choking, I'm choking. NA #5 reported Resident #70 started to vomit, and she gave him a basin. She reported she stuck her head out Resident #70's door and asked NA #2 to get Nurse #6. She recalled Nurse #6 came to assess Resident #70 and sent him to the hospital. She recalled the vomit had been yellow in color and looked like the apple juice he had been drinking. She remembered there had not been food in the vomit. NA #5 recalled Resident #70 wore oxygen, and he had his oxygen on. NA #5 stated she had assisted Resident #70 with his meals prior to the incident. She reported he did not have problems with coughing or choking when he ate the puree food but said when he would drink the nectar thick liquids it would go down wrong sometimes and he would start coughing. She reported the coughing he had prior when he drank the thickened liquids was not as bad as during the choking incident and he was able to clear it. She reported the coughing happened more when he would drink the thickened liquids fast. NA #5 stated she had reported Resident #70's coughing when drinking the nectar thick liquids to a Nurse and told them she thought he may need thicker fluids, but she did not remember who she had reported it to or when she had reported it. A hospital history and physical (H&P) note dated 1/8/25 indicated Resident #70 had presented to the emergency department of the local hospital and a chest scan had shown significant food bolus with severe dilation of esophagus. The note said lung imaging was also concerning for underlying aspiration. The note indicated his oxygen saturation upon arrival was 74% on 3 liters of oxygen via nasal cannula (Normal oxygen saturation is 95% or greater). The H&P note reported Resident #70 was subsequently started on BiPAP (a type of non-invasive ventilation using a machine that helps people breath by delivering pressurized air into the airways). It indicated his oxygen levels improved with BiPAP therapy. His white blood cell count was found to be elevated, and he was started on antibiotics. The H&P indicated Resident #70 had been transferred to the current hospital for further evaluation of the food bolus with gastroenterology. A hospital Discharge summary dated [DATE] revealed Resident #70 had been admitted to the hospital on [DATE] and was discharged on 1/13/25. His discharge diagnoses included: esophageal dysphagia, aspiration pneumonia, and acute hypoxic respiratory failure secondary to aspiration pneumonia. The discharge summary indicated on 1/8/25 Resident #70 had a esophagogastroduodenoscopy (EGD) (a medical procedure that examines the upper gastrointestinal tract). It said, no bolus seen (may have passed) but abnormal esophagus, biopsies done showing inflammatory cells. The discharge summary said Resident #70 was discharged on a puree diet with honey thick liquids and would get speech therapy at rehab. He was re-admitted to the facility on [DATE] following hospitalization. There was not an order written for speech therapy by the facility from the 1/13/25 hospital discharge summary. A review of the physician orders following the hospital readmission of 1/13/25 did not reveal any orders for hospice services. There was an order entered on 1/21/25 that was pending confirmation and read: speech therapy to eval and treat as indicated. A continuous observation was completed on 1/21/25 from 1:08 PM to 1:14 PM of NA #1 assisting Resident #70 in his room with his lunch meal. At 1:08 PM NA #1 went to a red hydration cooler sitting on top of Resident #70's dresser, removed a carton of thickened liquid from the cooler, and poured the thickened liquid from the carton into a small plastic cup. NA #1 put a straw in the cup and gave it to Resident #70. Resident #70 was observed as he drank the thickened liquid from the cup using the straw. After drinking the liquid Resident #70 was heard coughing. Resident #70's meal ticket was reviewed with NA #1. His meal ticket indicated honey thick liquids were ordered. The carton of thickened liquids from the cooler was reviewed with NA #1, it was the only carton present in the cooler and had an open date of 1/21/25 written on the carton. NA #1 confirmed nectar thick liquid was printed on the carton of lemon water. NA #1 was interviewed at 1:10 PM and stated she was unsure about the nectar thickened liquids in the hydration cooler located in Resident #70's room. She explained she had not looked on the carton to check what type of thickened liquid it was, but had assumed it was the correct thickened liquid for Resident #70 since the carton was in his cooler. An interview was conducted on 1/21/25 at 3:37 PM with the Speech Therapist (ST). The ST said she had not received a speech therapy referral or been asked to evaluate Resident #70 before 1/21/25. The ST explained she had been asked to see Resident #70 on 1/21/25 after an incident at lunch where Resident #70 had been given nectar thick liquids instead of honey thick liquids. The ST reported she attended the morning meetings and new admissions were discussed in the morning meetings. The ST recalled Resident #70 had been admitted to the facility in December under long term care not short-term rehab. The ST said she had been told he was going to receive hospice at the facility during the morning meeting when he was admitted in December. The ST further explained, therapy did not evaluate or see hospice patients unless specifically asked to do so and therapy was approved by hospice. She recalled no one had communicated to her that Resident #70 had decided he did not want hospice and was not admitted to hospice. The ST reported all short stay residents were evaluated by all therapy disciplines, including speech therapy. She stated long-term care admission residents were not automatically evaluated on admission unless a therapy referral was submitted using the therapy communication form. She stated she had not received a therapy communication form or therapy referral for Resident #70 since he had been admitted on [DATE]. The ST explained the order entered on 12/17/24 that read, speech therapy may evaluate as indicated was not an order for him to be evaluated by speech therapy. She explained it was part of the facility's standard admission orders that was entered for all residents on admission and allowed speech therapy to evaluate them if needed. The ST stated she had not been aware he had issues with aspiration during his December 2024 hospitalization, or that he had been treated for pneumonia in December after being admitted to the facility. The ST reported she had not been aware Resident #70's diet had been downgraded on 12/19/24 from mechanical soft to puree. The ST further stated she had not been aware Resident #70 had been hospitalized in January for aspiration pneumonia, had been changed from nectar thick liquids to honey thick liquids during his January hospitalization, or that his January hospital discharge summary indicated he needed speech therapy services. She stated it was possible Resident #70 could have needed honey thick liquids in December, but she did not know for sure because she did not see him. The ST stated she had completed a bedside swallow study today. She reported she trialed nectar thick liquids during the bedside swallow study and Resident #70 had shown signs of aspiration with nectar thick liquids, which were coughing. The ST stated Resident #70 needed honey thick liquids. The ST reported Resident #70 needed an instrumental swallow study, which was a fiberoptic endoscopic evaluation of swallowing (FEES) (a procedure that examines how well someone swallows) to further assess his swallowing. An interview was conducted on 1/23/25 at 9:38 AM with the PA. The PA reported Resident #70 had aspiration that resulted in respiratory failure during his hospital stay in December before being admitted to the facility. The PA further explained, Resident #70 had been treated for pneumonia at the facility with antibiotic therapy starting on 12/18/24, she said his pneumonia was aspiration pneumonia. She said Resident #70 had a worsening cough and she ordered a chest x-ray because he had new symptoms, to check if there was anything else acute going on in the chest that could have caused an increased cough. She reported the chest x-ray had showed pneumonia. The PA explained it could take a while for pneumonia to clear off a chest x-ray. She stated it would be hard to differentiate if a pneumonia was new or old on a chest x-ray, but said regardless if someone had new/ worsening symptoms you would treat it the same with antibiotics. She explained if someone aspirated it would take a few days before the pneumonia would show up on a chest x-ray, she said it would not show up immediately. She reported it would have been too soon for aspiration pneumonia to show up on the 12/18/24 chest x-ray if Resident #70 had aspirated at the facility after being admitted on [DATE], she said it would not show up that quick. The PA stated Resident #70's diet consistency had been downgraded from mechanical soft to puree on 12/19/24. She recalled that no one had consulted with her about Resident #70's diet. The PA explained she had ordered a follow up chest x-ray that had been completed on 1/3/25, to ensure Resident #70's pneumonia had been resolved. She reported the chest x-ray from 1/3/25 had been negative. She stated Resident #70 had a choking and aspiration episode at the facility on 1/7/25 and was sent to the hospital for evaluation. The PA explained Resident #70 had been admitted to the hospital with aspiration pneumonia and had returned to the facility on 1/13/25. She further explained, prior to his hospitalization Resident #70 had nectar thick liquids ordered but he had been changed to honey thick liquids during his hospitalization. The PA had thought Resident #70 had been receiving speech therapy services at the facility. She said the discharge summary from Resident #70's January hospitalization clearly stated, he was supposed to receive speech therapy, and she was not aware that it was not taking place. The PA said Resident #70 should have been evaluated by speech therapy when he was originally admitted to the facility in December. She reported she expected for speech therapy to evaluate a resident typically within 2 days of admission or receiving a referral. An interview was conducted with the Admissions Coordinator on 1/24/25 at 10:45 AM. She reported hospice services had been mentioned in the hospital paperwork for Resident #70 in December. She said Resident #70's spouse had been going back and forth at the hospital between doing therapy or hospice. She recalled Resident #70's spouse had called and spoken to her before he was admitted to the facility and said they wanted intensive therapy and did not want hospice. The Admissions coordinator remembered she had discussed it during the morning meeting about Resident #70 wanting therapy and not hospice. A follow up interview with the ST was conducted on 1/24/25 at 11:00 AM. The ST reported she was present at the facility and would have attended the morning meetings on 12/17/24, 12/18/24 and 1/13/25. She reported that if she was unable to attend the morning meeting, she had someone from therapy attend the meeting in her place. An interview was conducted with the Director of Nursing (DON) on 1/24/25 at 11:53 AM. The DON recalled hospice had been discussed with Resident #70 and his spouse the day after he was admitted on [DATE] and that they had not wanted hospice. The DON reported Resident #70 should have been evaluated by all therapy disciplines when he said he did not want hospice because he was a new admission. The DON stated she was not aware speech therapy had not evaluated Resident #70 and had not known he was not hospice. She reported the rehab director, who was also the ST attended the morning meetings. The DON recalled Resident #70 not wanting hospice and needing to be evaluated by therapy being discussed in the morning meeting. She reported on admission Resident #70's payor source had not been hospice so therapy could have evaluated him. The DON said in the morning meeting all residents who were admitted the day prior were discussed. The DON stated she could not say why therapy did not know they needed to evaluate him or that he was not hospice. The DON said a new admission resident that had a diet change should have been a trigger for speech therapy to evaluate them. She explained she had assumed speech therapy had evaluated Resident #70 but had not looked to make sure. The DON stated she could not say where the ball was dropped with Resident #70 not being evaluated by therapy. An interview was conducted with the Administrator on 1/24/25 at 3:10 PM. The Administrator reported the facility went over admissions in their morning meeting and the rehab director attended the morning meetings. The Administrator explained the electronic documentation system used by therapy was different than the electronic documentation system used by the facility. She further explained that the facility could not access therapy's electronic system to see the notes or to see if someone had been evaluated by therapy. The Administrator said when Resident #70's diet had been downgraded from mechanical soft to puree on 12/19/24 it should have triggered an evaluation by speech therapy at that time. An interview was conducted with the Medical Director on 1/24/25 at 4:09 PM. The Medical Director said residents who received a modified diet, thickened liquids, or had their diet downgraded should be evaluated by speech therapy. The Medical Director stated if Resident #70's diet had been downgraded then speech therapy should have seen him. The Medical Director reported it could take a while for pneumonia to clear off a chest x-ray. She explained, if someone aspirated, they might have symptoms, but it may take a few days for it to show up on a chest x-ray. She said Resident #70 was admitted on [DATE] and the chest x-ray from 12/18/24 would probably have been too soon for aspiration pneumonia to show up on the chest x-ray if he had aspirated at the facility. The Medical Director said it would be hard to tell if Resident #70's pneumonia was new or old on his 12/18/24 chest x-ray, but clinically he was worse and that was why he was treated. She explained that you could not tell 100% if pneumonia was new or old on a chest x-ray unless it was in a different location or there was a negative chest x-ray prior to the one showing the pneumonia. The Medical Director said Resident #70 was at continued ongoing risk for aspiration. She could not say if having speech therapy involved would have made a difference in his aspiration risk or prevented his hospitalization in January. A follow up interview was conducted with the PA on 2/7/25 at 2:15 PM. The PA explained that aspiration pneumonia occurred more prominently on the right side of the lungs because the right bronchus (large airway that carries air from the windpipe to the lungs) was shorter. She said aspiration pneumonia typically showed up on a chest x-ray as a right sided pneumonia. The PA further explained, she thought Resident #70's pneumonia from 12/18/24 had been aspiration pneumonia because of his background and all of his risk factors combined with his chest x-ray that had shown right side pneumonia. She said Resident #70's risk factors included his history of aspiration and dysphagia. The PA indicated she looked at the entire clinical picture and that was why she was more inclined to think aspiration was involved. She said Resident #70 had a modified diet and speech therapy was important to see if the modified diet he was on was the appropriate diet for him. The PA said puree food could potentially cause a food bolus that could get stuck in the esophagus but was unlikely to do so. She explained the imaging from the scan done during Resident #70's 1/8/25 hospitalization had indicated there was a concern something was seen in his esophagus, but the EGD was to identify what it was. She said the EGD was what was definitive and when the EGD had been performed a food bolus had not been seen. The PA said there was no way to know for sure if a food bolus had been present or not, but that it had not been seen on the EGD. A follow up interview was conducted with the DON on 2/7/25 at 3:00 PM. The DON said Nurse #4 had called the hospital when Resident #70 was admitted in December and asked what his diet was supposed to be and had been told his diet was mechanical soft with nectar thick liquids. She reported she did not know who Nurse #4 had spoken to at the hospital. The DON thought anyone who received a modified diet should be evaluated by speech therapy to determine if the diet was appropriate and safe. The DON did not specifically remember Resident #70's downgraded diet from 12/19/24 being discussed during the morning meeting on 12/20/24, but the DON said she printed all the orders entered into the electronic computer system the prior day and reviewed them all during the morning meeting. The facility's Administrator was informed of the immediate jeopardy on 2/7/25 at 4:57 PM. The facility submitted 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 On 12/17/24 Resident #70 was admitted to the facility from hospital with diagnosis of cholecystitis, and a diet order of mechanical soft and nectar thick liquids. Upon admission from the hospital, all documentation related to admission stated that Resident #70 would be receiving hospice services. With the presumed knowledge of this resident being under hospice services, speech therapy did not evaluate the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to notify the physician when two medications, an intravenous (IV) antibiotic and an antiarrhythmic medication (a medicine used to treat irregular heartbeat) were unable to be delivered to the facility and failed to notify the physician when the medications were unable to be administered. Resident #1 missed three doses of the IV antibiotic and four doses of the antiarrhythmic medications after admission to the facility. Additionally, the facility failed to notify the physician when Resident #1 missed three additional doses of the IV antibiotic due to the antibiotic being unavailable. This was for 1 of 3 sampled residents reviewed for notification (Resident #1). By not receiving these medications there was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias and/or return to hospital. Immediate jeopardy began on 12/11/22 when the facility failed to notify the physician when two medications (an intravenous antibiotic and antiarrhythmic medication) were unable to be administered to Resident #1. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: Review of hospital discharge summary physician order dated 12/10/22 revealed an order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-% (antibiotic used to treat bacterial infection). Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of hospital discharge summary physician order dated 12/10/22 revealed an order for Flecainide Acetate Tablet 100 milligrams (MG) (medication used to prevent irregular heartbeat). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on Sunday, 12/11/22 with diagnoses to include bacteremia due to methicillin susceptible staphylococcus, chronic atrial fibrillation, and diabetes. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she confirmed Resident #1's medication orders and sent the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his IV antibiotic and antiarrhythmic medication available upon admission and would not receive them until the following day, Monday (12/12/22). Nurse #1 stated she did not notify the physician about Resident #1's medications not being available upon admission or any missed doses on 12/11/22. Review of Medication Administration Record (MAR) for December 2022 revealed Resident #1 was to receive the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses on 12/11/22 at 10 PM, 12/12/22 at 6AM, 12/12/22 at 2PM, 12/19/22 at 2PM, 12/19/22 at 10PM, and on 12/20/22 at 6AM due to being on order from pharmacy and not available at facility. Flecainide Acetate Tablet 100 milligrams (MG). Give one tablet by mouth two times daily (8AM, 8PM) for atrial fibrillation (A-fib) starting 12/10/22. Resident #1 was not administered doses on 12/11/22 at 8PM, 12/12/22 at 8AM, 12/12/22 at 8PM, and 12/13/22 at 8AM due to being on order from pharmacy and not available at facility. Review of Resident #1's electronic medical record and physician correspondence notebook revealed there was no documentation of the physician being notified of Resident #1's missed medication doses or medications not being available at facility. A telephone interview was conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed when she arrived at work on 12/11/22 for her 6:30PM to 7AM shift she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day, 12/12/22. She stated a notebook had been available at nurse's station for nursing staff to leave correspondence or notify the physician about issues with residents to include issues with medications, but she does not recall if she informed physician or made a note in the notebook of Resident #1's missed doses of IV antibiotic or antiarrhythmic medication not being available to be administered. A telephone interview was conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and not receiving his medications upon his admission on [DATE] until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 for her 6:30AM to 7PM shift she was told Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. Nurse #3 stated she did not notify the physician of being unable to administer the medications. She revealed a notebook had been available at nurse's station for nursing staff to correspond with physician about any issues with residents but she did not leave any correspondence about Resident #1 because she assumed the nurse from previous shift had notified physician. A second interview was conducted with Nurse #1 on 01/19/23 at 12:20 PM. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she does not recall informing the physician of Resident #1 missing his dosage of IV antibiotic on 12/19/22 during her 6:30AM to 7PM shift. Nurse #1 stated a notebook was located at nurse's station for physician correspondence to include issues with medications, but she does not recall writing down any correspondence about Resident #1's missed doses and medication not being available. A telephone interview was conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1 evening dose of his IV antibiotic. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She revealed she did not notify the physician Resident #1 missed doses of his IV antibiotic on 12/19/22 or 12/20/22. An interview was conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 by Resident #1 that his medications had been delayed and when asked nursing staff about Resident #1 medication was told they were enroute from pharmacy and would be available later that day. The PA revealed she was not made aware of Resident #1 missed doses of his IV antibiotic on 12/19/22 and 12/20/22 and had she been told she could have investigated another way of receiving the antibiotic and ordered a culture to see if there had been any growth. A second interview was conducted with Physician Assistant (PA) on 01/19/23 at 12:54 PM that revealed Resident #1 was admitted with diagnosis of having atrial fibrillation (a-fib) which can cause an irregular heartbeat and was ordered an antiarrhythmic medication to be administered two times a day. The PA revealed she was not notified of Resident #1 missing four doses of his a-fib medication (from 12/11/22 through 12/12/22) and the medication not being available at the facility and had she been told she could have administered another medication until medication was available and monitored for any signs of A-fib. An interview was conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today by the State Agency of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated no knowledge if medical providers were notified of Resident missed doses of his IV antibiotics. The Administrator and DON revealed nursing staff should have contacted medical providers or left a note in the medical provider notebook located at nurses' station to inform of missed doses. A telephone interview was conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or antiarrhythmic medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed and Bacteremia. From December 11 through December 21, 2022, facility failed to ensure an ordered IV antibiotic to treat sepsis for Resident #1 was available for 6 of the 42 ordered administrations. *Resident #1 was at risk of suffering from the deficient practice placing him at increased risk for rehospitalization, however showed no adverse outcome as a result of non-compliance. Resident had planned discharge to home on [DATE] and continued his Cefazolin IV antibiotic with a stop date of 12/28/22. *All other residents prescribed medications are also at risk from suffering from the deficient practice. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders for the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining all medications from pharmacy, the utilization of the stat safe (an electronic emergency/stat dose medication cabinet), the process of obtaining back up services from pharmacy, and the requirement to notify the DON and Physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on how and when to notify the on-call or in-house physician if medications were not available and/or unable to be administered. The facility provided evidence in-service education. It was determined in-service education was completed for staff. The facility provided evidence of audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, Pharmacist, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to have an effective system in place to ensure a physician ordered Intravenous (IV) antibiotic and an antiarrhythmic medication (medication used to prevent irregular heartbeat) was available to administer for 1 of 3 residents (Resident #1) reviewed for pharmacy services. Resident #1 was ordered an IV antibiotic for bacteremia and did not receive the first three doses of the antibiotic due to the medication being on order from pharmacy and not available at the facility. Resident #1 did not receive another three doses of the IV antibiotic beginning on 12/19/22 due to being on reorder from the pharmacy and staff not checking the facility back-up safe for the medication. Resident #1 was also ordered an antiarrhythmic medication for atrial fibrillation (A-fib) and did not receive the first four doses of this medication due to the medication being on order from pharmacy and not available at the facility. By not receiving these medications there was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias or return to hospital. Immediate jeopardy began on 12/11/22 when facility failed to obtain Resident #1's antibiotic and antiarrhythmic medications. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: Review of facility medication order policy revised July 2022 revealed read in part under documentation of medical order: Clarify order and call, fax, or electronically submit the medication orders to Pharmacy. The facility began using the current pharmacy on 07/01/22. Review of the hospital discharge physician order dated 12/10/22 revealed an order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of the hospital discharge physician order dated 12/10/22 revealed order for Flecainide Acetate Tablet 100 milligram (MG). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on Sunday 12/11/22 and discharged home on [DATE] with diagnoses to include bacteremia due to methicillin susceptible staph, chronic atrial fibrillation, and diabetes. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders, and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his IV antibiotic and his antiarrhythmic medication available upon admission and would not be available until the following day 12/12/22. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from the pharmacy was an ongoing issue, especially for residents admitted on the weekends due to the pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe, residents would not receive ordered medications until they arrived from pharmacy. Review of the Medication Administration Record (MAR) for December 2022 revealed the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses at 10 PM on 12/11/22, 6AM on 12/12/22, 2PM on 12/12/22, 2PM on 12/19/22, 10PM on 12/19/22, and 6AM on 12/20/22 due to being on order from pharmacy and not available at facility. Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day (8AM, 8PM) for atrial fibrillation. Resident #1 was not administered scheduled doses at 8PM on 12/11/22, 8AM on 12/12/22, 8PM on 12/12/22, and 8AM on 12/13/22 due to being on order from pharmacy and not available at facility. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not having medications available upon his admission on [DATE] until the following day. She stated when she arrived at work on 12/11/22 at 6:30 PM she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications and nursing staff has expressed these issues to the Director of Nursing (DON). She stated she did not recall if she checked the back-up safe to see if there were any medications available including Resident #1's IV antibiotic and a-fib medication that could have been administered. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and him not having received his medications upon his admission on [DATE] until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 at 6:30 AM she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. She stated she contacted the pharmacy who stated Resident #1 medications were enroute. She revealed this had been an on-going issue with pharmacy and not having resident medications available upon admission or medications not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated residents not having their medications happens weekly and the issues with pharmacy have been brought to the Director of Nursing's (DON) attention and it continued to happen. She revealed she did not recall if she had checked the facility back-up safe to see if IV antibiotic or a-fib medication was available that could have been administered to Resident #1. An interview conducted with Nurse #1 on 01/19/23 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she contacted the pharmacy and was told IV antibiotic had been reordered and was enroute to facility. Nurse #1 stated this was an ongoing issue with pharmacy and not receiving medications on time and residents having to wait for their medications and she had spoken with her Director of Nursing (DON) about these issues and was told it was a pharmacy issue. She revealed she does not recall if she checked the facility back-up safe for medications that could have been administered to Resident #1. A telephone interview conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1 evening dose of his IV antibiotic due to being told by the daytime nurse the medication was on order from the pharmacy and not available at the facility and the MD had been aware. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She also stated she had not been given access to the back-up safe and was not able to check for any back-up medications. Nurse #4 revealed there had been on-going issues with pharmacy and medications not being available for residents upon their admission and during their stay at the facility and she had made the DON aware of these concerns and was told it was a pharmacy issue and nothing else was done. An interview conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed she was familiar with Resident #1. She stated Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 his IV antibiotic and antiarrhythmic medication for a-fib had been delayed but was enroute from pharmacy and would be available later that day. She revealed this had been an ongoing issue with pharmacy and medications not being available upon resident admission and she has had to call pharmacy herself about medication orders and had also spoken with the DON about the pharmacy issues and was told it was a pharmacy issue. A telephone interview conducted with Pharmacist on 01/18/23 at 4:57 PM revealed the pharmacy received the medication orders electronically for Resident #1 on 12/11/22 at 3:25 PM. She stated the medication order was filled and sent out to the facility on [DATE] at 11:00 AM. She also stated if an order for medication was received on a workday prior to 2PM the order would be filled on the same day and sent out for night delivery, and if an order for medication was received after 5PM during the workday or received on the weekend the medication would be filled the morning of the next working day and sent out for delivery before lunch. The Pharmacist revealed although Resident #1 IV antibiotic order was for 18 days the pharmacy sent a 7-day supply for the IV antibiotic. She stated the IV antibiotic was on automatic reorder and the next 7-day supply was filled at 8:22 PM on 12/19/22 and sent out to the facility between 9PM and 10PM. The Pharmacist revealed the facility should have had enough doses of IV antibiotics available on 12/19/22 for Resident #1 and should not have missed any of his doses. She stated the facility also had a back-up safe in the facility with extra medications and 1-gram bags of the IV medication for Resident #1 was available in the back-up safe. She revealed the facility could have administered Resident #1 the 1-gram bags of IV antibiotics back-to-back to make the 2 grams and no doses would have been missed. She stated she had no knowledge if staff had been made aware of the IV antibiotic being available in facility back-up safe. A follow up telephone interview conducted with the Pharmacist on 01/23/22 at 9:45 AM revealed the pharmacy received Resident #1's order for the Flecainide Acetate, a-fib medication on 12/11/22 at 3:25 PM and the medication was filled and sent out to the facility on [DATE] at 11:00 AM with his other medications. She stated Resident #1's a-fib medication was available at the facility for his evening dose on 12/12/22 and his morning dose on 12/13/22 and should not have been missed due to pharmacy issues or not being available at the facility. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated when a resident was going to be admitted to the facility, they received a list of ordered medications prior to admission but were not able to send order for medication to pharmacy until the resident was in the building. They revealed they were not aware of pharmacy delivery times on weekends but through the week medication orders and reorders had to be sent to pharmacy before 5PM for late delivery. The Administrator and DON stated the facility did not have back-up contracts with the hospital or any of the local pharmacies. They revealed the pharmacy would be responsible for contacting another local pharmacy about a resident's medications and for making sure resident receive their medications. They stated they were not aware of what medications had been available in the facility back-up safe and did not understand why pharmacy did not inform nursing staff when they called on 12/19/22 about back-up IV antibiotics being available for Resident #1. The Administrator and DON stated the facility had switched to the current on pharmacy on 07/01/22 and there had been on-going issues with pharmacy and medications not being available upon admission and not being reordered or sent to facility on time and they have spoken with upper management about the issues. A telephone interview was conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or of his a-fib medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. The MD revealed he had spoken with the Administrator about the facility did not having a back-up contract with the hospital and other local pharmacies to be able to send in an order and receive medications when not available from main pharmacy and was told that was a pharmacy issue and the main pharmacy out of [NAME] was responsible for contacting other pharmacies if they had issues with medications. A telephone interview conducted with Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including bacteremia which is bacterial infection in the bloodstream and atrial fibrillation (a-fib) which is when the heartbeat is out of rhythm or an irregular heartbeat. He stated he had ordered Resident #1 and IV antibiotic to be administered uninterrupted every 8 hours for 18 days for treatment of bacteremia. He revealed best practice would have been for Resident #1 to have received all of his scheduled doses of IV antibiotic and missing doses could have caused bacterial regrowth and a possible return to hospital. He stated he had ordered antiarrhythmic medication for Resident #1 to be administered twice daily to continue his heartbeat at a normal rhythm and administering this medication as prescribed was best practice. He revealed Resident #1 missing his doses of his a-fib medication was a potential for harm due to each resident being different in how they respond to missed doses of a-fib medication. The Hospital Physician stated every resident responds to a-fib differently and some residents might be able to miss doses of medication and have no issues and other residents may miss one dose of medication and it would send them into a-fib and they would have to be sent back to hospital and there is no way of knowing how each resident would respond. He revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed, bacteremia, atrial fibrillation. From December 11 through December 21, 2022, facility failed to ensure an ordered IV antibiotic to treat sepsis was available for 6 of the 42 ordered administrations, and failed to ensure an antiarrhythmic medication was available for 4 missed doses for Resident #1. *Resident #1 was at risk of suffering from the deficient practice placing him at increased risk for rehospitalization, however showed no adverse outcome as a result of non-compliance. Resident had planned discharge to home on [DATE] and continued his Cefazolin IV antibiotic with a stop date of 12/28/22. *All other residents prescribed medications are also at risk from suffering from the deficient practice. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders for the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining all medications from pharmacy, the utilization of the stat safe (an electronic emergency/stat dose medication cabinet), the process of obtaining back up services from pharmacy, and the requirement to notify the DON and Physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on medication administration, obtaining medicine through pharmacy, and how to notify the on call or in-house provider if medicines are not available. Facility stat safe was observed in locked medication room behind nurse's station where nursing staff have a personalized code to enter for access to receive back-up medications for residents and staff interviews revealed if resident medication was not available on medication cart they were to utilize stat safe first and if not there then to contact pharmacy about other option for receiving medication and to notify physicians of missing medication. Audits were completed to residents who had received IV medication and missed medication for all residents in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, Pharmacist, Physician Assistant (PA), Medical Director (MD) and Hospital Physician interviews, the facility failed to administer antibiotics for 1 of 3 residents (Resident #1) reviewed for pharmacy services. Resident #1 was not administered the first three doses of an Intravenous (IV) antibiotic for bacteremia as ordered due to the medication being on order from pharmacy and not available at facility. Resident #1 did not receive another three doses of the IV antibiotic beginning on 12/19/22. The facility also failed to administer the first four doses of an antiarrhythmic medication (medication used to treat or prevent irregular heartbeats) due to being on order from the pharmacy and staff not checking the facility back-up safe for the medication. There was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias, or return to hospital due to the missed medications. Immediate jeopardy began on 12/11/22 when facility failed to administer Resident #1's antibiotic medication and antiarrhythmic medication. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: 1a. Resident #1 was admitted to the facility on Sunday 12/11/22 with diagnoses to include bacteremia due to methicillin susceptible staphylococcus aureus (an infection the blood that can lead to sepsis and death), chronic atrial fibrillation, and diabetes. Resident discharged home on [DATE]. Review of hospital Discharge summary dated [DATE] revealed Resident #1was anticipated to be discharged to facility on 12/11/22 with diagnoses to include methicillin susceptible staphylococcus aureus (MSSA) bacteremia due to positive blood culture for growth. Physician ordered medications included an intravenous (IV) antibiotic (Cefazolin 2 grams) every 8 hours with an end date of 12/28/22. Review of hospital discharge physician order dated 12/10/22 revealed order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of the Medication Administration Record (MAR) for December 2022 revealed the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses at 10 PM on 12/11/22, 6AM on 12/12/22, 2PM on 12/12/22, 2PM on 12/19/22, 10PM on 12/19/22, and 6AM on 12/20/22 due to being on order from pharmacy and not available at facility. A telephone interview conducted with the Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including bacteremia and methicillin-susceptible staph bacteremia or MSSA (bacterial infection in bloodstream). He stated he had ordered an IV antibiotic as treatment for Resident #1's MSSA to be administered uninterrupted every 8 hours for 18 days ending on 12/28/22 and administering this medication as prescribed was best practice. The Hospital Physician revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. Review of admission nursing note written by Nurse #1 dated 12/11/22 at 1:53 PM read in part: Resident #1 arrived via hospital van to the facility on 3 liters of oxygen. He was alert and oriented to person, place, time, and event. Resident #1 had a peripherally inserted central catheter (PICC), used for access of large central veins near the heart, and was to receive medications through the PICC line. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and coded for intravenous medications and receiving antibiotics. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his IV antibiotic available upon admission and did not receive them until the following day. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from pharmacy was an ongoing issue, especially for residents admitted on the weekends due to the pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe for them to use, residents would not receive ordered medications until they arrived from pharmacy. Review of nursing note written by Nurse #2 dated 12/11/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 Days. On order. Review of nursing note written by Nurse #2 dated 12/12/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. On order. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not receiving medications upon his admission on [DATE] until the following day. She stated when she arrived at work on 12/11/22 she was told by Nurse #1 who had worked the previous shift, Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with the pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications, she reported nursing staff had expressed these issues to supervisors. Nurse #2 stated the facility does have a back-up safe for medications that can be administered to residents until they receive their medications from the pharmacy, but she could not recall if she checked the back-up safe to see if there were any medications to include Resident #1's IV antibiotic. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and him not receiving his medications upon admission on [DATE] until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 she was told by Nurse #2 who had worked the previous shift, Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. She revealed this has been an on-going issue with pharmacy not having resident medications available upon admission or not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated when a resident did not have their medications she looked to see if the medications had been ordered and sent to pharmacy and then she checked to see if the medication were available in the facility back-up safe. She stated she did not recall if she had checked the facility back-up safe to see if medications to include IV antibiotic were available that could have been administered to Resident #1. Review of nursing note written by Nurse #1 dated 12/19/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. Unavailable. An interview conducted with Nurse #1 on 01/19/23 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she contacted pharmacy and was told the IV antibiotic had been reordered and was enroute to facility. Nurse #1 stated this was an ongoing issue with pharmacy and not receiving medications on time and residents having to wait for their medications and she had spoken with her supervisors about these issues. She revealed she did not recall if she checked the facility back-up safe for the medications. Review of nursing note written by Nurse #4 dated 12/19/22 read in part Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. Awaiting pharmacy. MD aware. A telephone interview conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1's evening dose of his IV antibiotic due to being told by the daytime nurse the medication was on order from the pharmacy and not available at the facility and the MD had been aware. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She stated she was not given access to the facility back-up safe and would not have been able to check and see if there were any back-up doses of IV antibiotic for Resident #1 that could have been administered. Nurse #4 revealed there had been on-going issues with pharmacy and medications not being available for residents upon their admission and during their stay at the facility and she had made her supervisors including the DON aware of these concerns and was told it was a pharmacy issue and nothing else was done. Review of the facility Physician Assistant (PA) progress note dated 12/12/22 revealed Resident #1 had been admitted to the facility on [DATE] from the hospital with multiple medical diagnosis to include methicillin susceptible staphylococcus aureus infection and bacteremia with an ordered IV antibiotic for treatment to be administered every 8 hours for 18 days. The PA noted when speaking with Resident #1 he was anxious his medications had not yet arrived from pharmacy, and he was concerned he would decompensate if he had to wait much longer. The PA reviewed the medication administration record (MAR) and noted medication enroute today. An interview conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed she was familiar with Resident #1. She stated Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 by Resident #1 his IV antibiotic had been delayed and when she checked with nursing, she was told Resident #1's medications were enroute from pharmacy and would be available later that day. She revealed this had been an ongoing issue with pharmacy and medications not being available upon resident admission and she has called the pharmacy herself about medication orders and had also spoken with the DON about the pharmacy issues and was told it was a pharmacy issue. The PA revealed she was not made aware of Resident #1's missed doses of his IV antibiotic on 12/19/22 and 12/20/22 and had she been told she could have investigated another way of receiving the antibiotic and ordered a culture to see if there had been any new bacterial growth. She stated Resident #1's missing doses of his IV antibiotic could have caused bacterial growth, sepsis, or to become resistant to the antibiotic. She revealed Resident #1's IV antibiotic was ordered because of his culture and the IV antibiotic ordered was specific to his treatment and not any antibiotic could have been used. A telephone interview conducted with the facility Pharmacist on 01/18/23 at 4:57 PM revealed the pharmacy received the medication orders electronically for Resident #1 on 12/11/22 at 3:25 PM. She stated the medication order was filled and sent out to the facility on [DATE] at 11:00 AM. The Pharmacist revealed although Resident #1's IV antibiotic order was for 18 days, the pharmacy sent out the antibiotic in a 7-day supply. She stated the IV antibiotic was on automatic reorder and the next 7-day supply was filled at 8:22 PM on 12/19/22 and sent out to the facility between 9PM and 10PM. The Pharmacist revealed the facility should have had enough doses of IV antibiotics available on 12/19/22 for Resident #1 and should not have missed any of his doses. She stated the facility also had a back-up safe in the facility with extra medications and 1-gram bags of the IV medication ordered for Resident #1. She revealed the facility could have administered Resident #1 the 1-gram bags of IV antibiotics back-to-back to make the 2 grams and no doses would have been missed. The Pharmacist stated Resident #1's IV antibiotic had a half-life of 1.8 hours and missing 3 doses at a time, the IV antibiotic would be completely out of Resident #1's system and could cause bacteria growth, sepsis, or Resident #1 to become resistant to antibiotic. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated when a resident was going to be admitted to the facility, they received a list of ordered medications prior to admission but were not able to send order for medication to pharmacy until the resident was in the building. They revealed they were not aware of pharmacy delivery times on weekends but through the week medication orders and reorders had to be sent to pharmacy before 5:00 PM for late delivery. The Administrator and DON stated the facility did not have back-up contracts with the hospital or any of the local pharmacies. They revealed the pharmacy would be responsible for contacting another local pharmacy about a resident's medications and for making sure resident received their medications. They stated they were not aware of what medications had been available in the facility back-up safe and did not understand why the pharmacy did not inform nursing staff when they called on 12/19/22 about the back-up IV antibiotics being available for Resident #1 in the safe. The Administrator and DON revealed nursing staff should always check the back-up safe for medications that could have been administered to residents. They stated there had been on-going issues with pharmacy and medications not being available upon admission and not being reordered or sent to facility on time. Review of Medical Director (MD) progress note dated 12/16/22 revealed Resident #1 had been admitted to the facility on [DATE] from the hospital with multiple medical diagnosis to include bacteremia and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere and will continue IV antibiotic through and including 12/28/22. A telephone interview conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or of his a-fib medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. He stated Resident #1's IV antibiotic was ordered as a treatment for sepsis and should have been given as prescribed and by not doing so could have caused bacterial growth or for him to become septic again. b. Review of physician order for Resident #1 from Discharge summary dated [DATE] revealed order for Flecainide Acetate Tablet 100 milligram (MG). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on [DATE] (Sunday) with diagnoses to include sepsis due to methicillin susceptible staphylococcus aureus, chronic atrial fibrillation, and diabetes. Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #1 was coded for atrial fibrillation (a-fib). Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders, and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his a-fib medication available upon admission and was not to receive them until the following day. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from pharmacy was an ongoing issue, especially for residents admitted on the weekends due to pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe for them to use, resident would not receive ordered medications until they arrived from pharmacy. Review of medication administration record (MAR) for December 2022 revealed Resident #1 was to receive Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day (8AM, 8PM) for atrial fibrillation. Resident #1 was not administered scheduled doses at 8PM on 12/11/22, 8AM on 12/12/22, 8PM on 12/12/22, and 8AM on 12/13/22 due to being on order from pharmacy and not available at facility. Review of nursing note written by Nurse #2 dated 12/11/22 revealed Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). On order. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not receiving medications upon his admission on [DATE] until the following day. She stated when she arrived at work at 6:30 PM on 12/11/22 she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications and nursing staff had expressed these issues to supervisors. Nurse #2 stated the facility does have a back-up safe for medications that can be administered to residents until they receive their medications from pharmacy. She stated she did not recall if she checked the back-up safe to see if there were any medications to include Resident #1's medications for atrial fibrillation that could have been administered to Resident #1 until his medications arrived. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and not having his medications available until the following day. She stated when she arrived at work on 12/12/22 she was told Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his medication for atrial fibrillation had been administered. She stated she contacted the pharmacy who stated Resident #1's medications were enroute and she informed Resident #1 and his wife. She revealed this has been an on-going issue with pharmacy not having resident medications available upon admission or not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated when a resident did not have their medications she would first look to see if the medications had been ordered and sent to pharmacy and then she checked to see if the medication was available in the facility back-up safe. She revealed residents not having their medications happens weekly and the issues and have been brought to supervisors' attention. She revealed she was not made aware from nursing staff who had worked the previous day of Resident #1's a-fib medication being available on 12/13/22 and believed it to still be on order from the pharmacy and not available at the facility due to not being on medication cart. Nurse #3 also revealed if she had been made aware Resident #1's a-fib medication had been available for his morning dose on 12/13/22 she would have administered the medication as ordered. She stated she did not recall if she had checked the facility back-up safe on 12/12/22 or 12/13/22 to see if medication for atrial fibrillation was available that could have been administered to Resident #1. A telephone interview conducted with the Pharmacist on 01/23/22 at 9:45 AM revealed the pharmacy received Resident #1 order for an a-fib medication on 12/11/22 at 3:25 PM and the medication was filled and sent out to the facility on [DATE] at 11:00 AM with his other medications. She stated Resident #1's a-fib medication was available at the facility for his evening dose on 12/12/22 and his morning dose on 12/13/22 and should not have been missed due to pharmacy issues or not being available at the facility. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues of him not being administered medications for atrial fibrillation (a-fib). They stated nursing staff should checked the back-up safe to see if there was a back-up supply of medications that could have been administered. An interview conducted with Physician Assistant (PA) on 01/19/23 at 12:54 PM revealed Resident #1 was admitted to the facility with diagnosis of having atrial fibrillation (a-fib) which can cause an irregular heartbeat and was ordered an antiarrhythmic medication to be administered two times a day. The PA revealed medication for atrial fibrillation (a-fib) should have been given as prescribed and when not given could have caused the heart to get out of rhythm which could have led to cardiac arrest. A telephone interview conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed Resident #1 a-fib medications should had been administered as prescribed and missing doses could had resulted in irregular heartbeats. A telephone interview conducted with Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including atrial fibrillation (a-fib) which is when the heartbeat is out of rhythm or an irregular heartbeat. He stated he had ordered antiarrhythmic medication for Resident #1 to be administered twice daily to continue his heartbeat at a normal rhythm and administering this medication as prescribed was best practice. He revealed Resident #1 missing his doses of his a-fib medication was a potential for harm due to each resident being different in how they respond to missed doses of a-fib medication. The Hospital Physician stated every resident responds to a-fib differently and some residents might be able to miss doses of medication and have no issues and other residents may miss one dose of medication and it would send them into a-fib and they would have to be sent back to hospital and there is no way of knowing how each resident would respond. He revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed, Bacteremia, and atrial fibrillation. On December 11, 12, 19 & 20, 2022, facility failed to administer six doses of ordered intravenous (IV)antibiotic, Cefazolin, and four doses of and antiarrhythmic medication, Flecainide Acetate, to Resident #1 with adverse outcome. *Resident #1 was at increased risk for rehospitalization as result from the deficient practice; however, resulted in no adverse outcomes. *All other residents prescribed an intravenous (IV) antibiotic and antiarrhythmic medications are also at risk from suffering from the deficient practice. Resident #1 was discharged home from the facility on 12/22/22 with a written order for IV antibiotic, Cefazolin, with the stop date of 12/28/22. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders from the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, an electronic emergency/stat dose medication cabinet, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on medication administration, obtaining medicine through pharmacy, and how to notify the on call or in-house provider if medicines are not available. Facility stat safe was observed in locked medication room behind nurse's station where nursing staff have a personalized code to enter for access to receive back-up medications for residents and staff interviews revealed if resident medication was not available on medication cart they were to utilize stat safe first and if not there then to contact pharmacy about other option for receiving medication and to notify physicians of missing medication. Audits were completed to residents who had received IV medication and missed medication for all residents in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and physician interview, the facility failed to operationalize effective systems so staff could respond to an emergency situation as needed for 1 of 3 residents (Resident #1) reviewed for cardiopulmonary resuscitation. When Resident # 1 required cardiopulmonary resuscitation (CPR) and suctioning, only chest compressions were provided until emergency medical services arrived. EMS transported Resident # 1 to the hospital and given the extended cardiac arrest time of 32 minutes and the lack of neurologic responsiveness Resident #1 was intubated and admitted to the intensive care unit (ICU). Resident #1 was transitioned to comfort care and palliatively extubated. Resident #1 passed away on [DATE]. Immediate Jeopardy began on [DATE] when Resident #1 who was a full code, was not provided airway ventilation as part of CPR, until EMS arrived on scene. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: The facility policy based on guidelines from the American Heart Association for Cardiopulmonary Resuscitation (CPR) dated [DATE] stated, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. The policy read the sequence of events were referred to as C-A-B (chest compressions, airway, breathing). Airway included to tilt the residents head back and lift the chin to clear the airway. Breathing included after 30 chest compressions to provide 2 breaths via ambu bag or manually with a CPR shield. Resident #1 was admitted into the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. A nursing progress note dated [DATE] at 3:45 PM written by Nurse#1 revealed Resident #1 had just arrived at the facility by EMS. Resident #1 was alert and oriented with no pain. The resident had oxygen at 2 liters via nasal cannula and his medications were verified with the medical director. Record review revealed an initial admission nursing assessment had not been completed for Resident #1. The code status of Resident #1 was located under the orders tab in the electronic medical record. Resident #1 was a full code. A nursing progress note dated [DATE] at 9:10 PM written by Nurse #2 revealed at 8:00 PM Resident #1 was alert and oriented with an oxygen saturation level of 96%. The note revealed around 9:15 PM Resident #1 began to complain of having trouble breathing. Nurse #2 increased the resident's supplemental oxygen to 3 liters via nasal cannula. Resident #1 began turning blue in color, had a faint pulse and became unresponsive. Life saving measure took place until Emergency Medical Services (EMS) arrived. Nurse #2 documented she called the on-call physician and Resident #1 left the facility for the hospital at 9:45 PM. On [DATE] at 3:35 PM an interview with Nurse #1 revealed she had received Resident #1 as a new admission during her shift on [DATE]. She stated he was alert and oriented when he came into the facility and had shown no signs of distress. An interview conducted with Nurse #2 on [DATE] at 11:05 AM revealed on [DATE] she came on shift at 7:00 PM and received report from Nurse #1 that Resident #1 was a new admission and was doing well. She stated she completed rounding and saw Resident #1 at 7:45 PM laying in bed in no distress. The interview revealed she was completing her medication pass when she went into his room around 8:30 and Resident #1 stated to her that he was having trouble breathing. She stated she placed the pulse oximetry monitor on his finger and his oxygen saturation level would not show on the pulse oximetry meter which meant his oxygen level was low. Nurse #2 asked Resident #1 if he had a history of COPD but then noticed the resident was turning blue in color around his face and fingers. She stated she immediately looked into his mouth to make sure there was nothing impeding his airway. Nurse #2 then laid the resident back onto the bed and began chest compressions while yelling for help from another nurse. She stated Nurse Aide #1 came into the room and she stated she needed the crash cart. Nurse #3, Nurse #4, and Nurse #5 also entered the room. She stated someone brought the crash cart into the room however it was locked, and the nurses did not know where the key was located. Nurse #3 stayed with her to rotate chest compressions. Nurse #5 ran out of the room to find the key to the crash cart and Nurse #4 went to call emergency medical services. Resident #1 began to have white foam around his mouth. Nurse #2 stated a suction canister was located on the top of the crash cart but the tubing to the suction was located inside of the cart so she could not suction Resident #1's mouth. She stated nothing on the crash cart was helpful to her in a time of need. Nurse #2 stated the ambu bag to provide airway support to the resident was also locked in the crash cart. Nurse #3 returned to the room and assisted Nurse #2 in 5 rounds of chest compressions until EMS arrived. She stated she had one of the NAs to go get a nebulizer machine but once it was in the room the machine malfunctioned and would not work. She stated Resident #1 had oxygen in his nose at 3 liters via nasal cannula during the incident. She stated once EMS arrived, they took over with the resident in the room for approximately 30 minutes before transporting him to the hospital. Nurse #2 stated she was an agency nurse and had never used the crash cart in the facility prior to that night. She stated she had no idea the cart was kept locked and nobody in the facility had told her where the key was located. The interview revealed she still worked in the facility and did not know where the crash cart key was located. She stated she was extremely upset after the incident and called the Unit Manager #1 to explain to her what had happened. She stated she told the Unit Manager #1 that she felt she didn't have the proper equipment to save Resident #1's life and knew she hadn't done everything possible in a time of need. She stated Unit Manager #1 apologized to her and stated she would do some education with the staff. Nurse #2 stated she never received any education following the incident. An interview was conducted with Nurse #4 on [DATE] at 11:21 AM. Nurse #4 stated she was working on the 200 hall on the night of [DATE]. She stated she had just completed her medication pass between 8:30-9:00 PM and went to the nurse's station when someone came out of Resident #1's room and yelled there was a code. Nurse #4 stated she got up and ran to the room to see how she could help. She stated she saw Nurse #2 laying the resident back onto the bed, calling his name and began giving chest compressions to the resident and she left the room to call EMS. She stated the nurses could not use the crash cart because it was locked and nobody in the building knew where the key was located. She stated they later learned there was another crash cart in the building that was unlocked but it had been covered with Halloween decorations at the time of the incident and nobody saw it. She stated she had never had to run a code in the building, and she had worked there since [DATE]. The interview revealed Nurse #2 did not have access to an ambu bag or suction supplies. She stated by the time a Nurse Aide obtained an ambu bag EMS had arrived in the building. Nurse #4 stated during orientation she did not remember the crash cart being discussed. An interview was conducted with Nurse #3 on [DATE] at 1:21 PM. Nurse #3 stated he was in the television room of the facility when he saw Nurse #4 looked panicked. He went to Resident #1's room and saw Nurse #2 doing chest compressions. He stated he stayed with Nurse #2 and when she became tired, he would take over doing chest compressions. He stated Nurse #5 came in the room stating she could not find the crash cart key so he went to look for it and she took his place. The interview revealed the nurses completed approximately 15 minutes of chest compressions before EMS arrived. He stated a staff member brought in the crash cart but they couldn't use it because it was locked. Nurse #3 stated they did not have access to an ambu bag or suctioning. The interview revealed he and a NA had gone to central supply to get the suction tubing and an ambu bag but by that time EMS arrived in the building. Nurse #3 stated he observed Resident #1 to be blue in color with white foam around his mouth. He stated there was another crash cart in the building, but he didn't work on that hall and he wasn't aware of it. He stated it was covered with decorations and they couldn't see it. An interview conducted on [DATE] at 11:43 AM with Nurse #5 revealed she was getting ready to go on her break around 8:30 PM on [DATE] and went down the 100 hall to see if they needed anything when she realized there was a code. Upon entering the room, she saw Nurse #2 and Nurse #3 initiating chest compressions on Resident #1. She stated they asked her where the key to the crash cart was, so she went out of the room and back to the nurse's station to find it. The interview revealed Nurse #4 was on the phone with EMS. She stated she looked everywhere she knew and could not find the crash cart key. Nurse #5 went back to the room and asked what the nurses needed. She stated they needed suction tubing, so she took over doing chest compressions for Nurse #3 and he went to find the tubing and crash cart key. She stated in total the nurses completed 5 rounds of chest compressions prior to EMS arrival. The interview revealed following the incident they learned the crash cart key was taped to the bottom of a drawer in the nurse's station after they called Unit Manager #1 to tell her what had happened. She stated she was agency and didn't know where anything was in the facility. Nurse #5 stated she felt incompetent by not being able to take care of Resident #1 because she was not properly oriented to the facility. An interview conducted on [DATE] at 11:59 AM with NA #1 revealed she was walking down the hall when she heard Nurse #2 say there was a code. She stated she went looking for the crash cart but when they got it to the room it was locked. The interview revealed she left the room and began looking for the key to the cart. She stated after she could not find the key, she remembered she had seen a ambu bag in the supply room so she went and got it. NA #1 stated by the time she got back to Resident #1's room EMS had arrived in the building. On [DATE] at 12:05 PM an interview was conducted with Unit Manager #1. She stated Nurse #2 called her and said they had to send Resident #1 out of the facility. She stated the nurse told her the resident had coded and the staff could only do chest compressions. Nurse #2 asked her where the key for the crash cart was located, and she instructed her it was taped to the bottom of a drawer in the nurses station and there was another cart on 100 hall. Unit Manager #1 stated to her that she did not know where the crash cart key was located during the code. She stated the key had been there for years and she thought it was odd out of the 4 nurses working that night that nobody knew where it was located. The interview revealed the staff were oriented to the facility by her and she stated she usually completed the orientation training. She stated the orientation consisted of telling the nurses where the crash cart was located along with the key. An interview conducted on [DATE] at 12:15 PM with the Director of Nursing (DON) revealed she was alerted to the situation by Unit Manager #1 on [DATE]. She stated Unit Manager #1 had been the on-call staff member working that night when staff called her stating they could not find the crash cart key. The DON explained the crash cart was locked because residents would get into it and the key had been in the same location for over a year. She stated agency staff received a packet with information in it for orientation and are shown around the facility. The DON stated she did not directly speak with Nurse #2 about the incident or ask about details of what had happened because she felt like Unit Manager #1 handled the situation. She stated Unit Manager #1 had went around asking everyone if they knew where the crash cart was located and if they did not know she would show them. The DON stated there was no written documentation of a in-service. On [DATE] at 1:03 PM an interview was conducted with the Medical Director (MD). During the interview he stated that during CPR giving chest compressions alone would not be 100% effective. He stated there had been changes in CPR techniques, but ventilation was important to a successful resuscitation. The interview revealed a full code status meant full scope of CPR including chest compressions and airway support. The Medical Director further stated an emergent situation was not the time to be looking for a key. The interview revealed Resident #1 was admitted on the evening of [DATE] and discharged on the same date within a few hours of being in the facility. Review of the hospital records dated [DATE] revealed Resident #1 arrived at the hospital intubated without sedation and unresponsive. Resident #1 was diagnosed with profound encephalopathy affecting basic brain functions that control wakefulness, breathing, heartbeat and temperature. Resident #1 displayed no organized neurologic activity, had a blown pupil on the left side and a negative head computed tomography (CT). The report read given the extended cardiac arrest time of 32 minutes per emergency medical services and Resident #1's lack of neurologic responsiveness he was admitted to the Intensive Care Unit. Resident #1 was transitioned to comfort care on [DATE] and palliatively extubated with the family at bedside. Resident #1 passed on [DATE] at 1:45 PM. The Emergency Medical Services (EMS) was unable to locate the report from [DATE]. The facility Administrator was notified of the immediate jeopardy on [DATE] at 5:30 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On [DATE] the facility failed to provide basic life support to include ventilation and suctioning. * On [DATE] resident #1 required CPR and received chest compressions with no ventilation or suctioning. *All other residents who have advanced directives that require a full code are at risk from suffering from the deficient practice. On [DATE], The DON and ADON completed an audit to determine all residents who have advanced directives that require full code. All residents identified to have advanced directives that require full code were assessed for signs or symptoms of cardiac arrest on [DATE] with no concerns found. On [DATE], an audit was performed by the DON on all crash carts to ensure they are unlocked and are complete with suctioning equipment and an Ambu bag. Both crash carts have been relocated to the nurses' stations and are fully stocked, unlocked, and accessible to all staff. Both crash carts require a key to be locked. The keys to both crash carts were removed and secured by the DON to ensure the carts remain unlocked and keys are no longer accessible for staff use. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n [DATE], education was provided to the Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) by the Corporate Consultant, Regional Director of Operations, regarding emergency procedures and cardio-pulmonary resuscitation. On [DATE], after being reeducated as outlined above, education for all staff including agency staff, was completed in person or via phone by the Administrator, DON, ADON or designee. The education consisted of the following: The need to Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. It is the Director of Nurses responsibility to ensure equipment is maintained and supplies necessary for CPR/BLS are accessible to staff at all times. Crash carts are to remain stored at the each nurses' station unlocked, and be equipped with suctioning equipment and an Ambu bag. The facility's procedure for administering CPR shall incorporate the steps covered in the Emergency Cardiovascular Care or facility BLS training material. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR by: a. Facility nurse will instruct a staff member to activate the emergency response system (code) and call 911. b. Facility nurse will instruct a staff member to bring the crash cart to the code location. c. Facility nurse will verify or instruct a staff member to verify the DNR or code status of the individual. d. Clinical staff to Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Alleged IJ removal date is [DATE]. The credible allegation was verified on [DATE] as evidenced by observations, staff interviews and record review. Interviews were conducted with the nursing staff to confirm in-services were completed on how and when to conduct CPR, how and when to request assistance with CPR and where to find the crash carts. Observations were made of the unlocked crash carts and supply audits were competed. The facility's immediate jeopardy removal dated of [DATE] was validated.