**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, and Medical Director interview the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors (Resident #31). Nurse #1 administered 38 units of insulin glargine (a long-acting insulin that lasts for 24 hours and does not have a peak onset of action) in error to Resident #31, a resident who did not have a diagnosis of diabetes. Resident #31's blood sugar dropped throughout the night and the resident was sent to the hospital due to a blood sugar level of 50 (normal range 90-100) requiring an overnight hospitalization. A serious set of symptoms of hypoglycemia can occur in people without diabetes including tremors, palpitations, anxiety, sweating, dizziness, weakness, increased risk for falls and fractures, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. The symptoms occur when the glucose level falls below 55 mg/dL, although this can be variable. There was high likelihood for serious harm. The findings included: Resident #31 was admitted into the facility on [DATE] with diagnosis which included hypertension and asthma. Resident #31 did not have a diagnosis of diabetes mellitus. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring limited assistance of one staff member for most activities of daily living (ADL). Resident #31 was coded as not receiving insulin. A nursing progress note dated 05/14/23 at 2:07 AM written by Nurse #1 revealed she had made a medication error by administering Resident #31 38 units of insulin glargine, a long-acting insulin. The note revealed Nurse #1 gave the resident peanut butter cookies, apple juice, ice cream and orange juice. The nurse monitored Resident #31's blood sugar every 15 minutes with the following results. - 11:00 PM: 111 - 11:15 PM: 82 - 11:30 PM: 78 - 11:45 PM: 80 - 12:00 AM: 90 The note revealed Nurse #1 notified the Director of Nursing (DON) by text message and placed a note in the Medical Director's communication book for when he came into the facility. Nurse #1 placed a call to the on-call provider and was awaiting a return phone call. A nursing progress note dated 05/14/23 at 4:38 AM written by Nurse #1 revealed Resident #31 was sent out to the hospital for an evaluation due to low blood sugar. The Director of Nursing, Medical Director was notified via communication book. The note revealed Nurse #1 would notify the resident's Responsible Party and primary Medical Director at 6:00 AM. Review of Resident #31's May 2023 Medication Administration Record (MAR) revealed no active orders for insulin glargine. Resident #31's physician orders dated May 2023 revealed no active orders for insulin. An interview conducted on 06/04/23 at 12:39 PM with Resident #31 revealed on 05/14/23 Nurse #1 came into his room during the night and asked him his name and date of birth . He stated the next thing he knew the nurse had popped him in the right arm with a shot. The resident stated he later learned what she had given him was insulin. Resident #31 stated he had never taken insulin nor had his blood sugar checked while in the facility. The interview revealed Nurse #1 then started monitoring Resident #31's blood sugar level and kept him up during the night. He stated he had to go to the hospital because his blood sugar levels kept dropping even after he ate crackers and drank juice. Resident #31 stated, the nurse didn't know what she was doing. An interview was conducted on 06/04/23 at 9:45 AM with Nurse #1. During the interview Nurse #1 stated she was agency staffing and not familiar with Resident #31. She stated she was responsible for two halls and had a medication aide. The interview revealed the medication aide had written down residents' blood sugars that had orders for insulin and gave Nurse #1 the list of residents. She stated around 11:00 PM she was told by the Medication Aide (MA) that she had to administer the insulin for the hall. Nurse #1 stated she did not go and log onto a computer, instead she took the paper sheet the MA had written and transferred onto another piece of paper the residents' blood sugars and insulin orders. She stated she did not look at a computer to know what the resident looked like or verify the nursing orders. The interview revealed she immediately felt like she had made a mistake because the resident was thin, and she felt like he didn't look like he would need that much insulin. She stated when she began to question Resident #31 about insulin the resident stated to her that his blood sugar had never been checked while in the facility. Nurse #1 stated she went and got the MA who went back into the room with her and verified that she had given insulin to the wrong resident. Nurse #1 stated she immediately took the resident's blood sugar with a reading of 111. Nurse #1 gave Resident #31 peanut butter cookies, orange juice and ice cream to try and keep his sugar maintained. The interview revealed that she continued to monitor his blood sugar every 15 minutes for the next hour up until it reached 90 and she felt like he was going to be okay. She stated she called the on-call provider but received no return phone call. She sent the DON a text message and placed a note in the Medical Director communication book. Nurse #31 stated she came back to Resident #31 around 4:00 AM to recheck his blood sugar with a result of 53. She then called the DON who told her the facility had glucagon (a medication used to increase a resident's blood sugar level) and to send the resident to the hospital for an evaluation. She stated she went to the cubex (facility medication dispensing machine) but there was no glucagon in the cubex. Nurse #1 then called Emergency Medical Services and they arrived shortly after. She stated Resident #31 remained without symptoms or change in color or sweating through the incident. On 06/04/23 at 11:43 AM an interview was conducted with Medication Aide (MA) #1. During the interview she stated she had given medication on Resident #31's hall however could not administer insulin to residents so she told Nurse #1 she would have to administer them. She stated she handed Nurse #1 a paper with the resident's blood sugar results on it with the correct resident's name. MA #1 stated she was sitting at the nurse's station when she overheard Resident #31 tell Nurse #1, he had never had his blood sugar checked since being in the facility and did not take insulin. She stated Nurse #1 administered the insulin anyway despite what Resident #31 told her. MA #1 stated she went into the room and stated to Nurse #1 that she had administered the insulin to the wrong resident. The interview revealed the incident happened quickly and MA #1 did not have a chance to stop Nurse #1 prior to administration. She stated Nurse #1 immediately said to start monitoring the resident's blood sugar every 15 minutes. MA #1 stated the resident's blood sugar reached 90 at midnight and he remained without symptoms. She stated Nurse #1 had attempted to call the on-call provider but hadn't received a return phone call or orders. The interview revealed when they rechecked his blood sugar at 3:30 AM they received a result of 53 and Nurse #1 called the Director of Nursing (DON) who stated to send the resident to the hospital for an evaluation. MA #1 stated it was shortly after that Emergency Medical Services (EMS) arrived and took Resident #31 to the hospital. On 06/05/23 at 2:30 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Nurse #1 had given Resident #31 his roommate's insulin by mistake on 05/14/23. She stated the nurse immediately realized she had made a mistake and notified the on-call provider. The DON stated Nurse #1 sent her a text message, but she did not receive it. She stated the nurse should have called her instead for a medication error. The DON stated she received a phone call from Nurse #1 around 3:45-4:00 AM to tell her what had happened. The DON stated she told the nurse to send the resident to the hospital since the insulin was long acting and his blood sugar could continue to drop. She stated Resident #31 needed closer monitoring than the facility could provide. The interview revealed Nurse #1 was able to get in touch with the on-call provider and Resident #31 was sent to the hospital for an evaluation. The DON stated following the incident she obtained statements from all staff involved and completed education on the 6 rights of medication administration. All nurses and medication aides were in-serviced, and the 6 rights of medication administration were placed on the front of all of the narcotic books on the medication carts. An incident report was completed, and she believed the issue arose when Nurse #1 did not use the electronic charting system while administering the insulin. She stated Nurse #1 never looked in the computer system and had written the insulin order under Resident #31's name by mistake. The DON stated Nurse #1 had not been back into the facility since the incident. She believed Nurse #1 was in a hurry and that was when the error occurred. On 06/06/23 at 2:32 PM an interview was conducted with the Medical Director (MD). He stated he was not working in the building at the time of the incident but after review thought the nurses had acted appropriately after realizing the medication error. The MD stated he felt like the mistake had a potential for harm but there was no harm to Resident #31. However, the MD stated that a low blood sugar was more dangerous than a high blood sugar and could lead to death. Emergency Medical Service (EMS) records dated 05/14/23 revealed EMS was dispatched to the facility at 3:48 AM and arrived on scene at 4:02 AM due to resident with a diabetic issue. EMS services found the resident sitting upright at the edge of the bed eating crackers with peanut butter. The resident stated, Nobody here knows what they're doing. The resident denied any complaints of pain and stated his blood sugar had been low. The resident also stated he did not have diabetes. Nurse #1 informed EMS that she was new to the hall and was not familiar with the residents. She told EMS that the resident's roommate was supposed to receive the insulin, but she had mixed up the residents and gave it to the wrong one. The note revealed due to the circumstances the resident was transported for observation to the emergency department. Resident #31's blood sugar level was recorded as 50. On 06/06/23 at 11:32 AM an interview was attempted with Emergency Medical Services (EMS). The surveyor left their phone number for a return phone call. Hospital records dated 05/14/23 revealed Resident #31 presented to the emergency department after accidentally being administered insulin. Resident #31 received 38 units of long-acting insulin and he did not have diabetes. Upon evaluation Resident #31 showed no signs of low blood sugar and his blood sugar was 91 then decreased to 69. The resident was placed on a D5 drip (infusion used to provide the body with extra water and carbohydrates (calories from sugar), and the ED Medical Director contacted poison control who recommended to monitor his blood sugar every 2 hours for at least 24 hours. Resident #31 was admitted into the hospital for observation. At around 2:00 PM Resident #31's blood sugar was ranging 121-257. Resident #31 returned to the nursing facility on 05/15/23. Facility administration was notified of immediate jeopardy on 06/16/23 at 9:02 PM. The facility provided the following the following corrective action plan with completion date of 05/15/23: Date: 5/14/2023 PROCESSES THAT LEAD TO THE ALLEDGED DEFICIENCY CITED: Resident #1 was sent to the hospital on 5/13/2023 regarding a medication error. Resident was given 38 units of Insulin Glargine during the night shift. During the night shift Nurse #1 reviewed the 24-hour report and noted the blood sugar of written under the Resident #2 name. Nurse #1 retrieved the medication Insulin Glargine for resident #2. Nurse #1 entered the room and asked the resident in bed A if he was the name on the insulin pen. The resident #1 stated yes. The nurse dialed the pen to 38 units and proceeded to administer the medication. The nurse walked out of the room and had a conversation with the medication aide #1. She informed she just gave the insulin to bed A. The medication aide #1 stated that is not the right resident. It was to be given to Bed B. The nurse immediately checked the resident #1 blood sugar and gave the resident a bag of peanut butter cookies, apple juice 120 milliliter (ml), ice cream 120ml, orange juice 120ml. Nurse #1 called the medical doctor. Nurse #1 checked the blood sugar every (Q) 15min. Blood sugar 111 at 11pm, 96 at 1115pm, 82 at 11:30pm, 78 at 11:45pm, 80 at 12am, 90 at 12:30, and 88 at 1:30. Resident #2 was administered his 38 units of insulin. During this time the nurse practitioner called back and gave an order to send the resident to the emergency room. The resident was sent to the emergency room. Upon arrival the residents blood sugar was 91. Resident #1 was admitted to the hospital. The nurse was immediately removed from the building pending the investigation. Root cause analysis: Based on medical record review and interviews Nurse #1 did not follow the 6 medication rights. Right RESIDENT - identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as photo on the MAR, asking a resident his/her name, etc. THE PROCEDURES FOR IMPLEMENTING THE ACCEPTABLE CREDIBLE ALLEGATION FOR THE ALLEGED IMMEDIATE JEOPARDY: Timeline of Event: On 5/13/2023 Director of Nursing reviewed Resident #1 medical record and determined that resident #1 did receive 38 units of insulin. The administrator was notified immediately. On 5/13/2023 the Director of Nursing and designee assessed confused residents for signs and symptoms of hypoglycemia. No concerns were noted. On 5/13/2023 the Director of Nursing and designee interviewed alert and oriented residents to ensure if the residents were on insulin, they were receiving it and if the residents were not on insulin, they had not received it. No concerns were noted. On 5/13/2023 the Director of Nursing initiated educated the License Nurses and Medication Aides on the 6 medication rights. Right RESIDENT - identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as photo on the MAR, asking a resident his/her name, etc. Right MEDICATION - the name of the medication ordered by the physician; always use the three checks. Right DOSE - the amount of medication ordered. Right ROUTE - the method of medication administration Right TIME - when the resident is ordered to receive the medication. Right DOCUMENTATION - the process of writing down that a medication was administered to the resident on the MAR OR if a medication was not administered and the reason it was omitted. On 5/14/2023, 1:1 Education was provided by the Director of Nursing with Nurse #1 that was involved in medication error. THE MONITORING PROCEDURE TO ENSURE THAT THE CREDIBLE ALLEGATION IS EFFECTIVE AND REMOVE THE ALLEGED IMMEDIATE JEOPARDY: On 5/14/2023, the Director of Nursing or designee will monitor 5 medication passes a week for 4 weeks, 3 medication passes a week for 4 weeks, 2 medication passes a week for 4 weeks to ensure the 6 medication rights are being followed during the medication passes. Results of all audits will be reviewed in the facility Quality Assurance and Performance Improvement Committee meeting monthly for three months (3) months. The Quality Assurance and Performance Improvement Committee will review the audits to make recommendations to ensure compliance is sustained ongoing; and determine the need for further auditing beyond the three (3) months. The title of the person implementing this acceptable plan of correction: Effective 5/13/2023, the facility Administrator and Director of Nursing will be responsible for the implementation of this plan of correction. The Administrator will ensure the facility attains and maintains substantial compliance. Date of Immediate Jeopardy removal: 5/15/2023 On 06/07/23, the facility's corrective action plan effective 05/15/23 was validated by the following: Nursing staff interviews revealed they had received education on the 6 rights of medication administration. The 6 rights of medication administration document were placed on every medication cart in the facility as a reminder to nurses. Administrative staff interviews revealed they had completed audits of nurses and medication aides during medication pass. Documents were reviewed from the facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. The facilities medication error rate was 0% during the medication pass facility task completed by the survey team. The facility's action plan was validated to be completed as of 05/15/23.

Based on observation, record review and staff interviews, the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 2 of 2 residents observed (Resident #3 and Resident #105) during a medication pass on 06/06/23 at 9:05 AM. The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter. The facility had three residents in the building with a diagnosis of a bloodborne pathogen (microorganisms that cause disease and are present in human blood) (Resident #104, Resident #64 and Resident #76). This deficient practice had a high likelihood for transmitting bloodborne pathogens within the facility. Immediate Jeopardy began on 06/06/23 when Nurse #6 was observed during medication pass removing two glucometers from the medication cart and use them without disinfecting per manufacturer's guidelines. The immediate jeopardy is present and ongoing. Findings included: Review of the facility policy Glucometer Disinfection revised in October 2020 read, in part, to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The blood glucose meter manufacturer's instructions for cleaning and disinfecting dated 9/2019 indicated the blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. A list of Environmental Protection Agency (EPA) wipes were recommended on the cleaning instructions. Additional instructions were to read the manufacturer's instructions for the use of the wipes. The wipes container which was located on top of the medication cart read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. An observation on 06/06/23 at 9:07 AM of Nurse #6 revealed she gathered necessary supplies, removed the glucometer from the top right drawer of the medication cart and went into Resident #3's room and obtained her blood sugar with a result of 84. She exited the room and returned to the medication cart in the hall. Nurse #6 was observed placing the glucometer immediately back into the top right drawer on the medication cart. An observation on 06/06/23 at 9:16 AM of Nurse #6 revealed she gathered necessary supplies, removed a second glucometer from the top right drawer of the medication cart and went into Resident #105's room and obtained his blood sugar with a result of 184. She exited the room and returned to the medication cart in the hall. Nurse #6 was observed placing the glucometer immediately back into the top right drawer on the medication cart. An interview conducted on 06/06/23 at 11:13 AM with Nurse #6 revealed she was an agency nurse. She stated she knew she was supposed to disinfect the glucometers after each use. Nurse #6 stated she had gotten nervous and just forgotten. An interview on 6/07/23 at 11:44 AM with the Director of Nursing (DON). She stated that the disinfecting contact time for the blood glucose meter should be two minutes. She stated the staff have been trained and she did not know why the nurse didn't follow policy. The DON stated that she did not know why each resident did not have their own personal glucometer. The interview revealed as far as she knew that's how it had always been in the facility with the residents not having individual glucometers. An interview on 06/07/23 at 6:47 PM with the Administrator revealed that blood glucose meters should be disinfected according to the manufacturer's instructions. An interview was conducted on 06/14/23 at 10:30 AM with the Administrator. The Administrator provided information regarding the number of residents in the facility with a diagnosis of a bloodborne pathogen. The document provided revealed the facility had three residents in the facility with a bloodborne pathogen, one with Hepatitis B and C (a severe form of viral hepatitis transmitted in infected blood), and two with Hepatitis C. Facility administration was notified of immediate jeopardy on 06/14/23 at 2:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, and Medical Director interviews the facility failed to prevent a significant medication error by failing to administer a physician ordered post-surgical antibiotic for three days after the resident readmitted to the facility for 1 of 1 resident reviewed for significant medication errors (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included nephrolithiasis (kidney stone) and chronic suprapubic catheter use. Review of a Brief Interview for Mental Status (BIMS) dated 12/08/22 revealed that Resident #1 was cognitively intact. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was not assessed. The MDS further revealed that Resident #1 required extensive to total assistance with activities of daily living. The MDS further revealed that Resident #1 had an indwelling catheter, and his bladder incontinence was coded as not rated. Review of a discharge summary from the local hospital dated 05/06/23 read in part; Current Discharge Medication List: New medications: Cefpodoxime (antibiotic) 200 milligrams (mg) by mouth two times a day for five days. Start 05/05/23 and end 05/10/23. Review of a physician order dated 05/07/23 read; Cefpodoxime 200 mg give one tablet by mouth two times a day for infection. The order was entered by Nurse #8. Review of a physician order dated 05/08/23 read discontinue Cefpodoxime. The order was entered by Nurse #1. Review of a physician order dated 05/08/23 read Cefpodoxime 200 mg give one tablet by mouth two times a day for infection. The order was entered by Nurse #1. Review of Resident #1's Medication Administration Record (MAR) dated May 2023 revealed the following: Cefpodoxime 200 mg give one tablet by mouth two times a day. On 05/06/23 at 9:00 AM and 5:00 PM there are x's indicating the medication was not given. On 05/07/23 at 9:00 AM and 5:00 PM it was coded as being held and see nurse's notes. On 05/08/23 at 9:00 AM and 9:00 PM it was coded as being held see nurse's notes. Review of a nurses Medication Administration Note dated 05/07/23 at 3:12 PM by Nurse #8 read pharmacy contact regarding Cefpodoxime 200 mg. Review of a nurses Medication Administration Note dated 05/07/23 at 6:08 PM by Nurse #8 read, Cefpodoxime awaiting pharmacy. Review of a nurses Medication Administration Note dated 05/08/23 at 9:35 AM by Nurse #1 read, Cefpodoxime spoke with pharmacy about medication and medication will be sent out on run today. Review of a nurses Medication Administration Note dated 05/09/23 at 6:31 AM by Nurse #9 read; Cefpodoxime not in stock, on order. An interview was conducted with Resident #1 on 05/15/23 at 10:06 AM. Resident #1 stated that he recently returned to the facility after having a surgical procedure to remove a kidney stone on 05/06/23. He stated he was supposed to be on an antibiotic to prevent infection from the surgical procedure, but he had not received his first dose until 05/09/23. He added that the last dose was to be on 05/10/23 but he did not get it timely, so he remained on the antibiotic at this time. Nurse #9 (agency) was interviewed via phone on 05/15/22 at 10:47 AM. Nurse #9 confirmed that she worked in the facility on 05/08/23 from 7:00 PM to 7:00 AM and was taking care of Resident #1. She stated Resident #1 was prescribed an antibiotic and it had not come in from the pharmacy, so she did not have it to give. Nurse #9 stated that another staff member who she did not know had told her that it would be coming from the pharmacy. On 05/09/23 the staff member that was relieving her was running late so at approximately 7:00 AM the pharmacy arrived with the delivery of medications. Nurse #9 stated that she obtained the antibiotic medication from the pharmacy tote and placed it on the medication cart to be administered at 9:00 AM. The Pharmacist in Charge was interviewed via phone on 05/15/23 at 1:51 PM who stated that the pharmacy received the Cefpodoxime order on 05/08/23 at 4:50 PM and was filled on 05/08/23 and was delivered to the facility on [DATE] at 7:03 AM. Nurse #8 (agency) was interviewed via phone on 05/15/23 at 2:35 PM who confirmed that she worked on 05/06/23 and 05/07/23 and was responsible for Resident #1. She stated that she could not recall if she made a note when he returned to the facility and did not know what time he returned to the facility. She stated that she did not enter any orders but gave the packet of information to the oncoming shift to handle but could not recall which nurse that was. Nurse #8 stated that when a resident readmitted to the facility, they generally did not receive any new medications until the following day when they arrived from the pharmacy. Nurse #8 stated she did not recall contacting the pharmacy but if she documented that she did, then she did. She further stated she did not recall contacting the Medial Doctor (MD) regarding the antibiotic but stated if there were new orders, she would have entered them into the electronic record. Nurse #1 (agency) was interviewed via phone on 05/16/23 at 9:43 AM and confirmed that she had worked with Resident #1 on 05/08/23. She stated that the Cefpodoxime had not come in the from the pharmacy so she contacted the pharmacy, and they stated that it would be coming that evening on 05/08/23 but Nurse #1 stated her shift ended before the delivery arrived from the pharmacy, so she was not sure if it came in or not. Nurse #1 stated that she had discontinued the original order and re-entered it so that it would be correct on the MAR of when the medication was started and was to end. If the Cefpodoxime had an end date she would have entered that date was well so that it would be stopped on the MAR after the correct number of doses. Director of Nursing (DON) #1 was interviewed on 05/15/23 at 4:49 PM. DON #1 stated that when Resident #1 returned from the hospital on [DATE] his medications should have been reordered and the staff should have gone to the back up supply and pulled what they could and administered those medications. Then the staff should have contacted the MD for an order to hold the other medication until they arrived from the pharmacy. DON #1 stated that she was not made aware of any issues with Resident #1's Cefpodoxime or medications. The MD was interviewed via phone on 05/15/23 at 1:33 PM who stated that he was no longer the MD at the facility effective 05/07/23. He stated that new orders for antibiotics should be started no later than twenty-four hours after the order was given to significantly reduce the risk of infection post operatively. If the antibiotic was not available in twenty-four hours, then the provider should have been made aware to make other recommendations to get the antibiotic started sooner rather than later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff and the Nurse Practitioner the facility failed to prevent a significant medication error when Narcan (reversal agent used in case of overdose) was not administered as prescribed for a resident who had a known history of substance abuse that included crushing and snorting pills/medications. The Nurse Practitioner ordered Narcan as needed for overdose on [DATE] for Resident #3. Resident #3 was found unresponsive in his room on [DATE], Cardiopulmonary Resuscitation (CPR) was initiated but Narcan was not administered as ordered and the resident was unable to be revived. Nursing Assistant (NA) #11, NA #12, and Housekeeper #1 had observed a white, powdery substance on the tray table in Resident #3's room. The facility also failed to notify Emergency Medical Services (EMS) that responded to Resident #3's cardiac arrest on [DATE] that he had a history of drug abuse nor that there was a white powdery substance found next to him. This affected 1 of 4 residents reviewed with sudden cardiac arrest (Resident #3) Resident #3 expired in the facility on [DATE]. Immediate Jeopardy began on [DATE] when Resident #3 was found unresponsive in his room with a white powdery substance on his bedside table and the facility staff failed to administer an ordered dose of Narcan for a suspected drug overdose. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included cocaine dependence, congestive heart failure, and chronic respiratory failure. Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, or rejection of care. Resident #33 was coded with having frequent pain and he received opioids 7 of 7 days during the lookback period. The MDS revealed Resident #3 was born in 1960 indicating he was [AGE] years old. Review of Resident #3's physician orders revealed the following physician orders: - Oxycodone (opioid pain medication) HCl Tablet 20 milligrams (mg) - Give one table by mouth every 6 hours as needed for pain. Crush oxycodone and the patient is to take the medication in front of the nurse. The order's start date was [DATE] - Narcan [reversal agent used in case of overdose] liquid 4mg/0.1 milliliter (ml) - 4 mg in nostril every 6 hours as needed for overdose. The order's start date was [DATE]. Resident #3's care plan last updated on [DATE] revealed the following information: - Resident #3 exhibits or has the potential to exhibit verbal/physical behaviors related to opioid dependence and anxiety; history of snorting pills/medications, misuse of oxygen. Interventions included monitoring medication administration to ensure medications are taken and swallowed prior to leaving resident. - Resident #3 does complain of pain at times due to impaired mobility. Resident #3 has a diagnosis of chronic pain and opioid dependence. Resident has pain medication in place and is followed by pain clinic. Interventions included Per MD order Narcan 1 milliliter by nasal route as needed for opioid overdose. Repeat every 2 minutes until emergency medical services arrive. An interview with the Pharmacist on [DATE] at 12:12 PM revealed they received the physician order for Narcan on [DATE] and that the prescription was filled and delivered on [DATE]. She reported the Narcan they sent would have had Resident #3's name on it along with the dosing schedule. A review of Resident #3's medication administration record from [DATE] revealed the order for Narcan to be administered in the event of an overdose. No dose of Narcan was signed off on as having been given on [DATE]. A review of Resident #3's physician progress notes revealed a note from [DATE] that included the following: Behavioral concerns - this NP [Nurse Practitioner] recommends that the patient be discharged from this facility for numerous documented reports from the staff of overdose, abuse, and noncompliance. I believe that the patient puts the facility at risk for liability if he were to overdose. I have added Narcan 4mg [Milligrams] nasal every 6 hours as needed for overdose. I have expressed by concerns with the [Former] Director of Nursing, Administration, and Medical Director. The note was electronically signed by NP #2. During an interview via telephone on [DATE] at 9:01 AM with Nurse Practitioner (NP) #2 reported she was no longer working at the facility. She reported Resident #3 had a history of taking his narcotic pain medication and then turning his oxygen up on his portable tanks and concentrator until he would pass out. She stated she was concerned about Resident #3 abusing his narcotics because she heard from unknown staff members that he pocketed the medications and then crushed and snorted them. She reported several months before August of 2022 she refused to prescribe him narcotic pain medications and referred him to a pain clinic for monitoring. The pain clinic ordered oxycodone. She reported Resident #3's narcotic pain medication was to be crushed and Resident #3 observed until it was fully taken in applesauce or another medium. She reported she received information from a staff member whom she could no longer remember, who informed her there was a picture of Resident #3 cutting a white powdery substance on his tray table in the facility that was turned into administration. She explained this was when she prescribed Resident #3 Narcan ([DATE]) to be given in the event of an accidental overdose. The Medication Administration Record (MAR) for [DATE] revealed oxycodone was administered to Resident #33 on [DATE] at 2:16 AM by Medication Aide (MA) #3. An interview with Medication Aide #3 (MA) on [DATE] at 3:14 PM revealed she was assigned on the medication cart and was responsible for providing Resident #3 with his medication from 7:00 PM on [DATE] until 7:00 AM on [DATE]. She stated she last gave him his narcotic pain medication at 2:16 AM on [DATE] and found him unresponsive around 5:30 AM. She could not recall with certainty if she crushed his oxycodone when she last administered the medication. She went onto say that she would have administered them as it was ordered on the MAR. MA #3 stated she had worked with Resident #3 a few times previously and she remembered reading in his chart that he had some drug seeking behaviors. She revealed when she worked with him, he came up to her medication cart before he was due to receive his narcotic pain medication and waited there until it was time for it to be administered. She further stated Resident #3 did not have a physician order for Narcan because she would have made a note to herself. She also reported she did not have Narcan on her cart and that it would have been out of the ordinary for a resident to have a physician order for Narcan. She reported during the entirety of time she assisted with Resident #3's emergency, she never saw anyone administer Narcan or tell EMS personnel when they arrived that Resident #3 had a history of drug abuse. Med Aide #3 indicated she had not received any formal education on how to administer Narcan nor any education on how to identify a resident who had an overdose. A nurse progress note completed by Nurse #13 dated [DATE] at 7:28 AM read in part, Resident #3 reported on floor at 6:15 AM by [Med Aide #3] following ambulation by resident from smoking area .emergency medical services [EMS] notified by staff while this nurse and additional nurse performed cardiopulmonary resuscitation in resident room. EMS arrived at 6:25 AM .Resident #3 pronounced expired by EMS at 6:46 AM. During an interview with Nurse #13 via phone on [DATE] at 3:44 PM, he reported he responded to calls for help from MA #3. He stated he went to Resident #3's room and found him on the floor, still warm but with no pulse or respiration. He stated he immediately called a code blue and began chest compressions. Nurse #13 stated Resident #3 was not on his assignment, and he did not know anything about Resident #3's medical history including past drug abuse or overdoses. He stated he had no reason to suspect a drug overdose and stated that Narcan was not administered by him. He reported he was assigned to oversee the Medication Aide #3 on that hall but stated he had no knowledge of Resident #3's medical history or care needs. A review of the EMS run report from [DATE] at 6:25 AM revealed they arrived at the facility and began CPR on an unresponsive resident. Per the report, the responding EMS personnel were not informed of a potential overdose situation when they arrived or at any time while they provided emergency assistance to Resident #3. An interview with NA #11 (agency) on [DATE] at 12:05 PM via telephone, she reported she was assigned to Resident #3 on [DATE] on 3rd shift. She stated MA #3 went into Resident #3's room to give him his medications around 5:00 AM and found him unresponsive. She reported MA #3 screamed for assistance and she and NA #12 went running. She stated when she got to the room, she noticed a white, powdery substance on Resident #3's tray table. Interview with NA #12 (agency NA) on [DATE] at 12:35 PM revealed she worked the night of [DATE] Resident #3 and had run to the room when MA #3 called for help after finding him unresponsive. She stated when she arrived at the room, she noticed a white, powdery substance on his side table. An interview with Housekeeper #1 on [DATE] at 3:33 PM via telephone, revealed she went into Resident #3's room on [DATE] and wiped off a white, powdery substance from his tray table. She reported she did not know Resident #3's medical history or if he had a history of substance abuse. She reported she only wiped off the tray table after EMS requested her to do so. She could not provide any information on why EMS asked her to wipe off Resident #3's tray table. During an interview with NA #7 on [DATE] at 3:28 PM she reported she believed Resident #3 died due to an overdose due to her experience of seeing him snort an unidentified powdery substance on more than one occasion. NA #7 stated each time she observed Resident #3 snorting a white substance, she stopped him and got the nurse on the hall. She reported by the time she and the nurse returned to the room, the white, powdery substance was gone, and Resident #3 stated it was baby powder and denied snorting it. She reported she also wrote two separate reports regarding what she observed and slid them under Administrator #3's door. NA #7 stated she could not remember the dates she completed the reports but was certain she slid them underneath Administrator #3's door. She reported to her knowledge, nothing was done to prevent Resident #3 from snorting a white, powdery substance. Administrator #1 was asked on [DATE] at 4:30 PM to locate the written statements from NA #7 regarding Resident #3's observed behaviors of crushing and snorting his medications but she reported on [DATE] at 10:00 AM she was unable to locate them. An interview with Resident #3's former roommate, Resident 13, was conducted via telephone on [DATE] at 1:16 PM revealed he had reported Resident #3's drug abuse to facility staff multiple times including to the Wound Nurse and to former Social Worker #1. He stated he even sent pictures and video he had taken on his cell phone to them on their personal cell phones. Resident #3's former roommate reported he felt that someone from the facility was bringing in either cocaine or opioids and providing them to Resident #3. He stated he watched Resident #3 numerous times pull out pills, chop them up on his tray table, and snort them. On [DATE] at 12:18 PM the photograph and video recorded by Resident #13 was reviewed. They showed Resident #3 sitting in his wheelchair, in his room, next to his bed with his back to the door. Resident #3 was wearing a lime green t-shirt and had a bank debit card in his hand pressing the edge down onto a white, powdery substance that was on his tray table beside his bed. An interview with the Wound Nurse on [DATE] at 12:01 PM via telephone revealed it was very well known that Resident #3 had a substance abuse problem and crushed his opioid medications and snorted them. She also reported she had received a photograph and a short video, unable to recall the date, from Resident #3's roommate, Resident #13, that showed Resident #3 using a credit card to cut a white, powdery substance on his tray table in his room at the facility. She reported she immediately sent them to Director of Nursing #3 and provided them to a Corporate Staff member who was a female. She was unable to remember her name or her position. She stated she also wrote a statement, unable to recall the date, and provided it to the Corporate Staff member. The Wound Nurse reported she heard nothing back from Director of Nursing #3 or the Corporate Staff member about the situation. The Wound Nurse reported she felt that the situation was ignored. Interview with the former Social Worker #1 via telephone on [DATE] at 3:15 PM revealed she remembered Resident #3 and that he had a history of abusing his medications by crushing and snorting them. She reported Resident #3's former roommate, Resident #13, had approached her in her office some time, unable to recall the date, and told her Resident #3 was storing medications under his tongue then crushing and snorting them. She stated she brought it up to Director of Nursing #3 and Administrator #3 immediately after being informed, but it was blown off. She stated, everyone knew about it, and no one did anything. She reported there were no additional interventions put into place to increase supervision and despite his behaviors being discussed weekly at morning meeting; it was always not taken seriously. An interview was attempted with Director of Nursing #3 and was unsuccessful. An interview was attempted with Administrator #3 by telephone and was unsuccessful. An interview with Director of Nursing (DON) #1 on [DATE] at 10:26 AM, revealed although she was not working in the facility at the time of the incident, if there was a suspected overdose situation with a resident with a known substance abuse issue, who had a physician order for Narcan, she expected her staff to administer the Narcan as ordered. She also reported she expected the medication aides and the hall nurses to know which residents were at risk for overdose and administer Narcan as ordered. She reported she also expected her medication aides and hall nurses to be educated on how to administer Narcan and to notify responding EMS personnel on the drug abuse history of the resident in distress immediately upon their arrival. During a follow up interview with Nurse Practitioner (NP) #2 via phone on [DATE] at 4:00 PM, she stated due to Resident #3's history of drug abuse, along with continued observed abuses of his opioid medications while admitted to the facility she prescribed Narcan to be administered not if but when Resident #3 overdosed. She reported the Narcan was on the medication cart and should have been dedicated to Resident #3. She stated the failure of the facility to administer the ordered Narcan was a significant medication error and reported if it had been given, more than likely, could have saved Resident #3's life. She reported giving Resident #3 a dose of Narcan if he was having a genuine cardiac arrest of respiratory failure situation would have had no significant adverse effect. She reported when Narcan was ordered, it should have shown up directly under Resident #3's opioid prescription because that was the medication, she was worried he would overdose using. Administrator #2 was notified of the immediate jeopardy on [DATE] at 4:33 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #3 was identified as having a significant medication error. Resident #3 was found unconscious on [DATE] with a white, powdery substance noted on the bedside and NARCAN was not administered. Resident #3 had a history of substance abuse. Resident #3 expired on [DATE] at the facility. All current residents that have a history of drug abuse have the potential to be affected. A list was made by the Chief Nursing Officer of the residents who had a history of polysubstance abuse. The list was placed on the nurse carts and placed in the narc book. The Director of Nursing will be responsible for updating the list with new admissions that have a history of polysubstance abuse. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On [DATE], the Director of Nursing and Chief Nursing Officer educated licensed nurses and medication aides on the administration of NARCAN in the event a resident with known drug use history should be found unconscious and that residents with history of polysubstance abuse had physician order for NARCAN. Education also included signs and symptoms of overdose and nursing communication shift to shift on residents with history of polysubstance abuse and presence of list of residents with history of polysubstance abuse being located in the narc book on the cart for ease of access. Furthermore, education included notifying EMS upon their arrival of the substance abuse history and the administration of Narcan. The Director of Nursing will ensure no licensed nurses or medication aides will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on [DATE] by the Director of Nursing or Chief Nursing Officer. Effective [DATE], Administrator #2 will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is [DATE]. On [DATE] and [DATE] the credible allegation of immediate jeopardy was validated. A full list of residents with histories of drug abuse was observed at the nurses' stations and on the medication carts. The interviewed medication aides and nurses were aware of the individuals identified by the facility as having histories of drug abuse and were also able to articulate what they needed to do in a suspected overdose situation and how to administer doses of Narcan. The facility's immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner and Medical Director interviews the facility failed to have basic lifesaving equipment readily available for use to immediately begin cardiopulmonary resuscitation (CPR) when Resident #3 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because the first crash cart (cart of emergency supplies) that was brought to the bed side did not have a ambu bag or manual resuscitator (device to administer rescue breathing) on it, staff began chest compressions and it took the staff approximately three minutes to get the second crash cart that did have a ambu bag to begin rescue breathing. Resident #1 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because the staff could not locate an ambu bag or manual resuscitator to begin rescue breaths and could not locate a backboard (hard surface to do chest compressions on while in bed). It took the staff approximately five minutes to locate the needed items to begin CPR. On [DATE] Resident #2 experienced sudden cardiac arrest and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because they could not locate an ambu bag or manual resuscitator and had to borrow one from another resident's room. The staff also could not locate the paddles for the Automatic External Defibrillator (AED) (device used to deliver a shock to the heart). It took staff several minutes to locate the ambu bag and paddles for the AED to begin CPR. This affected 3 of 4 residents reviewed who experienced sudden cardiac arrest. Resident #1, #2, and #3 expired in the facility or in the hospital. Immediate Jeopardy began on [DATE] when Resident #3 experienced sudden cardiac arrest and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because they could not locate an ambu bag to begin rescue breathing. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The finding included: Review of the facility's policy titled CPR Procedures, last revised on 03/22 read in part: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing a. Verify or direct a staff member to verify the DNR (Do Not Resuscitate) or code status of an individual b. Instruct a staff member to activate the emergency response system (code) and call 911 c. Instruct a staff member to retrieve the crash cart d. Initiate the basic life support (BLS) sequence of events. 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia and congestive heart failure. Review of a physician order dated [DATE] indicated Resident #3 was a full code. Review of a care plan dated [DATE] read; Resident #3 has an established advanced directive; Full Code. The goal read: Resident #3 wishes as expressed in Advanced Directive will be followed. Review of Resident #3's progress notes revealed a note by Nurse #13 dated [DATE] at 7:28 AM that read in part: Resident reported on floor at 6:15 AM by Med Aide #3 (MA) following ambulation by resident from smoking area. Resident assessed for pulse and respiration. Resident #3 was placed in a supine position and chest compressions were initiated immediately. EMS (Emergency Medical Services) notified by staff while this Nurse #13 and additional Nurse #7 performed CPR in (cardiopulmonary resuscitation] in residents' room. EMS arrived at 6:25 AM and began working with resident. Resident pronounced expired by EMS at 6:46 AM. An interview with Nurse #13 (agency nurse) was conducted on [DATE] at 3:44 PM via telephone and revealed he was an agency nurse and the first nurse to respond to calls for help from MA #3 on [DATE] when Resident #3 was found unresponsive but still warm. He reported he requested the crash cart and assistance from Nurse #7. He stated he immediately began chest compressions until Nurse #7 arrived at the room and began assisting with rescue breaths via an ambu bag. He reported he did not know if a second crash cart had to be retrieved as his main concern was trying to save Resident #3's life. Review of the facility's staffing schedule from [DATE], the morning Resident #3 passed away, revealed Nurse Aide (NA) #11, NA #12, Nurse #7, Nurse #12, Nurse #13, and Medication Aide (MA) #3 were working. An interview with MA #3 on [DATE] at 3:14 PM revealed when she found Resident #3 in the floor of his room unresponsive around 5:30 AM on [DATE] she immediately called for help and Nurse #13 arrived at the room. She reported she was told by Nurse #13 to go gather the necessary paperwork for transport, so she left the room. She did not know if there were issues with items not being on the crash carts. An interview with NA #13 (agency) was conducted on [DATE] via telephone, at 2:42 PM and revealed she was working in the facility on [DATE] as a nurse aide the morning Resident #3 had passed away. She stated around 5:30 AM, MA #3 entered Resident #3's room and found him unresponsive. She reported the first crash cart was brought to the room and she ran to get Nurse #7 who was working on the other unit. She stated when she returned from notifying Nurse #7, she found out the crash cart did not have an ambu bag on it and she ran back down the hall to get the other crash cart. She reported there was an approximate 5-minute delay in getting the supplies gathered to begin CPR. During an interview with NA #11 on [DATE] at 12:05 PM she reported she and NA #12 were assigned to Resident #3 on [DATE], the morning he passed away. She reported he had gone out to smoke around 4:00 AM and seemed his normal self. She reported when MA #3 went into his room around 5:00 AM, she found him on the floor and screamed for help. NA #11, NA #12, NA #13 and Nurse #13, responded to Resident #3's room. She reported NA #13 ran to get the crash cart while Nurse #13 began Cardiopulmonary Resuscitation (CPR). She reported she remembered the second crash cart had to be retrieved because the first crash cart did not have an ambu bag. An interview with NA #12 was conducted on [DATE] at 12:35 PM and revealed she was working on [DATE] the morning Resident #3 died. She reported that when the staff were made aware Resident #3 was in cardiac arrest, Nurse #13 sent NA #13 to go get the crash cart while she started CPR. NA #12 reported when NA #13 returned with the crash cart she had to go get a second crash cart because the first one did not have a backboard or an ambu bag. She reported it took 2-3 minutes before all the supplies were at Resident #3's room to begin CPR. An interview was attempted with Nurse #7 and was unsuccessful. A joint interview with Unit Manager (UM) #1 and UM #2 on [DATE] at 1:15 PM revealed they were responsible for ensuring crash carts were stocked and that the crash carts were checked daily and completed a log of inventory that was kept on the crash carts. They reported they checked the crash carts to ensure they contained ambu bags, oxygen, a suction machine, and other needed materials in the event of a cardiac arrest event. They also reported the logs from [DATE] had been long removed and were unable to locate them. UM #1 and UM #2 insisted both of the facility's crash carts had an ambu bag and that backboards were kept next to the crash carts. A telephone interview with the Medical Director on [DATE] at 5:13 PM revealed he expected the facility to have the supplies they needed on the crash carts to immediately start CPR in the case of a sudden onset of cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a backboard was next to each crash cart. The crash carts were also stocked with a suction machine, tubing, nasal cannulas, stethoscope, blood pressure cuff, and other supplies that may be needed during a cardiac arrest emergency. An interview was attempted with the Director of Nursing #3 and was unsuccessful. An interview was attempted with Administrator #3 and was unsuccessful. 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, peripheral vascular disease, atrial fibrillation, and others. Review of a physician order dated [DATE] read: Full Code. Review of a care plan dated [DATE] read; Resident #1 will have Full Code Advance Directives. The goal read: Resident #1 will have his Advance Directives followed. Review of a nurses note written on [DATE] as a late entry by Nurse #1 read, Resident was found to be unresponsive by the NA who was in the process of making rounds. CPR was started immediately. EMS was called and they arrived in 10 minutes. EMS took over CPR compressions and proceeded to continue to perform full code on resident. Resident continue to be none responsive. The ER doctor on call pronounced resident deceased at 2:26 AM. Resident #1 expired on [DATE]. Nurse #1 (agency nurse) was interviewed via phone on [DATE] at 12:14 PM who confirmed she was working third shift on [DATE]. She stated she was passing medications and had passed Resident #1's room and he was in bed and was his usual self. Nurse #1 stated that a short time later one of the NAs who she did not know came to her and stated that Resident #1 was not breathing. Nurse #1 stated that she was not aware how to page overhead, so she began yelling loudly to alert other staff that she needed some help. She stated that she sent the NAs to get the crash cart while she began chest compressions. Nurse #1 stated I was getting mad because they could not find anything that was needed, it took them over five minutes to find what we needed (backboard and ambu bag) and she was not aware of where they located the items. Nurse #1 stated she was the only nurse in the room and had to teach the nurse aides how to use the ambu bag really quick. Nurse #1 stated that she worked at the facility through an agency, and she did not get any orientation to the facility regarding emergency procedures or protocols. She stated she knew where the crash carts were from just observing during her times in the facility, she stated, I was very upset, I felt like that when you have crash carts it should be supplied even with the basics and that night it did not have an ambu bag and the back board could not be located. Nurse #1 confirmed that when the NA told her that Resident #1 was not breathing, she had gone to the electronic medical record and verified his code status as Full Code and when she began chest compression Resident #1's body was still warm to touch, and she confirmed that she checked all his pulse points and could not find one so chest compression were initiated while she waited for the appropriate equipment. NA #1 (agency NA) was interviewed via phone on [DATE] at 11:06 AM who confirmed that she worked at the facility through an agency and was working third shift on [DATE] when Resident #1 went into cardiac arrest. NA #1 stated that she was very familiar with Resident #1 and each night that she worked she would always go and check on him, she stated he particularly loved milk and shortly after the start of her shift on [DATE] she had gone and got Resident #1 a carton of milk to drink. She stated she had passed by his room several times during the shift and Resident #1 was in his bed in his usual state. She stated then she heard the staff verbally hollering that they had Code Blue (code for sudden cardiac arrest), and she went running towards Resident #1's room. NA #1 stated that someone had grabbed the crash cart but there was no ambu bag on it and no backboard was available. She stated that Nurse #1 began chest compressions, but he was on the soft bed not on a hard surface. NA #1 stated she suggested to Nurse #1 that they lower him to the floor to begin compressions, but she continued to do compressions while the staff frantically tried to locate an ambu bag to do rescue breathing. NA #1 stated that it took a few minutes for someone to find an ambu bag, but she could not recall who found it and she did not know where they found it. NA #1 stated that she believed the crash carts were to be checked daily to ensure all the supplies were available but stated that when they needed to do CPR on Resident #1 the crash cart did not have an ambu bag and no back board was available. She added that the crash cart they used stayed in disarray for about three weeks after the event until someone returned it to the correct place and restocked it. NA #2 was interviewed via phone on [DATE] at 11:23 AM and confirmed that she worked third shift on [DATE] and was responsible for Resident #1. NA #2 stated that she had answered a call light for another room and had walked past Resident #1's room on her way to the nurse's station to tell the nurse what that resident needed. She stated that as she passed by Resident #1's room he was in bed and was kicking the covers off of him, she proceeded to the nurse's station and as she walked back by Resident #1's room she noticed that his color was gone, and he was very pale. She stated that Resident #1 was warm to touch but was not breathing so she yelled Code Blue to the other staff on the unit. NA #2 stated she did not know how to overhead page, so she ran to the other side to alert the staff and on her way back grabbed the crash cart. She stated that there was no ambu bag on the crash cart and she could not find a backboard. NA #2 stated that she rushed around trying to find all the stuff that was needed for him. NA #2 recalled that eventually they found the backboard but finding the ambu bag was little more difficult because she was not sure what she was looking for. NA #2 stated that eventually another staff member who she did not know returned to the room with an ambu bag and they began rescue breathing around the same time that EMS arrived on scene. NA #2 stated that it took approximately five minutes to gather all the needed supplies to do CPR on Resident #1. Medication Aide (MA) #1 (facility staff) was interviewed via phone on [DATE] at 12:33 PM who confirmed that she was working third shift on [DATE]. She stated that she recalled hearing the Code Blue for Resident #1 and she went to assist as needed. She stated that Nurse #1 was a agency Nurse and really did not know what to do so she was telling her the procedure. She stated that Nurse #1 began CPR, but she could not recall anything regarding the supplies. MA #1 stated it had been a while since the event and she really could only recall that Resident #1 had passed away. NA #3 was interviewed via phone on [DATE] at 4:41 PM who confirmed that she was working third shift on [DATE]. She stated what she recalled about that evening was that Resident #1 coded and the crash cart was not fully stocked because it did not have an ambu bag and they could not find the backboard. She could not recall if they ever found the ambu bag but stated EMS was there quickly and they began working on Resident #1, but he passed away. NA #3 stated she was aware of where the crash cart was located but stated that when the staff brought it to the room it did not have what they needed. Unit Manager (UM) #1 and #2 were interviewed together on [DATE] at 1:15 PM. UM #2 stated that she was aware that Resident #1 had coded during the night when she was not in the building and had passed away. UM #1 stated that she and UM #2 were responsible for checking and stocking the crash carts daily and they logged those checks in a binder kept on the crash cart. UM #1 and UM #2 stated that they were not aware that the staff could not locate an ambu bag or backboard when Resident #1 went into cardiac arrest. Both stated that they checked the crash carts daily and both had an ambu bag and the backboard was always kept next to the crash cart. Both UM confirmed that they checked and restocked the crash carts daily on the days that they were working in the facility. Director of Nursing (DON) #2 was interviewed via phone on [DATE] at 11:18 AM. DON #2 stated that there were two crash carts in the building, one on each unit and the UMs were responsible for checking them and stocking them daily and as needed. DON #2 stated she recalled during one emergency the staff could not locate an ambu bag, but they found one and then she had the UMs check and restock the crash carts. She stated she could not recall if that emergency was with Resident #1 or not. DON #2 stated she believed that during the emergency the staff eventually found an ambu bag to use. Following the emergency when the ambu bag could not be immediately located they discussed the issue in morning meeting, and she had stressed the importance of checking the crash carts daily and ensuring that it contained all the supplies that would be needed during an emergency. Administrator #1 was interviewed on [DATE] at 5:03 PM who stated that she was not aware of issues with Resident #1 and could not say for sure how or when he passed away. Administrator #1 stated that she does not recall any staff member expressing concerns that the crash carts were not stocked appropriately and that they did not have the supplies they needed during an emergency. The Medical Director (MD) was interviewed via phone on [DATE] at 5:13 PM. The MD explained that Resident #1's diagnoses placed him at high risk for sudden cardiac arrest. The immediate start of CPR had a high likelihood of changing Resident #1's outcome and the MD stated he fully expected the facility to have the supplies they needed to immediately start CPR in the case of sudden cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a back board was next to each crash cart. The crash carts were also stocked with a suction machine and tubing, nasal cannulas, stethoscope, blood pressure cuff and other supplies that may be needed during an emergency. 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included history heart attack, diabetes, atrioventricular heart block, chronic kidney disease, and others. Review of a physician order dated [DATE] read: Full Code. Review of a nurse's note dated [DATE] written by Nurse #2 read; Resident seen upon morning care in dire [NAME], resident seen in bed foaming at the mouth; this nurse checked resident for responsiveness. When patient did not respond this nurse called a code-initiated others to get a crash cart and call 911. CPR was initiated after patient was placed on back board. Necessary staff was present, and EMS arrived shortly after. Resident #2 was transferred to the local hospital where he died on [DATE]. Attempts to speak to Nurse #2 (agency nurse) were unsuccessful. Nurse #3 (agency nurse) was interviewed on [DATE] at 3:09 PM who confirmed that she was working on [DATE] when Resident #2 went into cardiac arrest. She stated that the staff brought the crash cart to the room and there was no ambu bag on it. She stated the staff were doing chest compressions, and someone went and got a non-rebreather mask (mask used to deliver oxygen with a bag on end), and we began pushing oxygen through the mask. Nurse #3 stated that initially Nurse #2 was doing chest compressions and when the crash cart arrived at the room with no ambu bag she took over chest compressions and Nurse #2 went to find an ambu bag. Nurse #3 stated that when she began chest compressions Resident #2 was still warm and it took the staff several minutes to find the ambu bag and she believed that they went to another resident's room in the facility that had a tracheostomy and got the one in his room. The ambu bag was found as Emergency Medical Services (EMS) was coming on scene and they took over and transported Resident #2 to the hospital, but he passed away shortly thereafter. Nurse #4 (agency nurse) was interviewed on [DATE] at 3:25 PM who confirmed that she was working on [DATE] when Resident #2 went into cardiac arrest. She stated when she heard the Code Blue called, she immediately responded to the room. Nurse #2 was in the room, and she was beginning to do compressions without a backboard. She stated she hollered at the staff to get the backboard and once it was found and brought to the room chest compressions were started again. Nurse #4 stated she instructed Nurse #3 to turn the oxygen all the way up and then realized that there was no ambu bag on the crash cart. When the staff finally found the ambu bag and brought it to the room she began administering rescue breaths. At some point during the time, they could not find an ambu bag, Nurse #4 instructed the staff to go into another resident's room that had an ambu bag and get it so they could start rescue breaths on Resident #2. Nurse #4 stated that prior to Resident #2's cardiac arrest she had informed Unit Manager (UM) #2 that the crash cart needed an ambu bag because she had worked a night shift back in [DATE] and while doing a routine check of the crash cart, she discovered it did not have an ambu bag, so she reported to UM #2 that it needed one. Nurse #4 stated that she followed up and asked UM #2 about the ambu bag a of couple days later and she stated that she had told the former Director of Nursing #2 (DON) about the need for the ambu bag. Nurse Aide (NA) #4 was interviewed on [DATE] at 10:02 AM who confirmed that he was working when Resident #2 coded and went into cardiac arrest. He stated that when he arrived at Resident #2's room it was very disorganized, and staff were running around trying to locate equipment that was not on the crash cart. NA #4 stated he was on standby to do compressions if needed so he did not leave the room and was not sure where they located the ambu bag or backboard. He added that they located all the equipment around the same time EMS arrived and they took over CPR until Resident #2 was transferred to the local hospital. NA #5 was interviewed on [DATE] at 12:11 PM who confirmed that she was working on [DATE] when Resident #2 coded. NA #5 stated that when she got to Resident #2's room they did not have a backboard and the first crash cart was in the room and did not have an ambu bag on it. She stated that she recalled seeing a backboard in the break room, so she left to go and get it. NA #5 stated that as she was returning to Resident #2's room with the backboard she saw NA #6 coming down the hallway with the other crash cart, but it did not have an ambu bag either. When she got to Resident #2's room with the backboard another staff member had yelled to go and get the ambu bag from another resident's room and someone ran to get it, but she could not recall who that was. Once they had the supplies to do CPR, they staff began performing CPR until EMS came and took over and Resident #2 was transferred to the hospital. NA #7 was interviewed on [DATE] at 12:14 PM and confirmed that she was working on [DATE] when Resident #2 coded. She stated when she heard the Code Blue, she grabbed the other crash cart. NA #6 had grabbed the one from the other side of the building. NA #7 stated when the crash carts arrived in Resident #2's room there was no ambu bag on either crash art. NA #7 stated she ran to the resident's room in the facility that had an ambu bag in his room and grabbed it and ran to the supply closet and got a suction canister and tubing so that the Nurse Practitioner could suction Resident #2 because the crash cart did not have the right equipment to suction him. NA #6 was interviewed on [DATE] at 3:00 PM who confirmed she was working on [DATE] when Resident #2 coded. She stated that when she heard the page for Code Blue, she grabbed the crash cart and ran to Resident #2's room. NA #6 stated that once she arrived in the room, she broke the seal on the crash cart but could not find the ambu bag. She stated she looked over the crash cart several times and there was no ambu bag, she stated she heard that they found one in another's resident room. NA #6 stated both crash carts were supposed to have an ambu bag on them, but she could not say whether the other crash cart had one or not. Nurse Practitioner (NP) #1 was interviewed via phone on [DATE] at 3:52 PM who confirmed she was in her office charting on [DATE] when she heard the Code Blue page. She stated she when she got to the room the staff were doing chest compressions on the bed with no backboard, I instructed the staff to go and get the backboard. Then the NP said, where is the ambu bag so we can do rescue breaths? The crash cart was in the room with no ambu bag on it, so she again instructed the staff to go and find an ambu bag. The NP stated Resident #2 had fluids running out of his mouth and he needed to be suctioned but there was no suction machine on the crash cart, so instructed staff to go and find a suction machine. The NP stated she was aware that the facility had an Automatic External Defibrillator (AED) she questioned that staff where the AED was. She stated that another staff member ran to get the AED and when they brought it to the room there was no paddles to use it. The NP stated, we did the best we could with what we had until EMS arrived. She stated that she questioned UM #1 about why the crash cart was not stocked but the check list indicated that everything was there. The NP stated UM #1 stated that she had checked the crash cart, and everything was there. The situation was awful and should not have happened that way, the NP added that she expected the crash carts to be stocked to run codes and perform CPR when needed. The NP also stated she had met with Administrator #1 and Director of Nursing (DON) #2 and expressed her dissatisfaction with the situation but really did not get any answers as to why it had happened the way it did. Unit Manager (UM) #1 and #2 were interviewed together on [DATE] at 1:15 PM. UM #1 stated that she and UM #2 were responsible for checking and stocking the crash carts daily and they logged those checks in a binder kept on the crash cart. UM #1 and UM #2 stated that they were not aware that the staff could not locate an ambu bag, backboard, and other equipment when Resident #2 went into cardiac arrest. Both stated that they checked the crash carts daily and both had an ambu bag and the back board was always kept next to the crash cart. Both UM confirmed that they checked and restocked the crash carts daily on the days that they were working in the facility. DON #2 was interviewed via phone on [DATE] at 11:18 AM. DON #2 stated that there were two crash carts in the building one on each unit and the UMs were responsible for checking them and stocking them daily and as needed. DON #2 stated she recalled during one emergency the staff could not locate an ambu bag, but they found one and then she had the UMs check and restock the crash carts. She stated she could not recall if that emergency was with Resident #2 or not. DON #2 stated she believed that during the emergency the staff eventually found an ambu bag to use. Following the emergency when the ambu bag could not be immediately located they discussed the issue in morning meeting, and she had stressed the importance of checking the crash carts daily and ensuring that it contained all the supplies that would be needed during an emergency. Administrator #1 was interviewed on [DATE] at 5:03 PM who stated that she was not aware of issues with Resident #2 and could not say for sure how or when he passed away. The Administrator stated that she did not recall any staff member expressing concerns that the crash carts were not stocked appropriately and that they did not have the supplies they needed during an emergency. The Medical Director (MD) was interviewed via phone on [DATE] at 5:13 PM. The MD explained that Resident #2's diagnoses placed him at high risk for sudden cardiac arrest. The immediate start of CPR had a high likelihood of changing Resident #2's outcome and the MD stated he fully expected the facility to have the supplies they needed to immediately start CPR in the case of sudden cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a back board was next to each crash cart. The crash carts were also stocked with a suction machine and tubing, nasal cannulas, stethoscope, blood pressure cuff and other supplies that may be needed during an emergency. Administrator #1 and the DON #1 were notified of the Immediate Jeopardy on [DATE] 11:03 AM. The facility provide the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] at approximately 1:00 AM Resident #1 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. It took the staff approximately 5 minutes of time to locate the required items to deliver CPR when Resident #1 was pulseless. Resident #1 expired on [DATE] in the facility. On [DATE] at approximately 10:30 AM Resident #2 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. The Nurse Practitioner (NP) responded to the code and requested the basic lifesaving equipment and indicated that it took several minutes before a manual resuscitator was taken from another residents' rooms to use, the NP requested the facilities Automatic External Defibrillator (AED) and when staff retrieved the AED failed to have the paddles used to deliver the shock readily available for use by the NP. The NP also requested a suction machine that was not readily available for use. Resident #2 was transported to the emergency room (ER) and expired in the hospital. On [DATE] Resident #3 who had an extensive history of drug and opioid abuse was found on the floor with a white powdery substance on his bedside table. Resident #3 was warm to touch but was pulseless and was in cardiac arrest. Staff responded with the crash cart and there was no ambu bag on the crash cart. Another staff member had to obtain the other crash cart to get an ambu bag. It took approximately two to three minutes to obtain the other crash cart with the ambu bag and begin rescue breathing and compressions. Resident #1 expired on [DATE] at 2:26 AM in the facility. Resident #2 expired on [DATE] in the hospital. Resident #3 expired in the facility on [DATE]. All current residents that have a Full Code status have the potential to be affected by current practice deficiency. On [DATE], the Regional Nurse Consultant completed record review of residents that expired in a medical facility, expired in the facility, and/or discharged to another hospital for the following dates, [DATE] - [DATE] to ensure procedures for CPR were followed with no issues. Staff interviews completed with nurse involved. This was completed on [DATE]. Specify the action the entity will take to alter the process or system failure to prev[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #4 was initially admitted to the facility on [DATE] with diagnoses that included repeated falls, weakness, and a Thoracic-12 fracture (T-12 - lower back fracture), Alzheimer's, and Non-Alzheimer's dementia. Review of a fall risk assessment dated [DATE] revealed that Resident #4 was at high risk for falls due to his history of multiple falls and tendency to over-estimate or forget his limits. Resident #4 had a care plan initiated on [DATE] that read in part, The resident is at high risk for falls related to confusion. The interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear, non-skid socks when mobilizing in wheelchair. Review of Resident #4's medical record revealed a note written by Nurse #15 on [DATE] at 7:10 AM that read, this nurse and Nurse Aide (NA) were in front of resident's doorway and witnessed resident's fall. He rolled out of bed and fell. This nurse-initiated head to toe skin check and found no injuries related to this incident. Resident had no complaints of pain. Resident was placed back in his bed and on-call physician notified. Resident #4's care plan was updated on [DATE] to continue interventions on the at-risk plan and ensure bed is in lowest position prior to exiting resident's room. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 was moderately cognitively impaired and required extensive assistance of 1-2 staff members with activities of daily living (ADL). A fall within one month, prior to admission with a fracture was reported, and an additional fall since admission, with no injury, was reported on the MDS. Resident #4 was always incontinent of bowel and bladder, his balance was not steady and only able to stabilize with staff assistance, and ambulation with 1-2-person assistance only occurred 1-2 times in the look back period. On [DATE] at 7:30 AM a progress note made by Nurse #16 read, Medication Aide (MA) called to writer and stated Resident #4 was on the floor of his own room. Writer entered room and observed Resident #4 on his hands and knees on floor and observed blood on floor. Writer assessed Resident, and a laceration to the right eyebrow was noted. Writer and medication aids assisted Resident off floor and onto bed at this time. Resident alert at this time and stated that area to eyebrow hurt. Writer applied pressure to eyebrow. Vital signs obtained and within normal limits. Physician notified and order received to send resident to emergency room (ER). Writer called for Emergency Medical Services (EMS) transportation. Resident #4's care plan was revised on [DATE] to add floor mats for injury prevention. On [DATE] at 11:07 AM an Occupational Therapy encounter note written by the Occupational Therapy Assistant (OTA) read in part, Patient was found up in the wheelchair and was seen to address self-feeding. The patient was returned to his room via wheelchair and left up seated to visit his Family Member (FM) #1. In a phone interview on [DATE] at 12:30 PM with the OTA, she stated she worked at the facility as needed (PRN). She recalled Resident #4 as a small frail man who tried to stand-up on his own sometimes from his wheelchair, but he was too weak to support himself. The OTA stated she writes her notes after therapy was finished. The OTA confirmed Family Member (FM) #1 was not in the room when she left Resident #4 alone in his room in a wheelchair. She stated she must have assumed FM #1 was in the building or on her way to visit. The OTA stated she likely told someone at the nurses' desk that Resident #4 was back in his room but could not recall. She stated Resident #4's room was right across from nursing station or at least very close. The OTA stated with Resident #4's history of falls and high risk for falls, she would not have left him alone in his room without notifying a staff member. A phone interview was conducted with MA #6 on [DATE] at 4:40 PM and MA #6 confirmed she was working on the unit where Resident #4 resided on [DATE]. MA #6 stated she recalled Resident #4 was in therapy that morning. She recalled FM #1 was usually with Resident #4 and cared for him all day through supper, but on [DATE] she was not present. MA #6 stated she was passing medications around lunchtime when an NA (can't remember the name) came to her and said Resident #4 was on the floor. MA #6 stated she went into Resident #4's room and found him on his face on the floor bleeding from a facial cut. She stated she told the NA to find a nurse. MA #6 stated UM #2 came into the room, and they kept Resident #4 on the floor to avoid additional injuries. She stated he had a cut above one of his eyes that was open. MA #6 stated Resident #4 was conscious but never said anything. The MA was unsure if Resident #4 was a fall risk and added she usually observed him in bed but had observed when the resident was in his wheelchair, he tended to lean forward. An interview was conducted with NA #14 on [DATE] at 4:39 PM and she stated she assumed care for Resident #4 on [DATE] at 11:00 AM from NA #15. The NA stated while she knew Resident #4 was high risk for falls, she was a restorative aide and only works on the floor when there are a lot of call-outs such as on 03-17-23. She stated she was not very familiar with Resident #4's plan of care or fall interventions. NA #14 explained on [DATE] at 10:30 AM she saw therapy bring Resident #4 back to his room but was not the resident's nurse aide at that time. NA #14 further explained around 1:00 PM she saw Resident #4 sitting in a wheelchair alone in his room waiting for his lunch tray. She added she left him there sitting up in his wheelchair because therapy told her he ate better sitting up. NA #14 stated she left the hall to pass meal trays and as she was coming back to Resident #14's hall she saw Emergency Medical Services (EMS) entering Resident #4's room to take him to the emergency room (ER). She stated when she entered the room behind EMS, Unit Manager (UM) #1 and Unit Manager (UM) #2 were both attending Resident #4. She stated Resident #4 had fallen out of his wheelchair. NA #4 confirmed that Resident #4 was alone in his room, in his wheelchair, for approximately 3 hours and had not received his lunch tray prior to his fall. An interview with NA #15 was conducted on [DATE] at 3:16 PM she stated she was assigned to Resident #4 from 8:00 AM - 11:00 AM. She stated during this time, the resident was already dressed and out of his room with therapy. NA #15 explained at 11:00 AM NA #14 picked him up on her assignment. NA #15 did not recall the OTA or anyone telling her Resident #4 was back from therapy. She stated the first time she saw Resident #4 was when EMS was taking him out of his room on a stretcher. On [DATE] at 12:07 PM the Director of Therapy was interviewed and stated Resident #4 was admitted due to falls and high risk for falls. She stated she would have told someone Resident #4 was back or put him in the doorway, so he was visible. On [DATE] at 1:30 PM a progress note written by Unit Manager (UM) #2 read, Resident fell out of wheelchair to floor. Laceration noted above right eyebrow. Resident unable to answer questions due to Alzheimer's disease. Physician notified; EMS called for transport to the Emergency Department (ED) for evaluation. On [DATE] at 12:32 PM an interview was conducted with UM #2, and she shared Resident #4 was admitted to the facility due to falls at home. She stated when he was admitted he had several fractures in his neck and back, and stitches on the side of his head from falls he experienced at home. She stated she recalled on [DATE] she was working on the floor. She stated she knew OTA took Resident #4 to the therapy room at breakfast time because MA # 6 asked her where he was, so she called OTA to see if that had taken him to therapy and they confirmed they had picked him up for his therapy. She stated it was common practice for therapy to come get residents and bring them back without letting anyone know. She stated she did not know Resident #4 was back from therapy until she heard a loud thump that came from his room around 1:30 PM. She stated when she got to his room, she observed Resident #4 on his face on the floor. She added MA #6 was present in the room when she arrived. Review of the Emergency Medication Services (EMS) report dated [DATE] revealed the 911 call was received at 1:31 PM, EMS reached Resident #4 at 1:43 PM and Resident #4 was transported to the local hospital at 2:08 PM. The ER physician at the local hospital documented an admission note dated [DATE] that read, in part, Review of a computed tomography scan (CT scan) of the head and abdomen confirmed Resident #4 sustained right 9th through 11th rib fractures, and a sub-acute T-12 fracture (fracture in the spine that has already been present). Additionally Resident #4 sustained facial fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall (fracture that extended to the top and to the side of right eye socket), right hemothorax (blood collecting between chest wall and lungs which can collapse the lung), and intraparenchymal hemorrhage of the brain (bleeding in the tissue of the brain). A review of an ER physician notes from the local ER dated [DATE] at 6:42 PM, revealed Resident #4 was to be transferred to the local trauma center for definitive care (higher level of care). The noted further documented they had stabilized Resident #4 to the best of their ability. Review of a Trauma Center ED note dated [DATE], read in part, The patient presentation is most consistent with acute presentation with potential threat to life or bodily function. The trauma team managed Resident #4's care in the ED. Neurosurgery, Ophthalmology, Ear/Nose and Throat (ENT) consults ordered for evaluation of facial injuries. No surgical intervention was required. A trauma hospital physician discharge note dated [DATE], read in part, Palliative Care consulted for Goals of Care (GOC) due to patient injuries and history. After GOC meeting on [DATE] Resident #4 was transitioned to a Do No Resuscitate (DNR)/Comfort Care (CC) status. They will transfer Resident #4 back to a different skilled nursing facility (SNF) and will be followed by Hospice for end-of-life care. An interview was conducted on [DATE] at 12:00 PM with Director of Nursing (DON) #1 and Administrator #1. Administrator #1 stated it's their goal to keep all their residents safe. Residents who are at high risk for falls needed extra supervision and the staff were knowledgeable about preventing falls. The staff often kept residents at risk for falls visible in the hallway, by the desk, or even by the medication cart with the nurse for extra supervision. With Resident #4's fall history, he should have been monitored closely. She stated it sounded like miscommunication among departments and nursing staff. She stated he should not have been left alone in his room for 3 hours. Administrator #2 was notified of immediate jeopardy on [DATE] at 12:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. F689: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #3 had a known history of substance abuse. Resident #3 was not supervised for illicit drug use. Resident #3 had an order for oxycodone to be crushed and the nurse to watch the resident take. On [DATE] the nurse failed to supervise Resident #3 after medication administration. On [DATE] Resident #3 was found unconscious. Resident #3 expired on [DATE] at the facility. All current residents that have a history of drug abuse have the potential to be affected. A list was made of the residents who had a history of polysubstance abuse. The list is located at each nurse's station. The Director of Nursing reviewed and is responsible for updating the list. Resident #4 who was a high fall risk was left alone and unattended in his room for approximately three hours after therapy session. Resident #4 was found on his floor and was sent to the local emergency room and then transferred to local trauma center for treatment of his injuries. Resident #4 sustained right 9 through 11 rib fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall. Current residents that were identified at High fall risk using the Morse fall scale have the potential to fall and obtained injuries. The review and collaboration was conducted by the Regional Nurse Consultant on [DATE]. The Director of Nursing is responsible for updating the list with new residents that are high fall risk. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On [DATE], the Director of Nursing and Chief Nursing Officer educated staff on where to locate the list of residents with a history of polysubstance abuse. The Director of Nursing and Chief Nursing Officer educated staff on understanding of roles and responsibilities in identifying, reporting, and responding to residents who exhibit behaviors of seeking, acquiring and self-medicating with illegal drugs or medications not prescribed by the attending physician at the nursing home. Education included the following: dangers of self-medicating including serious adverse side effects and death, observing for medications/illegal substances in resident's room or in resident possession that are not prescribed by the nursing home MD/NP and responding by remaining with resident, calling out for nursing assistance for assessment and safe collection of substances and follow-up reporting by the licensed nurse to the MD/NP and to the Administrator or DON, intervening and asking to search resident with suspicious activity, ensuring resident safety by remaining with resident and calling for licensed nurse assistance, licensed nurse assessing resident for safety and s/s of potential self-medication such as changes in vital signs or altered mental status, visual observation of consumption, response in the event of resident self-medication to include; immediate removal of substance from resident to stop ingestion if possible, then providing emergency medical care as necessary and remaining with resident, calling MD/NP for new orders and calling 911 if indicated, then removing, counting and securing under double lock and key any medications/illegal substances with a second licensed nurse witness, then notification to the DON and Administrator for further investigation and follow-up, revising resident care plan to reduce risk of reoccurrence, education of the facility abuse and neglect policy and reporting immediately to the charge nurse if they hear or suspect a staff member is self-medicating or has an illegal substance in the facility. In the event illicit drug use is suspected the local police department will be contacted and a report made. The Director of Nursing will ensure no licensed nurses or medication aides will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. On [DATE], the Director of Nursing and Chief Nursing Officer educated current staff members on fall protocol. Education to include the following: Identifying high fall risk residents upon admission using the Morse fall scale and putting interventions using the Strategies for Reducing the Risk of Falls. Once residents are identified as high fall risk nurse management will update list and place at areas noted to staff. High risk fall residents will be communicated in the morning meeting with department heads and then to the floor staff. During meal tray pass, Department Heads, weekend Manager on Duty, and Night Supervisor is present on the floors in order to provide increased supervision of residents at high risk for falls. Care plans will be updated by Minimum Data Set Coordinator or designee with appropriate interventions. Nurse management will in-service staff on the appropriate interventions. The Director of Nursing will ensure staff will not work without receiving education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on [DATE] by the Director of Nursing and Chief Nursing Officer. Effective [DATE], Administrator #2 will be responsible for ensuring implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is [DATE]. On [DATE], the credible allegation of Immediate Jeopardy removal was validated by onsite verification through facility staff interviews. The interviewed staff across all disciplines including nursing, front office, and therapy, revealed they had all received in-service training regarding supervision of residents who had a history of drug abuse and those who were at high risk for falls. The facility had implemented lists of residents at high risk for falls and residents who had a history of substance abuse located at each nurses' stations and on each medication cart. Observations completed on-site revealed increased supervision of residents at high fall risk and those with substance abuse. The interviewed staff were able to articulate the newly implemented practices for increased supervision of residents with substance abuse histories and those who were at high risk of falling. The facility alleged completion of training on [DATE] with immediate jeopardy removed effective [DATE] was validated. Based on record review, observation, and interviews with resident, Nurse Practitioner, and staff, the facility failed to implement measures to mitigate the risk of an accidental drug overdose for a resident who had a known history of substance abuse that included crushing and snorting pills/medications. On [DATE] Resident #3 was found unresponsive in his room as a result of sudden onset cardiac arrest and he was unable to be revived. Nursing Assistant (NA) #11, NA #12, and Housekeeper #1 had observed a white, powdery substance on the tray table in his room. The facility also failed to provide the necessary supervision to prevent accidents for a cognitively impaired resident (Resident #4) who was assessed as a high fall risk due to a history of multiple falls and tendency to overestimate or forget his limits. On the morning of [DATE], Resident #4 was left unsupervised in his room in his wheelchair after a therapy session. He was found by staff that afternoon after suffering an unwitnessed fall that resulted in right 9th through 11th rib fractures, facial fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall (fracture that extended to the top and to the side of right eye socket), right hemothorax (blood collecting between chest wall and lungs which can collapse the lung), and intraparenchymal hemorrhage of the brain (bleeding in the tissue of the brain). He was transferred from the emergency room to the local trauma center for a higher level of care. This deficient practice was for 2 of 3 residents (Residents #3 and #4) reviewed for supervision to prevent accidents. Immediate jeopardy began for example #1 on [DATE] when Nurse Practitioner #2 was informed by staff that Resident #3 was seen cutting a white powdery substance on his tray table, she ordered Narcan (a reversal agent used in case of an overdose) to treat an accidental overdose, but no measures were implemented by the facility to mitigate the risk of an overdose. Immediate jeopardy began for example #2 on [DATE] when the facility failed to provide the necessary supervision to prevent an accident for Resident #4. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included cocaine dependence, congestive heart failure, and chronic respiratory failure. A physician's order for Resident #3 dated [DATE] indicated Oxycodone HCl (narcotic pain medication) tablet 20 milligrams (mg) every 6 hours as needed for pain. The order indicated to crush the tablet and for the resident to take the medication in front of the nurse. Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, or rejection of care. Resident #3 was coded with having frequent pain and he received opioids on 7 of 7 days during the lookback period. The MDS revealed Resident #3 was born in 1960 indicating he was [AGE] years old. A physician's order for Resident #3 dated [DATE] indicated Narcan liquid 4 mg/0.1 milliliter (ml), provide 4 mg in nostril every 6 hours as needed for overdose. Resident #3's care plan last updated on [DATE] revealed the following information: - Resident #3 exhibits or has the potential to exhibit verbal/physical behaviors related to opioid dependence and anxiety; history of snorting pills/medications, misuse of oxygen. Interventions included monitoring medication administration to ensure medications are taken and swallowed prior to leaving resident. - Resident #3 does complain of pain at times due to impaired mobility. Resident #3 has a diagnosis of chronic pain and opioid dependence. Resident has pain medication in place and is followed by pain clinic. Interventions included Per MD order Narcan 1 milliliter by nasal route as needed for opioid overdose. Repeat every 2 minutes until emergency medical services arrive. A progress note written by Nurse Practitioner (NP) #2 dated [DATE] for Resident #3 indicated the following: Behavioral concerns - this NP recommends that the patient be discharged from this facility for numerous documented reports from the staff of overdose, abuse, and noncompliance. I believe that the patient puts the facility at risk for liability if he were to overdose. I have added Narcan 4mg nasal every 6 hours as needed for overdose. I have expressed my concerns with the [Former] Director of Nursing, Administration, and Medical Director. During an interview via telephone on [DATE] at 9:01 AM with Nurse Practitioner (NP) #2 she stated she was no longer working at the facility. She reported Resident #3 had a history of taking his narcotic pain medication and then turning his oxygen up on his portable tanks and concentrator until he passed out. She stated she was concerned about Resident #3 abusing his narcotics because she heard from staff (unable to recall their names) that he pocketed the medications and then crushed and snorted them. She reported several months before August of 2022 she refused to prescribe him narcotic pain medications and referred him to a pain clinic for monitoring. The pain clinic ordered the oxycodone. She reported Resident #3's narcotic pain medication was to be crushed and Resident #3 observed until it was fully taken in applesauce or another medium. She revealed she received information from an NA (unable to recall the NA's name) who informed her a picture was turned into facility administration that showed Resident #3 cutting a white powdery substance on his tray table in the facility. She explained this was when she prescribed Resident #3 Narcan ([DATE]) to be given in the event of an accidental overdose. During a follow up interview with the NP #2 via phone on [DATE] at 4:00 PM she revealed she prescribed Narcan on [DATE] to be administered not if but when Resident #3 overdosed. The Medication Administration Record (MAR) for [DATE] revealed oxycodone was administered to Resident #3 on [DATE] at 2:16 AM by Medication Aide (MA) #3. During an interview with NA #7 on [DATE] at 3:28 PM she reported she believed Resident #3 died from an overdose due to her experience of seeing him snort an unidentified powdery substance on more than one occasion. NA #7 stated each time she observed Resident #3 snorting a white substance, she stopped him and got the nurse on the hall. She reported by the time she and the nurse returned to the room, the white, powdery substance was gone, and Resident #3 stated it was baby powder and denied snorting it. She reported she also wrote two separate statements regarding what she observed and slid them under Administrator #3's door. NA #7 stated she could not remember the dates she completed the reports but was certain she slid them underneath Administrator #3's door. She reported to her knowledge, nothing was done to prevent Resident #3 from snorting a white, powdery substance. Administrator #1 was asked on [DATE] at 4:30 PM to provide the written statements from NA #7 regarding Resident #3's observed behaviors of crushing and snorting his medications. Administrator #1 reported on [DATE] at 10:00 AM she was unable to locate them. An interview with Resident #3's former roommate, Resident #13, was conducted via telephone on [DATE] at 1:16 PM. He revealed he had reported Resident #3's drug abuse to facility staff multiple times including to the Wound Nurse and to Former Social Worker #1. He stated he even sent pictures and a video he had taken on his cell phone to them on their cell phones. Resident #3's former roommate reported he felt that someone from the facility was bringing in either cocaine or opioids and providing them to Resident #3. He stated he watched Resident #3 numerous times pull out pills, chop them up on his tray table, and snort them. On [DATE] at 12:18 PM the photograph and video recorded by Resident #13 was observed. They showed Resident #3 sitting in his wheelchair, in his room, next to his bed with his back to the door. Resident #3 had a bank debit card in his hand pressing the edge down onto a white, powdery substance that was on his tray table beside his bed. An interview with the Wound Nurse on [DATE] at 12:01 PM via telephone revealed it was very well known that Resident #3 had a substance abuse problem and crushed his opioid medications and snorted them. She also reported she had received a photograph and a short video, unable to recall the date, from Resident #3's roommate, Resident #13, that showed Resident #3 using a credit card to cut a white, powdery substance on his tray table in his room at the facility. She reported she immediately sent them to Director of Nursing #3 at the time and also provided them to a Corporate Staff member who was a female. She was unable to remember the Corporate Staff member's name or her title. She stated she also wrote a statement, unable to recall the date, and provided it to the Corporate Staff member. The Wound Nurse reported she heard nothing back from Director of Nursing #3 or the Corporate Staff member about the situation. The Wound Nurse reported she felt that the situation was ignored. An interview with Social Worker #1 via telephone on [DATE] at 3:15 PM revealed she remembered Resident #3 and that he had a history of abusing his medications by crushing and snorting them. She reported Resident #3's former roommate, Resident #13, had approached her in her office some time, unable to recall the date, and told her Resident #3 was storing medications under his tongue then crushing and snorting them. She stated she brought it up to Director of Nursing #3 and Administrator #3 immediately after being informed, but it was blown off. She stated, everyone knew about it, and no one did anything. She reported there were no additional interventions put into place to increase supervision and despite his behaviors being discussed weekly at morning meeting it was always not taken seriously. A nurse progress note completed by Nurse #13 dated [DATE] at 7:28 AM read, in part, Resident #3 reported on floor at 6:15 AM by NA following ambulation by resident from smoking area .emergency medical services [EMS] notified by staff while this nurse and additional nurse performed cardiopulmonary resuscitation in resident room. EMS arrived at 6:25 AM .Resident #3 pronounced expired by EMS at 6:46 AM. An interview with Medication Aide #3 (MA) on [DATE] at 3:14 PM revealed she was assigned on the medication cart and was responsible for providing Resident #3 with his medication from 7:00 PM on [DATE] until 7:00 AM on [DATE]. She stated she last gave him his narcotic pain medication at 2:16 AM on [DATE] and found him unresponsive around 5:30 AM. She could not recall with certainty if she crushed his oxycodone when she last administered the medication. She went onto say that she would have administered them as it was ordered on the MAR. MA #3 stated she had worked with Resident #3 a few times previously and she remembered reading in his chart that he had some drug seeking behaviors. She revealed when she worked with him, he came up to her medication cart before he was due to receive his narcotic pain medication and waited there until it was time for it to be administered. Interview with NA #12 (agency) on [DATE] at 12:35 PM revealed she worked the night shift (7:00 PM to 7:00 AM) that ended on [DATE] on the date Resident #3 expired. She indicated she ran to the room when MA #3 called for help after finding him unresponsive. She stated Resident #3 was well known in the facility as a substance abuser and had a history of crushing and snorting his medications and she believed there was a crush order for his opioid medications that he was prescribed. She stated when she arrived at the room, she noticed a white, powdery substance on his tray table, and she immediately believed that he had crushed and snorted his medication due to her understanding of his history. NA #12 also reported that at some point during the emergency, Housekeeper #1 entered the room and wiped down Resident #3's tray table. During an interview with NA #17 (agency) on [DATE] at 2:42 PM via telephone, she reported she was present on [DATE] working as an NA at the time Resident #3 was found unresponsive in his room. She stated it was well known that Resident #3 had a history of substance abuse and had a history of crushing his opioid medications and snorting them. She reported around 6:20 AM to 6:30 AM on [DATE], while EMS was working on Resident #3, she noted Housekeeper #1 entered the room and wiped down Resident #3's tray table. An interview with Housekeeper #1 on [DATE] at 3:33 PM via telephone, revealed she went into Resident #3's room on [DATE] and wiped off a white, powdery substance from his tray table. She reported she did not know Resident #3's medical history or if he had a history of substance abuse. She reported she only wiped off the tray table after EMS requested her to do so. She could not provide any information on why EMS asked her to wipe off Resident #3's tray table. During an interview via telephone on [DATE] at 9:01 AM with NP #2 she verified she was the NP at the time Resident #3 expired. She indicated the death certificate indicated he died of natural causes. She revealed when she was asked to sign the death certificate, she refused because based on the information she received from the staff (unable to recall specific staff members) that were present at the time he went into cardiac arrest, she believed Resident #3 had died of an accidental overdose and not due to natural causes as was listed on the death certificate. During a follow-up interview[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Nurse Practitioner, and Medical Director interviews the facility's Administration failed to provide leadership and oversight to ensure the facility had supplies that were readily available and easily accessible to immediately start Cardiopulmonary Resuscitation (CPR) when 3 of 4 residents experienced sudden cardiac arrest (Resident #1, Resident #2, and Resident #3). This practice had the high likelihood of affecting other residents. Immediate Jeopardy began on [DATE] when Resident #3 experienced cardiac arrest and the facility did not have an ambu bag (used to deliver rescue breaths during CPR) readily available for use and it took the staff approximately three minute to locate the ambu bag and start rescue breathing. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm with potential for more than minimal harm that is no immediate jeopardy) to ensure monitoring system are in place and the completion of employee education. The findings included: This tag is cross referenced to F678: F678: Based on record review, staff, Nurse Practitioner and Medical Director interviews the facility failed to have basic lifesaving equipment readily available for use to immediately begin cardiopulmonary resuscitation (CPR) when Resident #3 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR because the first crash cart (cart of emergency supplies) that was [NAME] to the bed side did not have a ambu bag or manual resuscitator (device to administer rescue breathing) on it, staff began chest compressions and it took the staff approximately three minutes to get the second crash cart that did have a ambu bag to begin rescue breathing. Resident #1 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR because the staff could not locate an ambu bag or manual resuscitator to begin rescue breaths and could not locate a backboard (hard surface to do chest compressions on while in bed). It took the staff approximately five minutes to locate the needed items to begin CPR. On [DATE] Resident #2 experienced sudden cardiac arrest and staff were unable to immediately begin CPR because they could not locate an ambu bag or manual resuscitator and had to borrow one from another resident's room. The staff also could not locate the paddles for the Automatic External Defibrillator (AED) (device used to deliver a shock to the heart). It took staff several minutes to locate the ambu bag to begin CPR and paddles for the AED. This affected 3 of 4 residents reviewed who experienced sudden cardiac arrest. Director of Nursing (DON) #1 was interviewed on [DATE] at 10:16 AM who explained that she began working in the facility as the Minimum Data Set (MDS) nurse at the beginning of [DATE] and had become the interim DON at the beginning of [DATE]. The DON stated she had no knowledge of Resident #1 as he was expired months prior to her arrival at the facility. She also stated she was not familiar at all with Resident #2 or any issues that arose during his sudden cardiac arrest and code situation. The DON further stated that she recalled hearing during the clinical morning meeting that when Resident #3 went into cardiac arrest and was coded by the staff that the facility did not have the appropriate equipment to immediately begin Cardiopulmonary Resuscitation (CPR). She added that she distinctly remembered the former Nurse Practitioner (NP) who was directly involved in the code situation voicing her dissatisfaction with how the code was handled and the lack of equipment that was available. The DON stated she recalled the former NP going around to the nurses talking to them about the situation and how it should have gone differently. The DON stated that she also recalled Administrator #1 asking the Unit Managers (UM) why the crash carts were not stocked, and they continued to insist that they had checked them, and they were stocked and believed that someone was taking the ambu bags off the crash carts. From what the DON could recall there was no resolution to that issue but stated after the event another staff member had gone to the hospital and borrowed a box of ambu bags. Administrator #2 was interviewed on [DATE] at 3:02 PM who confirmed that from [DATE] to [DATE] she was the Regional [NAME] President of Operations and provided oversight to the facility under the direction of Administrator #1. Administrator #2 stated that she had no knowledge of the situations that had occurred with Resident #1, Resident #2, and Resident #3, she stated that nothing had been communicated to her that there were issues that had arisen during the code situations that all three residents experienced. She contributed the failures of the facility on lack of effective leadership. Administrator #1 and DON #1 were notified of the Immediate Jeopardy on [DATE] at 11:03 AM. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility's administration did not ensure that the crash carts (used in emergency situations) were stocked with the needed equipment that included Ambu bag or manual resuscitator, back board, suction machine, and automatic external defibrillator (AED) which are all required to perform CPR in the event of cardiac arrest. On [DATE] at approximately 1:00 AM Resident #1 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. It took the staff approximately 5 minutes of time to locate the required items to deliver CPR when Resident #1 was pulseless. Resident #1 expired on [DATE] in the facility. On [DATE] at approximately 10:30 AM Resident #2 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. The Nurse Practitioner (NP) responded to the code and requested the basic lifesaving equipment and indicated that it took several minutes before a manual resuscitator was taken from another residents' rooms to use, the NP requested the facilities Automatic External Defibrillator (AED) and when staff retrieved the AED failed to have the paddles used to deliver the shock readily available for use by the NP. The NP also requested a suction machine that was not readily available for use. Resident #2 was transported to the emergency room (ER) and expired in the hospital. On [DATE] Resident #3 who had an extensive history of drug and opioid abuse was found on the floor with a white powdery substance on his bedside table. Resident #3 was warm to touch but was pulseless and was in cardiac arrest. Staff responded with the crash cart and there was no ambu bag on the crash cart. Another staff member had to obtain the other crash cart to get an ambu bag. It took approximately two to three minutes to obtain the other crash cart with the ambu bag and begin rescue breathing and compressions. Resident #1 expired on [DATE] at 2:26 AM in the facility. Resident #2 expired on [DATE] in the hospital. Resident #3 expired in the facility on [DATE]. All current residents that have a full code status have the potential to be affected by current practice deficiency. On [DATE], the Regional Nurse Consultant completed record review of residents that expired in a medical facility, expired in the facility, and/or discharged to another hospital for the following dates, [DATE] - [DATE] to ensure procedures for CPR were followed with no issues. Staff interviews completed with nurse involved. This was completed on [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On [DATE] Regional Director of Nursing educated Administrator on the facility CPR policy and procedure and their role, emergency crash cart checklist, location of crash carts in facility, and location of additional BLS equipment. Education included the following: Procedure 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Verify or instruct a staff member to verify the DNR or code status of the individual. Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the crash cart. 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). Chest compressions: a. Following initial assessment, begin CPR with chest compressions. Position flat hand over left chest and using heal of hand. b. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. Airway: Tilt head back and lift chin to clear airway. Breathing: After 30 chest compressions provide 2 breaths via resuscitator or manually (with CPR shield). All rescuers should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Continue with CPR/BLS until emergency medical personnel arrive. 2. Emergency Crash Cart Checklist 3. Location of crash carts 4. Location of backup BLS supplies On [DATE], Administrator was educated by Regional Director of Operations on Administrator's responsibility to thoroughly investigate cardiac events. Administrator must be notified by Director of Nursing or Designee of any cardiac events and must review code response to ensure CPR procedure was followed. Staff participating in cardiac event response must be interviewed by a member of nurse management team proceeding the incident and findings of cardiac event investigation must be shared with the Administrator for confirmation that CPR procedure was followed, basic life support supplies were readily available. If variation from CPR procedure is identified Administrator should immediately consult Regional Director of Nursing, initiate Ad Hoc QAPI meeting to include IDT and Medical Director, and modify plan of correction in order to achieve compliance. On [DATE], the Regional Nurse Consultant educated the nurse management team on interviewing the staff that participated in the CPR proceeding the incident to ensure CPR procedures were followed and basic lifesaving equipment was readily available. Effective [DATE], Administrator will receive on site visit from Regional Director of Operations or designated outside Administrator no less than once per week. Visit will include audit of the following: crash carts to ensure location, supply, and emergency crash cart checklist completed and accurate ensure adequate supply of BLS equipment is present on the crash cart and supply room and is housed in designated location review of cardiac event investigations since previous visit to ensure CPR procedure was followed interview staff to confirm knowledge of CPR procedure and role in cardiac event response. Review any new hires since last visit to ensure CPR procedure education was completed. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] On [DATE] and [DATE] the facility's credible allegation of immediate jeopardy removal was validated. Interviews with the DON and Administrator #2 revealed that they had been educated by the Regional Director of Nursing on the CPR policy and procedures, emergency crash cart check list, location of crash carts, and location of back up supplies. Administrator #2 is also the Regional Director of Operations (RDO) and was aware of her responsibility as the Administrator to thoroughly investigate cardiac events to ensure the facility's policy and procedures were followed. The investigation should include interviews with staff directly involved with the incident and should be reviewed by Administrator #2/RDO. Interviews with the management team confirmed that they had been educated on the importance of conducting thorough investigation after any cardiac event to ensure facility staff followed the proper procedures and that basic life saving equipment was readily available for use by the direct care staff. Administrator #2/RDO verbalized understanding of her responsibility to check crash carts and availability of supplies, review any cardiac events and review new hire orientation to ensure newly hired staff received the education during the orientation process. The facility's immediate jeopardy remove date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, staff, Medical Director, Telemedicine Physician, Regional Medical Director, and Infectious Disease Provider the facility failed to notify the Infectious Disease Provider that was managing Resident #1's intravenous (IV) antibiotic which was being used to treat a right subdural empyema (collection of pus between the layers of the brain) and Cerebritis (inflammation of cerebrum of the brain) that Resident #1's peripherally inserted central catheter (PICC) (an IV used to administer medications) had become dislodged and his antibiotics were not administered as ordered for 1 of 1 resident reviewed for significant medication errors. There was the high likelihood for bacterial regrowth, resistance to antibiotic, sepsis, or return to hospital due to the missed medications. Immediate jeopardy began on 12/22/22 when the facility failed to notify the Infectious Disease Provider Resident #1's PICC line became dislodged, and the IV antibiotics were not being administered as ordered. Immediate jeopardy was removed on 02/17/23 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: brain metastasis (cancer that has spread to the brain), chronic subdural hematoma, and sepsis. The physician order dated 12/18/22 read, Oxacillin (antibiotic) 10 grams (gm) reconstituted. Use 12 gm IV one time a day for encephalitis/sepsis for 27 days. Infuse 12 gm over a 24-hour period. The Medication Administration Record (MAR) dated 12/2022 revealed that Nurse #3 was responsible for administering Resident #1's Oxacillin on 12/18/22, 12/19/22, 12/21/22, and 12/23/22. Nurse #2 was responsible for administering Resident #1's Oxacillin on 12/20/22, 12/22/22, and 12/24/22. Nurse #4 was responsible for administering Resident #1's Oxacillin on 12/25/22. A nurse's note dated 12/22/23 at 7:34 AM written by Nurse #1 read, made aware that resident's PICC line was out and at the foot of the bed. Writer noted PICC line of 45 centimeters on the floor and asked resident what happened. Per resident he got caught up turning in bed and must have pulled it out. On coming nurse made aware for replacement. Nurse #1 was interviewed via phone on 02/14/23 at 3:55 PM who confirmed that she was working on 12/22/22. She stated she was responsible for Resident #1 and another staff member who she could not recall notified her that Resident #1's PICC line was out. Nurse #1 stated she went to Resident #1's room and found his PICC line lying on the floor at the foot of Resident #1's bed. Nurse #1 stated she measured the PICC line to 45 centimeters and placed the line in a bag and gave to Nurse #2 and instructed her to call the MD to get the IV line replaced. Nurse #1 confirmed that she had not called the MD or the Infectious Disease Provider, she stated she left the PICC line with Nurse #2 and instructed her to notify the MD to get the IV line replaced. Review of a physician order dated 12/23/22 read, obtain peripheral line due to antibiotic use. The order was electronically signed by Nurse #3 and the Medical Director (MD). Nurse #3 was interviewed via phone on 02/15/23 at 4:56 PM. Nurse #3 stated that she recalled Resident #1 as he was on IV antibiotics that ran for twenty-four hours at a time. She stated she was not on shift when his PICC line got pulled out and could not recall if the IV line got reinserted or not. Nurse #3 could not recall why or how she obtained the order dated 12/23/22 to obtain a peripheral IV line for antibiotic use for Resident #1. She confirmed that she had not notified the MD or the Infectious Disease Provider that Resident #1's PICC was out or to obtain any new orders. The MD was interviewed on 02/15/23 at 10:03 AM who stated that he had been the MD at the facility since June 2022 and was at the facility once a week. The MD stated that he was not at all familiar with Resident #1 as he never evaluated him while he was in the facility. He indicated that the Telemed Physician (a physician who evaluates a resident via computer or electronic device) had evaluated Resident #1 and maybe she could answer questions regarding Resident #1. The MD stated that if he had a resident who was receiving IV antibiotic via a PICC line and was being followed by Infectious Disease he would prefer to consult with them regarding any issues with the IV antibiotic or PICC line. A follow up interview via phone was conducted with the MD on 02/15/23 at 8:42 PM. The MD stated that he recalled getting a call from a nurse on 12/22/22 but he could not recall which nurse regarding Resident #1's PICC line coming out. The MD stated he used his judgement to just observe Resident #1. The MD indicated he provided no further orders that night and he thought at that point it was a better option to just observe him and if he deteriorated then we would get some lab work. The MD stated, looking back I should have done things differently. He further confirmed that he did not refer the nursing staff to the Infection Disease provider as he previously stated he would do. The MD again stated he thought it was best to just observe Resident #1. The Regional Medical Director was interviewed on 02/15/23 at 11:50 AM via phone who stated he was not familiar with Resident #1 but stated if a resident was on IV antibiotic it was for good reason and would be important if the resident missed doses of the IV antibiotic. He further stated that he had reviewed Resident #1's medical record and it did not appear that any provider was made aware that Resident #1's PICC line was out. The Telemed Physician was interviewed via phone on 02/15/23 at 11:18 AM. The Telemed Physician stated she really could not recall Resident #1. She stated she did not take call for the facility and was not notified Resident #1's PICC line came out. She stated that generally if she was not the provider that initiated the antibiotic therapy, she was not going to alter it, that would need to go through the provider that ordered the medication and in this case was the Infectious Disease Provider. She further stated had someone called her she would have had the staff contact the Infectious Disease Provider and then try to figure out how to get the resident the next dose of scheduled antibiotic as quickly as possible. Nurse #4 was interviewed via phone on 02/15/23 at 2:43 PM. Nurse #4 stated that he recalled Resident #1 and recalled that he was on IV antibiotics. Nurse #4 stated he was told in report on 12/25/22 that Resident #1 had pulled his PICC line out and they were waiting for it to be replaced. Nurse #4 stated he could not confirm that the IV was ever replaced and stated he had not contacted the MD or the Infectious Disease Provider for any additional orders. Nurse #2 was interviewed via phone on 02/16/23 at 2:39 PM. Nurse #2 stated she vaguely recalled Resident #1 and him pulling his PICC line out. She stated she had not called the MD to get any alternate medication or antibiotics as she was not familiar with which antibiotics Resident #1 was on, why he was on it, or the duration of his treatment of those antibiotics. Nurse #2 stated if the PICC line came out on her shift she would assess the resident and notify the MD but Resident #1's PICC line came out on the shift before hers and she assumed that had all been taken care of. Nurse #2 confirmed that she had not had any communication with the Infectious Disease Provider at all. She stated if I called the IV company then I am sure that I texted the MD to let them know that he had pulled the PICC line out and I was getting it replaced but could not recall which provider. Nurse #2 again stated that Resident #1's PICC line came out on Nurse #1's shift and it would have been her responsibility to notify the MD that the line came out and obtain any new orders. The Director of Nursing (DON) was interviewed on 02/15/23 at 3:58 PM who stated she vaguely recalled Resident #1. She stated he was on IV antibiotics and his PICC line that was used for administration of those IV antibiotics got pulled out. The DON stated that when PICC's line became dislodged the provider was immediately notified but she did not know which provider was notified regarding Resident #1's PICC line. She stated sometimes they got a hold order to just hold the antibiotic until the IV line can be replaced but they could also get an order to give another antibiotic via a different route like intramuscularly until the IV line could be replaced. The DON was not aware of any additional orders that were obtained regarding the IV Oxacillin. The Infectious Disease Provider was interviewed via phone on 02/15/23 at 1:50 PM who stated she was very familiar with Resident #1 as she had followed him several days while he was in the hospital before coming to the facility. She indicated that Resident #1 was on IV Oxacillin for a specific organism that was detected on a culture that was obtained. The Infectious Disease Provider stated that her office had contacted Resident #1's nurse at the facility on 12/22/22 at 10:04 AM to confirm that the facility had the correct order for the IV antibiotic, the correct duration for the antibiotics, and that they had orders for the required weekly blood work that was needed. At no time during that conversation or other time was her office made aware that Resident #1's PICC line was out, and he was not receiving his IV Oxacillin. The Infectious Disease Provider also explained that Resident #1 was on day 19 (4 at the facility and 15 at the hospital) of his entire six-week course of antibiotic indicating he was not just starting his course of therapy, but he had not reached the halfway point in his therapy. The Infectious Disease Provider stated that if she would have been made aware she would have immediately intervened by bringing Resident #1 back to the emergency room, getting his IV access replaced while simultaneously administering a different antibiotic via a different route. The Administrator was notified of the immediate jeopardy on 02/15/23 at 5:20 PM. The facility provided the following IJ removal plan: F580: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 did not receive IV antibiotics on 12/22/22, 12/23/23, 12/24/23, and 12/25/23 secondary to IV access becoming dislodged. The infectious disease provider was not notified the access was dislodged and the antibiotics were not received. On 02/15/23, the Director of Nursing reviewed resident's medications for administration compliance and notification to the provider for any missed administrations. Any opportunities identified during this audit will be addressed by 02/16/23. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 02/15/23, the Director of Nursing educated licensed nurses on requirements to notify the MD when medication cannot be administered as ordered. Education was also completed on notifying the provider in the event the IV access becomes dislodged. The MD will be notified by phone at the time medication is not given. The Director of Nursing will ensure no licensed nurses will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their first shift. Education will be completed on 02/16/2023 by Director of Nursing or Unit Manager. The Chief Nursing Officer educated the Administrator and Director of Nursing on 02/15/23 regarding the clinical morning meeting process to include reviewing MD notification of missed medications and dislodged IV access. Effective 02/15/2023, the Administrator will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is 02/17/2023. A credible allegation validation of notification was conducted in the facility on 02/20/23. The education provided to the licensed nurses in the facility including Nurse #1, Nurse #2, Nurse #3, and Nurse #4 was reviewed. The interviews revealed that the licensed nurses had been trained on the process of notification and immediately reporting to the medical provider when medications could not be given in the way they were ordered. The facility conducted a root cause analysis to help identify issues and was reviewed without concern. The facility's immediate jeopardy removal date of 02/17/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Regional Medical Director, Medical Director, and Infectious Disease Provider interviews the facility failed to prevent a significant medication error when staff failed to administer ordered doses of an IV antibiotic on [DATE] and [DATE]. The Peripherally Inserted Central Catheter (PICC) (intravenous (IV) line used to administer IV antibiotics) line was replaced with a different type of IV access on [DATE] and the staff failed to administer the IV antibiotic on [DATE] and [DATE] for 1 of 1 resident (Resident #1) reviewed for significant medication errors. There was the high likelihood for bacterial regrowth, resistance to antibiotic, sepsis, or return to hospital due to the missed medications. Immediate jeopardy began on [DATE] when staff failed to administer 4 doses of Resident #1's IV antibiotics. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: brain metastasis (cancer that has spread to the brain), chronic subdural hematoma, and sepsis. The physician order dated [DATE] read, Oxacillin (antibiotic) 10 grams (gm) reconstituted. Use 12 gm IV one time a day for encephalitis/sepsis for 27 days. Infuse 12 gm over a 24-hour period. The Medication Administration Record (MAR) dated 12/2022 indicated that Oxacillin was given as ordered on [DATE], [DATE], [DATE], and [DATE]. The MAR indicated that Oxacillin was not administered on [DATE], [DATE], [DATE], and [DATE]. The nurse's note dated [DATE] at 7:34 AM written by Nurse #1 read, made aware that resident's PICC (IV line used to administer IV antibiotics) line was out and at the foot of the bed. Writer noted PICC line of 45 centimeters on the floor and asked resident what happened. Per resident he got caught up turning in bed and must have pulled it out. Oncoming nurse made aware for replacement. Nurse #1 was interviewed via phone on [DATE] at 3:55 PM who confirmed that she was working on [DATE]. She stated she was responsible for Resident #1 and another staff member who she could not recall notified her Resident #1's PICC line was out. Nurse #1 stated she was finishing her shift and was ready to clock out, but she went to Resident #1's room and found his PICC line lying on the floor at the foot of Resident #1's bed. Resident #1 was unable to conversate with Nurse #1 and could not recall what had occurred. Nurse #1 stated she measured the PICC line to 45 centimeters and placed the line in a bag and gave to Nurse #2 and instructed her to call the Medical Director (MD) to get the IV line replaced. She added Resident #1's arm was not bleeding and did not require any additional treatment and then she left the facility because her shift was over. A nurse's note dated [DATE] at 9:56 AM written by Nurse #2 read, IV company called, stated a central line (type of IV line) would be appropriate and a nurse would call shortly to establish when it could be done. Nurse #2 was interviewed via phone on [DATE] at 2:39 PM. Nurse #2 stated she vaguely recalled Resident #1 and him pulling his PICC line out. She stated if she documented that she called to have it replaced then she had done so but had not called the MD to get any alternate medication or antibiotic as she was not familiar with which antibiotics Resident #1 was on, why he was on it, or the duration of his treatment of those antibiotics. Nurse #2 stated if the PICC line came out on her shift she would assess the resident and notify the MD but Resident #1's PICC line came out on the shift before hers and she assumed that had all been taken care of. Nurse #2 could not recall if she attempted to reinsert the IV line or not. Nurse #2 confirmed that Resident #1's Oxacillin was not administered on [DATE] because his PICC line had been pulled out. The MAR administration note dated [DATE] at 1:15 PM and written by Nurse #3 read, Oxacillin, unable to give at this time due to resident pulling out PICC line and waiting on IV access to come and place peripheral line. Nurse #3 was interviewed via phone on [DATE] at 4:56 PM. Nurse #3 stated that she recalled Resident #1 as he was on IV antibiotic that ran for twenty-four hours at a time. She stated she was not on shift when his PICC line got pulled out and could not recall if the IV line got reinserted or not. Nurse #3 confirmed that on [DATE] she did not administer Resident #1's Oxacillin because his PICC line had been pulled out and he did not have IV access. Nurse #3 stated that she knew that someone had called for the IV line to be replaced could not recall if she had attempted to reinsert the IV or not. She also confirmed she had not contacted any provider for any additional orders regarding the Oxacillin. The MAR administration note dated [DATE] at 11:31 AM and written by Nurse #2 read, Oxacillin, no iv access, IV replacement to be done today. A document from an external IV company indicated that on [DATE] at 3:48 PM they arrived at the facility and inserted an IV access in Resident #1's right hand. The line was secured and flushed, and Resident #1 tolerated procedure well. The MAR administration note dated [DATE] at 9:59 AM and written by Nurse #4 read, Oxacillin, waiting for IV insertion. Nurse #4 was interviewed via phone on [DATE] at 2:43 PM. Nurse #4 stated that he recalled Resident #1 and recalled that he was on IV antibiotics. Nurse #4 stated that he was off for a few days and when he came back, he was told in report on [DATE] that Resident #1 had pulled his PICC line out and they were waiting for it to be replaced. Nurse #4 stated he could not confirm that the IV was ever replaced and stated he had not contacted the MD because someone had already done that, nor had he attempted to reinsert the IV because they were waiting on the IV company to come and reinsert the IV. Nurse #4 also stated that Resident #1 had not pulled his IV out during his shift and was certain that he did not administer the Oxacillin on [DATE] because he did not have an IV because as that was what he was told in report. Resident #1 died on [DATE] in the facility. Resident #1's death certificate indicated his cause of death to be encephalopathy (a broad term for any brain disease that alters brain function mostly commonly caused by infection). The MD was interviewed on [DATE] at 10:03 AM and stated he had been the MD at the facility since [DATE] and was at the facility once a week. The MD stated he was not at all familiar with Resident #1 as he never evaluated him while he was in the facility. He indicated that the Telemed Physician (a physician who evaluates a resident via computer or electronic device) had evaluated Resident #1 and maybe she could answer questions regarding Resident #1. The MD stated that if he had a resident who was receiving IV antibiotic via a PICC line and was being followed by Infectious Disease he would prefer to consult with them regarding any issues with the IV antibiotic or PICC line. A follow up interview via phone was conducted with the MD on [DATE] at 8:42 PM. The MD stated that he recalled getting a call from a nurse on [DATE] but he could not recall which nurse regarding Resident #1's PICC line coming out. The MD stated he used his judgement to just observe Resident #1. The MD indicated he provided no further orders that night and he thought at that point it was a better option to just observe him and if he deteriorated then we would get some lab work. The MD stated, looking back I should have done things differently. He further confirmed that he did not refer the nursing staff to the Infection Disease provider as he previously stated he would do. The MD again stated he thought it was best to just observe Resident #1. The Regional Medical Director was interviewed on [DATE] at 11:50 AM via phone who stated he was not familiar with Resident #1 but stated if a resident was on IV antibiotic it was for good reason and would be important if the resident missed doses of the IV antibiotic. The Director of Nursing (DON) was interviewed on [DATE] at 3:58 PM who stated she vaguely recalled Resident #1. She stated that he was on IV antibiotics and his PICC line that was used for administration of those IV antibiotics got pulled out. The DON stated it was replaced in the facility by an external IV company. The DON stated that the process for when a PICC line become dislodged was the provider was immediately notified and sometimes we get a hold order to just hold the antibiotic until the IV line can be replaced but we could also get an order to give another antibiotic via a different route like intramuscularly until the IV line could be replaced. The DON stated it was important to get the IV line reinserted as quickly as possible, so the resident did not miss scheduled doses of their medications. The Infectious Disease Provider was interviewed via phone on [DATE] at 1:50 PM who stated she was very familiar with Resident #1 as she had followed him several days while he was in the hospital before coming to the facility. She indicated that Resident #1 was on IV Oxacillin for a specific organism that was detected on a culture that was obtained. She further explained that Oxacillin's affects peaked at thirty minutes which was why in the hospital setting it was given very frequently but in the skilled nursing facility it was infused over a twenty-four-hour period. The Infectious Disease Provider also explained that Resident #1 was on day 19 (4 at the facility and 15 at the hospital) of his entire six week course of antibiotic indicating he was not just starting his course of therapy but he had not reached the halfway point in his therapy. The Infectious Disease Provider stated that from an infectious disease standpoint it was a very significant medication error when Resident #1 missed four doses of the IV Oxacillin. She further stated she would have intervened if she had been aware that his PICC line had become dislodged by assisting with getting IV access reinserted and using a different antibiotic that could have been administered intramuscularly until IV access could be obtained. The Administrator was notified of the immediate jeopardy on [DATE] at 5:20 PM. The facility provided the following IJ removal plan: F760: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 was identified as having a medication error. Resident #1's intravenous access line was dislodged on [DATE] and he was not administered his IV antibiotics (Oxacillin) as ordered on [DATE], [DATE]. [DATE], and [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses included but not limited to viral encephalitis, nontraumatic chronic subdural hemorrhage, type II diabetes, malignant neoplasm of lung, and secondary malignant neoplasm of brain. On [DATE], the Director of Nursing reviewed resident medications for administration compliance. Any opportunities identified during this audit will be addressed by [DATE]. On [DATE], the Director of Nursing reviewed residents with intravenous access. Any opportunities identified during this audit will be corrected by the Director of Nursing by [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On [DATE], the Director of Nursing educated all licensed nurses on medication administration and the documentation to indicate completion of medication administration. Education also included requirements for notification to the MD for any missed administrations and in the event IV, access becomes dislodged/removed. The MD will be notified by phone at the time medication is not given. The Director of Nursing will ensure no licensed nurses will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on [DATE] by Director of Nursing or Unit Manager. The Chief Nursing Officer educated the Administrator and Director of Nursing on [DATE] regarding the clinical morning meeting process to include medication administration and the validation of documentation. Furthermore, education was provided on ensuring the provider is notified in the event the IV access is dislodged. Effective [DATE], the Administrator will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is [DATE]. A credible allegation validation of significant medication errors was conducted in the facility on [DATE]. The education provided to the licensed nurses in the facility including Nurse #1, Nurse #2, Nurse #3, and Nurse #4 was reviewed. The interviews revealed that the licensed nurses had been trained on the process of preventing significant medication errors by immediately reporting to the medical providing and either requesting a hold order or additional orders for other medication that could be used. The facility conducted a root cause analysis to help identify issues and was reviewed without concern. The facility immediate jeopardy removal date of [DATE] was validated.