**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, review of facility policies, observations and staff interviews, it was determined that the facility failed to timely assess and consistently provide recommended and/or prescribed treatment and services, to prevent new wound development, promote healing and prevent worsening of existing wounds. This failure resulted in actual harm to Resident R1 who developed new and worsening wounds on the right clavicle and neck which resulted in an Immediate Jeopardy Situation for one resident of four clinical records reviewed. (Resident R1) Findings include: Review of the United States Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. The American College of Physicians [ACP] is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and the second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and possible surgical repair. Review of an undated facility policy Wound Treatment Management revealed that 1. Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Review of an undated facility document Wound Management Program revealed that Based on the comprehensive assessment of a resident, 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Review of Resident R1's quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 6, 2023, revealed that Resident R1 was at risk for developing pressure sores and the resident was totally dependent on staff for activities of daily living to include bed mobility, transfers, and toilet use. The resident's cognition was severely impaired, and the assessment indicated that the resident was unable to complete interview. MDS also indicated that the resident rarely/never makes self-understood and able to understand others. Review of Resident R1's care plan dated December 30, 2023, revealed that the resident was at risk for skin integrity with interventions included body check weekly and as needed, notify physician and family of changes and provide skin care as needed. Observation of tracheostomy care to Resident R1 on January 5, 2024, at 11.44 a.m. with Unit Manager, Employee E4, and Licensed Nurse, Employee E5, was completed. During the observation a pack of gauze was observed on resident's right side of neck under his trach ties and the right neck area. Both employees did not know why the resident had gauze to the right side of the neck. Resident was observed with his neck towards right ride with his chin bone touching the area of the shoulder bone. A request was made to Employee E4 and E5 to open the gauze. Further observation after the gauze was removed from Resident R1's neck revealed that there were two new wounds under the gauze. There was a 2 x 2 boarder dressing on one of the wounds without any medications. There was no date on the dressing. The right clavicle wound appeared to be an area where resident's chin touching the clavicle bone and the neck wounds appeared to be an area where the trach tie touched the skin. It was observed that resident's neck tilted towards the right side and right side of the chin was touching the right clavicle bone. No offloading or pressure reducing measures were observed to the area. Interview with Licensed Nurse, Employee E5 on January 5, 2023, stated she was not aware of resident's two wounds to the right side of the neck. There was no information provided to the shift-to-shift report. Employee E5 stated there was no physician order to provide treatment or check residents wound to the right neck. Review of physician orders for Resident R1 dated July 7, 2023, revealed an order to check for skin integrity around the neck related to trach collar. Review of nursing progress note dated December 21, 2023 revealed that the resident was identified with moisture associated dermatitis to left clavicle which measured 0.5 centimeter (cm) x 1.0 cm. X 0.1 cm. Review of progress note for Resident R1 dated December 26, 2023, revealed a skin documentation that a new skin impairment was observed on residents left chin area which measured 1.5 centimeter (cm) x 2.0 cm. Review of physician orders for Resident R1 dated December 27, 2023, revealed an order to complete full body skin assessment three times a week. New skin impairment should be documented; initiate a treatment document in the nurses' notes. Review of the clinical record revealed that the resident was transfered to the hospital on December 27, 2023, with a repiratory change in condition. The resident was readmitted to the facility on [DATE]. Review of hospital record for Resident R1 dated December 29, 2023, revealed under skin condition that the resident had Stage II pressure ulcer on right and left clavicle, right leg wound and a DTI (Deep Tissue Injury) to the right foot. Review of facility admission assessment dated [DATE], revealed no evidence that the resident's right clavicle wound was indicated on the assessment, or a treatment plan was initiated. Review of a readmission assessment of Resident R1 dated December 29, 2023, revealed that there was no negative finding noted on the skin assessment. Review of progress note for Resident R1 dated December 30, 2023, revealed a skin documentation which indicated right clavicle's wound measuring 1 cm x 1.5 cm, and left clavicle's wound and left chin. All treatment in place. Review of progress note for Resident R1 dated December 31, 2023, indicated that resident's skin was assessed by the nurse and the supervisor which revealed a skin documentation which indicated that the resident had wounds to right clavicle, left clavicle and left chin. All treatment in place. Review of physician order for Resident R1 dated December 29, 2023, and December 30, 2023, revealed no evidence that there was a physician order for treatment to right clavicle wound. Review of a dietician progress note date January 2, 2024, revealed that the resident had multiple wounds to the left calf, left clavicle, right clavicle, left chin. Review of a skin assessment completed by Licensed nurse, Employee E4 on January 3, 2024, revealed that a skin assessment was performed, and no new skin issues identified. Further review of progress revealed no documented evidence that the right clavicle wound was identified in the skin assessment. Interview with Licensed nurse, Employee E4, on January 5, 2024, at 1:00 p.m. stated she was not aware of the new skin concerns when she documented the skin assessment for Resident R1 on January 4, 2024. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. stated Licensed nurse, Employee E4 did not conduct a proper skin assessment. Staff were expected to conduct skin assessment and document the findings in the medical record. Any changes to skin integrity should be addressed with the physician for treatment orders. Review of clinical record for Resident R1 revealed no documented evidence that the physician or wound care practitioner was notified about Resident R1's right clavicle wound when it was first documented on December 30, 2023, subsequently after. There were no interventions implemented to promote the wound healing or preventing further skin breakdown. A skin assessment completed on January 5, 2024, at 1:39 p.m., revealed that the right clavicle measured 1.5 cm x 2.3 cm. and right neck wound measured 0.7 cm. x 2 cm. A wound care consult report dated January 5, 2024, after the surveyor observation of the right clavicle and right neck wound revealed that resident had muscle weakness, reduced mobility and extreme contracture with right clavicle pressure ulcer and right lateral neck pressure ulcer. Right clavicle was an acute Stage 3 (ulcer involving full thickness of skin loss) pressure ulcer and measured 1.3 cm x 2 cm. x 0.2 cm. Right lateral neck was an acute Stage 3 pressure ulcer and measured 0.9 cm. x 1.3 cm x 0.1 cm. Further review of the wound care consult report dated January 5, 2024, and progress note for Resident R1 dated December 30, 2023, confirmed that the right clavicle wound increased in size and a new wound was developed adjacent to the right clavicle wound. Review of Medication Administration Record for December 2023 and January 2024 revealed that the nursing staff did not administer any care to the right clavicle and right neck area including, wound treatment, wound prevention, and interventions to promote wound healing. Interview with Director of Nursing, Employee E2, on January 5, 2024, at 2:00 p.m. confirmed that the staff did not notify physician when resident developed right clavicle wound and obtained treatment orders. Employee E2 also confirmed that the staff did not implement interventions for wound prevention and promote wound healing to Resident R1's right neck area. Employee E2 stated staff was expected to initiate an incident report and implement interventions when a new wound was identified which was not completed when Resident R1's wound was first identified with wounds to the right clavicle. Employee E2 also stated Licensed nurse, Employee E4 completed an inaccurate skin assessment on January 3, 2024, which resulted in facility not identifying the new pressure ulcers and resident not receiving treatment to the right neck pressure ulcer areas. The facility failed to identify, develop and implement interventions to promote wound healing and prevent wound development in accordance to the resident' plan of care, facility polices and professional standards of practice. Facility failed to timely identify, assess and provide treatment to pressure sore which resulted in actual harm to Resident R1, who developed new and worsening wounds on his right clavicle and neck. Immediate jeopardy was called on January 17, 2024 at 9:22 AM and the IJ Template was provided to the facility. Facility developed the following approved action plan: 1. Resident (R1) was assessed by the Nurse Practicioner on 1/5/2024. The area identified on Resident (R1's) right clavicle and right lateral neck were determined to be moisture associated skin dermatitis (MASD). Resident (R1) does not have any pressure-related wounds. Treatment orders were obtained and followed per physician orders. 2. On 1/10/2024 the unit managers assessed all residents in the facility. Treatment orders are in place for all wounds. 3. The facility has implemented additional skin assessments for all residents, a minimum of 2 times per week to identify any new alteration of skin integrity. 4. On 1/17/2024 Nurse management team started education for licensed nursing staff on the facility's pressure ulcer prevention policy and procedure including protocols for skin assessments and treatments for new and existing residents. The facility will have 80% of the staff educated by 1/18/2024. The remaining staff will be educated prior to the start of the shift. 5. The DON, NHA and/or designee will complete weekly audits for residents at risk for developing pressure ulcers. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. Review of facility documentation revealed that the corrective action plan was immediately initiated on January 17, 2024. On January 18, 2024, wound treatment orders were reviewed for Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 - treatment orders in place. Interviewed the following staff regarding PU/PI prevention policy and neglect related to prevention of skin wounds: 12 licensed nurses, employees E9, E10, E11, E12, E13, E14, E15, E16, E17, E18, E19, E20 and five nurse aides, employees E21, E22, E23, E24, E25. Reviewed Abuse/Neglect prevention education provided for 96% of all staff. Reviewed Wound Management education provided for nursing staff - completed at 96%. Immediate Jeopardy was lifted on January 18, 2024 at 4:05 PM. 28 Pa. Code 211.10(a)(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R92 was free from neglect related to a significant medication error. This failure resulted in an Immediate Jeopardy situation for Resident R92 who received 10 units of a fast-acting insulin that was intended for another resident and without proper monitoring following the administration of the insulin for one of 40 residents reviewed. (Resident 92). Findings include: Review of the facility policy entitled, Freedom from Abuse Neglect & Exploitation implementation date November 28, 2017, revealed The purpose of this procedure is to comply with reporting of crimes that may occur at the facility in accordance with section 1150B of the elder Justice Act (EJA). To protect elders with diminished capacity while maximizing their autonomy and help elders recognize the right to be free of abuse, neglect and exploitation. Review of Resident 92's clinical record revealed an admission date of April 25, 2017, with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit, delusional disorder. A review of Resident 92's clinical file confirmed that the resident is non-diabetic and does not have a physician order for insulin. Review of Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severely impaired, and had memory problems. A review of Resident 92's nursing notes dated September 20, 2023, at 7:23 p. m. revealed that License nurse, Supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u (units) of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime. Review of facility documentation submitted to the Department of Health on September 20, 2023, revealed a patient/resident neglect report submitted on September 20, 2023, revealed Resident R92 had a licensed charge nurse Employee E24 mistakenly given 10 units of Humalog. Resident R92 does not received insulin. Resident R92 does not have a diagnosis of diabetes. Resident R92 resides in room [ROOM NUMBER]B and was in room [ROOM NUMBER]A sitting in 320A chair. Licensed nurse, Employee E24 believed that Resident R92 was Resident R107. Employee E24 failed to properly identify Resident R92. Resident R92 was assessed by nursing supervisor Employee E23 no distress was noted. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s (signs and symptoms) of hypoglycemia and recheck her Resident R92 at bedtime Nurse Practitioner, Employee E27 evaluated Resided R92 and noted there was no ill effects noted. Facility determined the investigation to be unsubstantiated for neglect. Review of Resident R92's September 2023's physican orders revealed that on September 20, 2023, order for Accu check, one time only for Glucose (sugar). According to the Medication Administration Report (MAR) on September 20, 2023, at 11:53 p.m. the Accu-check reading was 153. Resident R92 also had a physician order to Monitor resident for s/s of hypoglycemia every shift for 3 days starting on September 20, 2023. Review of Resident R92's September 2023 Medication Administration Record revealed that Accu-check on September 20, 2023, at 10:53 p.m. reading of 153 blood sugar level and at 11:11 p.m. of 130 blood sugar reading. An attempt was made on September 21, 2023, at 4:20 a.m. and Resident R92 refused. Review of nursing notes revealed no documented evidence of continue monitoring of Resident R92 for signs and symptoms of hypoglycemia, and of what type of sugary drink and food was the resident provided with ordered by the physician. On October 18, 2023, at 11:31 a.m. an observation was made of Resident R92 sitting in her room without an identifying wristband. An interview was conducted with nursing supervisor, Employee E4 confirming that Resident R92 refused to wear identifying wristband. Further observation of another resident in the unit (Resident R157) revealed that the resident also did not have an identifying wristband. On October 18, 2023, at 11:39 a.m. an interview was held with Licensed agency nurse, Employee E22 who reported a resident would be identified based on the name sign in the room, census report or asking the supervisor. On October 18, 2023, between 3:40 p.m. and 4:03 p.m. about 19 residents were observed and/or interviewed on the 2nd floor and all of them had an identifying wristband on. On October 18, 2023, at approximately 2:00 p.m. an interview with the Director of Nursing (DON) confirmed that the facility unsubstantiated the neglect investigation related to Resident R92 as it was just a one time occurrence and that the agency nurse made an error. The neglect investigation only included two statements that the Nursing Supervisor, Employee E23 conducted. DON confirmed there was no evidence of proper monitoring following the administration of the insulin. There was no training conducted to all staff on medication administration, and/or identification of residents. An interview held with Nurse supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. revealed nurse Employee E24 failed to follow the five rights of medication administration which resulted in neglect of Resident R92. It further revealed most likely Licensed nurse, Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency to ensure competencies of medication administration. Nursing Supervisor, Employee E23 confirmed there was no evidence of proper monitoring following the administration of the insulin medication. Based on the above mentioned findings an immediate jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:47 p.m. The immediate jeopardy template was provided at the time to the Nursing Home Administrator and an immediate action plan was requested. On October 18, 2023 and 9:57 p.m. the facility provided the following corrective actions: 1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin. The employee responsible for the medication error no longer works in the facility. 2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON and there were no other occurrences of insulin administration to non-diabetic residents. 3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that the resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system. In the event of a medication error the facility will notify the physician and follow the physicians' order related to the type of medication error. The resident will be on 24-hour report and monitored based on the physician recommendation. The facility will obtain parameters for specific monitoring instructions for the medication error. The nurse will document monitoring in nursing notes. 4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Staff will be required to sing off on the training prior to their first shift worked in the facility. 5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. The implementation of the action plan was confirmed on October 18, 2023, at 10:12 p.m. Interviews were conducted with facility nursing staff on October 18, and 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. On October 19, 2023, at 4:57 p.m. the Immediate Jeopardy was lifted. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to ensure that a resident was free of medication errors for one of 40 residents reviewed (Resident R92). This failure resulted in an Immediate Jeopardy situation for Resident R92 who was administered 10 units of a fast- acting insulin medication that was intended for another resident. Findings include: Review of the facility policy entitled, Administering Medications date May 2016, revealed Medication are administered as prescribed in accordance with manufactures' specifications, good nursing principles and practices and only by person legally authorized to do so, Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. It further states under bulletin 10. Resident are identified before medication is administered using at least two resident identifiers. Methods of identification may include a. check identification band 2. Check photograph attached to medication record 3. Verify resident identification with other nursing care center personnel note: the resident's room number or physical location is not used as an identifier. Review of Resident R92's clinical record revealed an admission date of April 25, 2017, with diagnoses that included Alzheimer's disease (a brain disorder cause of dementia of progressive memory loss, impaired thinking disorientation and changes in personality and mood), dementia (memory loss), cognitive communication deficit and delusional disorder. Review of the Resident R92's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated October 10, 2023, indicated that the resident was severe cognitive impairment. A BIMS (Brief Interview of Mental Status) score was not documented due to resident being rarely/never understood. A review of Resident R92's September 2023 physician orders did not list the resident with a diagnosis of Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and no orders for insulin. A review of a nursing note dated September 20, 2023, at 7:23 p.m. revealed that License nurse supervisor, Employee E23 noted this nursing supervisor was asked to come 3rd floor by 3 East Charge Nurse, Employee 25 to assess and respond to an issue. Upon arriving to 3rd floor, this Nursing Supervisor, was informed by staff that the 3 South charge nurse, Employee E24 had accidently given the resident 10 u of Humalog. When asked about med error, 3 South charge nurse, Employee E24 reported that resident was sitting in another resident's room and that the resident didn't identify herself. The aide nearby didn't say anything and the other resident in the room just said that resident takes meds whole. 3 South charge nurse, Employee E24 said she then proceeded to give the resident the wrong medication. When asked by this charge nurse did she verify and check the resident's armband or her picture on the EMAR (electronic medical administration record), she said no and that she was just going off the census sheet. Resident given food and sugary drinks to help keep sugar elevated. Resident R92 checked and was with in normal range. MD made aware and ordered to continue to give sugary foods and drinks, continue to monitor resident for s/s of hypoglycemia and recheck her at bedtime. Review of facility documentation revealed a witness statement, dated September 20, 2023, by License nurse supervisor, Employee E23 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. noted that she was asked by 3 East charge nurse, Employee E25 to come to the floor and assess an issue. Upon arrival was told by staff that 3 south nurse had accidentally given resident 10 units of Humalog. When asked what happened, 3 south nurse, Employee E24 stated she saw resident sitting in 320 A chair and thought that was her room. Employee E24 stated the resident didn't property answer, aide/CNA (nurse aide), Employee E26 nearby didn't say anything and that the resident in 320 B (Resident 108) just said resident takes meds whole .(Resident R92) noted w/Alzheimer + confusion and wonders and sits in different rooms. When asked did the 3 South charge nurse, Employee E24 check resident's armband or picture on the EMAR, she stated no and was just going by the census sheet. MD made aware and ordered resident be given sugary snacks + drinks, monitor for s/s of hypoglycemia + accu-checks at bedtime. RP made aware and just wants to be updated with any changes. Resident given snacks and drinks. Review of facility documentation revealed a witness statement, dated September 20, 2023, completed by License nurse supervisor, Employee E23 regarding license nurse, Employee E24 who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed charge nurse gave Resident R92 10 units of Humalog accidentally stating that because Resident R92 was sitting in 320A chair & room, she thought it was Resident R107. License nurse, Employee E24 then said that while she was talking to Resident R92, nurse aide, Employee E26, who was nearby did not say she was talking to the wrong resident and that Resident R108 said Resident R92 takes her meds whole. Resident R92 has Alzheimer and confusion and wonders from room and wouldn't be aware enough to say anything. When nursing supervisor, Employee E23 told the charge nurse, Employee E24, she became irritable stating that at other facilities, residents are not allowed to sit in other resident's room. When asked did she check the resident's armband or picture on the EMAR she said no, she was just getting off the census sheet. She then tried to accuse/put blame on Employee E26, nurse aide for not saying anything and of Resident R108. License Nurse, Employee E24 came to the supervisor office and dropped the keys off and stating she wasn't and isn't in the right mental status to work . and then left the facility. An interview held with Nurse Supervisor, Employee E23 on October 18, 2023, at 4:03 p.m. confirmed the above-mentioned statements. Nursing Supervisor, Employee E23 stated that she received a call approximately at 4:30 p.m. on September 20, 2023, from charge nurse, Employee E25 making her aware that there was issue with Resident R92. Upon arrival Employee E23 learned that Employee E24 who was an agency license nurse assigned to Resident's 92's accidentally administered 10 units of Humalog to Resident R92 who was non-diabetic resident which should have been administered to Resident R107. Resident R92 was sitting in room [ROOM NUMBER]A chair which belong to Resident R107. Employee E24 failed to check resident's armband, Electronic Medical Administration Record (EMAR) or picture and depended on census report to identify the Resident R92. Nurse Supervisor, Employee E23 further revealed mostly likely was Employee E24's first time in the building and there was no orientation training for nursing staff who come from the agency. Nursing Supervisor, Employee E24 told Employee E25 make sugary nourishment to keep Resident R92's sugar elevated and notified the physician. Physician gave an order to give juices, snacks and monitor her blood sugar. Nursing Supervisor, Employee E23 assessed the Resident R92 there was no signs of hyperglycemia or distress. Nurse Practitioner, Employee E27 evaluated Resident R92 this same night at approximately 9:00 p.m. Employee E23 did not write a witness statement nor made herself available after the incident to be part of the investigation. Nursing Supervisor, Employee E23 wrote the above witness statement regarding his encounter with Employee E24. A telephone interview was held with License nurse, Employee E25 on October 18, 2023, at 6:16 p.m. who worked on September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed that nurse aide, Employee E26 approached her approximately 4:15 p.m. on October 20, 2023, and notified her that license nurse, Employee E24 accidently gave insulin to Resident R92 who is non-diabetic. Licensed nurse, Employee 25 immediately notified supervisor Employee E26 and went to assess the situation. Upon her arrival Resident R92 was as her normal self, sitting with her hands crossed her chest with no distress. Licensed nurse, Employee E24 notified Licensed nurse, Employee E25 that she measures her blood sugar before she gave an insulin, and it was 144. Licensed nurse, Employee E24 further reported that she did not verify Resident's R92 identity per the medication policy but only used her census sheet. Licensed nurse, Employee E25 checked Resident's R92's blood sugar level and to her best memory it was 80. Resident R92 had dinner that night and sugary snacks and drinks were provided such as orange juice and peanut butter sandwich to elevate her sugar level. Resident R92 at any point was not in any distress during the night. At approximately 6:00 p.m. Licensed nurse, Employee E24 left her shift and supervisor was notified. A telephone interview was held with nurse aide, Employee E26 on October 18, 2023, at 8:56 p.m. who worked the shift of September 20, 2023, from 3:00 p.m. to 11:00 p.m. revealed she was not in the room when insulin was administered to Resident R92. Employee E26 walked into room [ROOM NUMBER] and observed Resident R92 sitting in a 320A room's chair and License nurse, Employee E24 with a needle in her hand. Nurse aide, Employee E26, questioned if Licensed nurse, Employee E24 gave an insulin to Resident R92. Licensed nurse, Employee E24, responded, no I gave it to Resident 107. Nurse aide, Employee E26, then told Licensed nurse, Employee E24 that was not Resident R107 but Resident R92. Employee E26, immediately went to another nurse, Employee E25 who was covering 3rd floor South Unit and reported that Resident R92 was given insulin and Resident R92 was a non-diabetic resident. Licensed Nurse, Employee E25 immediately notified the nursing supervisor Employee E23 who came to assess the situation. On October 18, 2023, at 7:25 p.m. an attempt was made to conduct a phone interview with license nurse, Employee E24 whose number was not working. This same time an interview with Director of Nursing revealed that a staffing agency for whom nurse, Employee E24 was employed at was notified and Employee E24 was placed on the do not return list and not permitted at the facility moving forward. Review of Resident R92's clinical record revealed that physician orders obtained on October 20, 2023 for a one time Accu-Check for glucose level and to monitor the resident for signs and symptoms of hypoglycemia every shift for 3 days starting on September 20, 2023. Review of Resident R92's September 2022, Medication Administration Record revealed that on September 20, 2023, at 11:53 p.m. the one-time Accu-check reading was 153 blood glucose (sugar) reading. Based on the above mentioned findings, an Immediate Jeopardy was identified to the Nursing Home Administrator and Director of Nursing on October 18, 2023, at 4:45 p.m. The Immediate Jeopardy template was provided to the Nursing Home Administrator and an immediate action plan was requested at the time noted above. On October 19, 2023, at 9:57 p.m. the facility provided the following corrective action plan: 1. On 9/20/2023 Resident R92 was assessed by the RN supervisor after being administered insulin intended for another resident. Resident R92 was also seen and assessed by the Nurse Practitioner on 9/20/2023. Resident R92 was monitored as per physician orders. There was no adverse effect or signs of hypoglycemia from receiving insulin. 2. On 10/18/2023 the medication administration records for all residents were reviewed by the DON (Director of Nursing) and there were no other occurrences of insulin administration to non-diabetic residents. 3. On 10/18/2023 the department head staff audited all residents currently in the facility to [NAME] that they resident can be properly identified. Proper identification includes a name band and/or a picture in the facility's electronic record system. Residents who refuse to wear a name band will be identified by the picture in the EMR system. 4. On 10/18/2023 the facility started education nursing staff on following the facility's medication administration policy, the five rights of medication administration, methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The facility will have 80% of the staff educated by 10/19/2023. The remaining staff will be educated prior to the start of their shifts. Staff will be required to sign the education materials acknowledging the understanding of the training provided to them. Agency staff will be required to sign off on the training prior to their first shift worked in the facility. 5. The DON, NHA and/or designee will complete weekly audits for residents receiving insulin verifying that the 5 rights of medication administration are being followed. Audits will continue for 3 months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. The implementation of the action plan was verified on October 18, 2023 at 10:12 p.m. Interviews were conducted with nursing staff on October 18, 2023 and October 19, 2023. Nursing staff reported they had all been in-services on medication administration policy, the five rights of medication administration and methods of properly identifying residents who have been prescribed insulin and monitoring of residents following insulin administration. The Immediate Jeopardy was lifted on October 19, 2023, at 4:57 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12 (d) (5) Nursing Services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical record, review of hospital record, resident and staff interviews and policy review, it was determined that the facility failed to monitor residents for the possession of unprescribed substances and provide behavioral health services including the development of behavioral contracts for two of 38 residents reviewed with substance abuse disorder (Resident R141 and Resident R154). This failure resulted in Resident R154 obtaining and providing an unprescribed narcotic medication to Resident R141 and both residents receiving emergency medical care for narcotic overdosing at the facility. This failure placed Residents R141 and R154 at high risk for injury and resulted in an Immediate Jeopardy situation. Findings include: A review of the policy titled Safety for Residents with Substance Use Disorder dated October 2022, revealed that it was the intent of this policy to create an environment free of accident hazards for residents with a history of substance use disorder. The policy indicated that a resident with substance use disorder would be assessed for leaving the facility and using illegal or unprescribed drugs during the leave. A resident with substance use disorder would have a care plan implemented to include increased monitoring and supervision to include any visitors the resident may have. Continued review of the facility's policy stated that staff were expected to assess the resident for substance use (illegal drugs, unprescribed medication or alcohol use/abuse). The staff were to recognize if the resident was leaving the facility frequently with or without facility knowledge. In accordance with this policy the facility was responsible for preventing substance use for each resident by providing behavioral health substance use treatment services, medication-assistance treatment, alcoholic/narcotics anonymous meetings for the resident and family, increase monitoring and supervision of the resident and address goals related to discharge planning as needed. Review of the policy titled Behavioral Health Services dated October 2022, revealed the purpose of this policy was to ensure that all residents received necessary behavioral health services to assist residents to attain and maintain their highest level of mental and psychosocial functioning. This policy indicated that the facility was to ensure behavioral health care services were person centered and reflected the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. A review of the policy titled Behavioral Contracts dated October 2022, revealed that the purpose of this policy was to identify residents who exhibit behaviors which could endanger themselves, others or staff and to develop a behavioral health contract to ensure that the resident was receiving appropriate services and interventions to meet their needs. In accordance with this policy, residents with substance use disorder would have a contract to address inspections of the resident's possessions if there was reasonable suspicion of illegal, unprescribed drugs, alcohol, weapons or unauthorized items that could endanger the resident or others. This policy also indicated that drug testing would be considered if suspension of illegal drug use could adversely affect the resident's condition, restricted or supervised visiting would be necessary if the visits were deemed dangerous to the resident, other residents or staff, increased monitoring and supervision in the facility would be appropriate to maintain the health and safety of the resident suspected of substance use and the protection of the other residents from the substance user/abuser. Review of Resident R141's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnosis of substance abuse disorder. Review of Resident R141's Minimum Data Set (MDS- assessment of resident's care needs) dated January 23, 2023, revealed that the resident was cognitively intact. This assessment also indicated that this resident was independent with locomotion in the bedroom and on the nursing unit; with no upper or lower body extremity impairments. Review of Resident R141's nursing note dated January 23, 2023, at 2:59 p.m, revealed Resident noted to be more sleepier than normal. Resident unable to be woken up easily. Resident admitted to taking medication. Resident states she brought a Percocet 30 mg (milligrams). Resident was able to be woken up after hard sternum rubs. Resident was encourage to go to the hospital. Resident refused to go to the hospital. Review of nursing note dated January 23, 2023, at 3:28 p.m. noted that the resident assisted back to bed for comfort. Resident R141's vital signs were elevated with a blood pressure of 155/85 (normal blood pressure is 120/80) and heart rate was 112 (normal pulse rate is 60-100). Review of Resident R141's care plan revealed that there was no care plan developed for substance abuse or a behavioral contract as indicated in the facility's policy. Interviews conducted with Nursing Home Administrator and Director of Nursing on March 28, 2023, at 1:00 p.m. confirmed that there was no investigation conducted by the facility related to how the resident was able to obtain the narcotic medication Percocet. Further, it was confirmed during interview that there was no person centered care planning or behavioral contract established with Resident R141 to protect the resident from substance use and abuse. Review of Resident R141's nursing documentation dated March 16, 2023, at 7:30 p.m. by Licensed nurse, Employee E31 revealed that approximately at 6:40 p.m. Employee E31 was called to assess Resident R141. The nursing supervisor was informed by the charge nurse that Resident R154 had told the charge nurse that Resident R141 was in his room and had overdose on something he gave her. Upon assessing resident, resident was noted with slow shallow breathing, cold and clammy skin and slow pulse. When asking [Resident R154] what happened, he stated she came to him because she was in pain and according to [Resident R154] gave her some narcotics including Percocet 30 mg and then began to become unresponsive. 2 doses of Narcan given to resident via alternating nostrils. 911 (Emergency Medical Services) called for transportation to ER (Emergency Room) for evaluation. DON/MD (medical doctor) made aware. Resident became more alert and responsive appx. 5-10 minutes after Narcan administration. Continued review of nursing documentation revealed a nursing note dated March 16, 2023, at 9:02 p.m. which noted that Resident R154 came to the nurse to report that Resident R141 overdose in his room. Resident R154 was asked what Resident R141 had taken and how did she get it. Resident R154 said she asked him to get her some Heroin and Oxycodone which he did when he went out on a leave of absence. A review of Resident R141's hospital record dated March 16, 2023, revealed that this resident was treated for an opioid overdose. The hospital record indicated that Resident R141 was evaluated after opioid overdose and that emergency care with Narcan was administered to Resident R141. The hospital emergency department staff discharged Resident R141 on March 16, 2023; to return to the nursing facility for further observation and monitoring. Review of Resident R141's nursing documentation dated March 17, 2023, revealed that the nursing staff witnessed Resident R141 demanding Resident R154 to give her that black plastic bag. The nursing staff member asked to see what was in the black plastic bag however, Residents R141 and Resident R154 would not allow the licensed nurse to visualize the contents of this bag. Review of Resident R141's nursing note dated March 22, 2023, revealed that during the 11-7 shift a licensed nurse found Resident R141 vaping. When the licensed nurse questioned the resident about what was happening, Resident R141 denied using the vape. The nursing assistant found the vaping devise on the floor in front of Resident R141's bed. The nursing documentation indicated that the drug paraphernalia was turned into the supervisor on March 22, 2023. Interview with the Director of Nursing, on March 28, 2023 at 1:30 p.m. confirmed that there was no investigation into how the resident was able to have access to this vaping device. The Director of Nursing also confirmed that there was no investigation of the vaping device that was turned in to the supervisor on March 22, 2023. Observation and interview with Resident R141 on March 28, 2023, at 11:00 a.m. revealed that the resident utilized a wheelchair for mobility. Resident R141 confirmed during interview using a vaping device and that she prefers to use marijuana with the device, when she can get a hold of this drug. Interview with the Director of Nursing on March 28, 2023, at 2:00 p.m., confirmed the event that took place on March 16, 2023, between Resident R154 and Resident R141. The Director of Nursing reported that both of these residents have a significant history for substance use disorder. The Director of Nursing also reported that since Resident R141 and Resident R154 have been associating with each other both residents have relapsed into using unprescribed medications and other narcotics. Further interview with the Director of Nursing revealed that Resident R154 had been obtaining unprescribed medications from individuals at the outside treatment clinic that he attended daily. According to the Director of Nursing, Resident R154 was being supplied with unprescribed drugs from friends that take him out on outings as well. Review of clinical record revealed that R154 was admitted to the facility on [DATE], with diagnoses of Psychoactive Substance Abuse, Alcohol Abuse, Major Depressive Disorder, Rhabdomyolysis, Osteoarthritis, Hypertension. Review of Resident R154's quarterly MDS dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 15 suggesting that Resident R154 was cognitively intact. Review of Resident R154's May 2022 physician orders revealed an order dated May 31, 2022, may have therapeutic leave of absence. Review of Resident R154's substance abuse care plan initiated on February 9, 2022, revealed that the resident will not be under the influence of alcohol or illicit substances. The care plan interventions included to encourage expression of feelings, assist the resident to recognize what triggers behaviors and develop constructive ways of dealing with these behaviors, provide diversional activities as needed, provide factual information about substance abuse and correct misinterpretations. provide information/access to groups (nursing assistants/activity assistants) as needed, provide therapeutic sessions that address addiction and associated behaviors, and teach stress management techniques and coping strategies. Review of Resident R154's care plan initiated on February 9, 2022, for potential for alteration in activities indicated that Resident R154 attends NA/AA (Narcotics Anonymous/Alcoholic Anonymous) meetings weekly. Review of Resident R154's nursing notes dated December 21, 2022, revealed that Resident R154 tested positive for marijuana. Further, due to the positive test for marijuana, Resident R154 was no longer allowed to have his methadone administered in the facility. Resident R154 had to go to the methadone clinic every day to receive his daily methadone dose with an escort for three months (until March 21, 2023). Review of Resident R154's nursing note dated January 24, 2023, at 12:03 a.m. revealed that at approximately 5:45 p.m. nurse was alerted by CNA (nurse aide) that resident was slumped over on his wheelchair and has not touched dinner tray. This nurse came into room to assess resident, HR (heart rate) 50 RR (respirations) 16 Sp02 (oxygen level) 94% at room air. Nurse was unable to obtain B/P (blood pressure). Resident R154 unable to be aroused. made UM (unit manager) aware. UM attempted to arouse resident also noted ineffective. Nursing supv. (supervisor) made aware, resident responding briefly to nsg (nursing) supv. Resident appeared to be suffering from overdose recommended that Narcan be admin (administered). 2 doses of Narcan adm. 3 minutes apart 1 in each nostril. Resident R154 was sent to local hospital via 911 (Emergency Medical Services). Resident R154 returned to the facility on January 24, 2023. Review of hospital emergency department discharge notes dated January 23, 2023, revealed a diagnosis of Opioid dependence, Opioid withdrawal, and Opioid overdose. Further review of Resident R154's documentation dated January 24, 2023 at 7:55 p.m. revealed that Nursing Home Administrator (NHA) and Director of Nursing (DON) interviewed Resident R154 and Resident R154 admitted to NHA and DON that he bought a pill from someone outside of the clinic while getting his methadone treatment. Review of Resident R154's nursing note dated March 16, 2023, at 8:35 p.m. confirmed that Resident R154 admitted that he gave Resident R141 30 milligrams of Percocet because Resident R141 kept asking him for it. Continued review of Resident R154's nursing notes dated March 16, 2023, revealed that at 9:46 p.m. the resident was observed with signs and symptoms of overdose. Resident R154 was observed to be very lethargic and sleeping (nodding) while wheeling himself in the hallway. Resident R154 was observed to periodically stop and sleep off and required hard tapping to get him up. Resident R154 appeared to be breathing normally with vital signs as follow: Blood pressure-142/90, Pulse-85, Respiration-20. Resident R154 was offered a dose of Naloxone (Narcan), but he refused. Further, on March 17, 2023, at 4:41 a.m., Resident R154 was observed giving Resident R141 items in black plastic bag that he would not allow nurse to see. Resident R154 was agitated during the shift and was cursing at CNA (nurse aide) assigned to him. Resident R154 was observed to be very lethargic and sleeping very deeply slumped over in wheelchair in room. Every two hourly checks were performed. Resident R154 continued to require hard tapping to arouse. Review of Social Services note dated March 17, 2023, at 12:56 p.m. revealed that Social Service Director, Employee E14 met with resident at 7:00 a.m. to educate him on the dangers of brining drugs into the facility and giving them to other residents. Resident understands and agrees. SSD (Social Service Director) and Unit Manager asked resident if they could perform room search. Resident agrees. SSD and Unit Manger searched resident's room. Marijuana vape pen found. No other drug paraphernalia found . SSD called 911 (Emergency Medical Services) to report drug overdose. Further review of Resident R154's nursing notes revealed that on March 17, 2023, at 3:00 p.m. NHA and DON spoke to Resident R154 regarding bringing in drugs to the facility and giving them to Resident R141 causing Resident R141 to overdose which resulted in hospitalization. Resident R154 refused to get help for drug rehabilitation. DON informed Resident R154 that he will not be going to the methadone clinic daily and his bottles will be picked up and administered at facility. Further, Resident R154 was informed that the clinic was reducing his methadone daily dose from 180 milligrams to 162 milligrams. Review of Resident R154's physician's orders dated March 17, 2023, revealed an order for Resident cannot go out on leave of absence. Review of Resident R154's care plan revealed that a care plan for the potential for opioid overdose was not initiated until March 17, 2023. Further, Resident R154's behavior of supplying drug to another resident was not addressed in the care plan until on March 29, 2023 Review of the NA/AA (Narcotics Anonymous/Alcoholic Anonymous) meeting (via zoom meeting) list revealed that there was only one meeting in February 2023 and two meetings in March 2023. Further, Resident R154 did not attend the meeting dated February 8, 2023, attended only half of the meeting on March 22, 2023, and did not attend the meeting on March 29, 2023. Further review of Resident R154's clinical record revealed that there was no documented evidence that resident R154 was monitored after returning from a methadone clinic for the pocession of unprescribed medications. Further, there was no evidence that toxicology tests were offered/conducted on Resident R154 after he was observed exhibiting signs and symptoms of drug use on January 23, 2023, February 9, 2023, and March 16, 2023. Interview with Resident R154 conducted on March 29, 2023, at 1:28 p.m. confirmed that he got the pills outside of the methadone clinical but did not provide details regarding the incident. Interviews with Facility Administrator and Director of Nursing conducted on March 28, 2023, at 1:00 p.m. confirmed that resident admitted to them that he purchased the pills from someone at the methadone clinic. Further interview with NHA and DON also confirmed that there was no behavioral contract established with Resident R154 to address both his substance use and giving unprescribed narcotic to Resident R141. Further interview with DON confirmed that the substance abuse care plan for Resident R154 was not updated and did not have new interventions to address Resident R154's positive for marijuana on December 21, 2022, and his bringing unprescribed medication into the facility and using it on January 23, 2023. Based on the above findings an Immediate Jeopardy situation was identified to the Nursing Home Administrator on March 28, 2023, at 3:41 p.m. for the failure to identify and intervene with care and services to meet the needs of two residents with a history of substance abuse disorder. The two residents received emergency care for narcotic overdosing at the facility. The facility also failed to prevent access to unprescribed narcotics for these residents and other residents of the facility. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator (NHA) on March 28, 2023, at 3:41 p.m. On March 28, 2023, at 7:45 p.m., the facility's action plan was accepted. The action plan included the following: - On March 17, 2023, [Resident R154] was moved to the 4th floor and [Resident R141] was moved closer to the nursing station on the [NAME] wing. The reason for the move was to separate and to increase the visibility of [Resident 141]. -On March 21, 2023, Cheltenham Nursing and Rehab reviewed all resident's electronic health record and identified a list of residents with a diagnosis of substance use disorder. -On December 21, 2022, Cheltenham Nursing and Rehab conducted education for the facility on CMS's implementation of Phase 3, dealing with Behavioral Health and Substance Use Disorder. -On January 26, 2023, during QAPI (Quality Assurance Improvement Plan), Cheltenham Nursing and Rehab reviewed and approved new policies and procedures for residents with mental health diagnosis and substance use disorder. -Cheltenham Nursing and Rehab Center has implemented various interventions to prevent access to unprescribed medications. These interventions include, with resident permission a search of belongings brought into the facility after an outing or delivery, search of the resident's room, non-approval of leave of absence request, securing windows of resident rooms with ground level access. The facility sends and escorts on trips to the methadone clinic to limit access to narcotics. The facility has also implemented NA (Narcotic Anonymous) and AA (Alcoholic Anonymous) meetings for identified residents. -Interventions specific to [Resident R154] include January 24, 2023, facility spoke with the Methadone clinic to inform the clinic of the drug transaction that occurred at their location. On January 24, 2023, Maintenance team secured the window outside of [Resident R154's] room to eliminate the possibility of narcotics being supplied through his window. On January 24, 2023, Resident agreed to allow the staff to search his belongings when he returns from an outing or has a delivery sent to the facility. On January 24, 2023, [Resident R154] informed the NHA that he wanted to start attending NA meetings again. On March 17, 2023, NHA and DON spoke with the Medical Director of the Methadone Clinic and got approval for a facility staff member to pick-up take home bottles of Methadone in order to limit his ability to have access to obtain narcotics. On March 17, 2023, the Medical Director of Cheltenham wrote an order to restrict [Resident R154] from going on leave of absence and outings. The Medical Director deemed [Resident R154] unsafe to go into the community alone. On March 20, 2023, the facility sent a referral to [Alcohol and Drug Rehabilitation Facility] -On March 28, 2023, the facility started training facility staff on identifying residents with possible drug abuse history and developing interventions to prevent residents access to unprescribed drugs. The facility will have 80% of the staff educated within 24 hours. The remaining staff will be educated prior to the start of their shift. Staff will be required to sign the education material acknowledging the understanding of the training provided to them. -The DON, NHA and/or designee will complete weekly audits of new admissions and current residents with a history of substance use for three months. Audits will be reviewed at the Quality Assurance Performance Improvement meeting. Interviews were conducted with facility staff on March 29, 2023, between 8:00 a.m. and 4:30 p.m., to verify the implementation of the Action Plan. Facility staff were able to verbalize how they would identify residents with substance abuse disorder and implement interventions to prevent these residents from access to unprescribed drugs. A review was conducted of the education provided to the facility staff related to behavioral health care and services for residents with substance abuse disorder and the prevention of these residents from accessing unprescribed drugs. A review of resident's care plans confirmed that residents care plans were updated to include that close monitoring and supervision was added to prevent access to unprescribed medications and promote a safe environment free of accident hazards. Following the verification of the immediate action plan the Immediate Jeopardy was lifted on March 29, 2023 at 5:27 p.m. 28 Pa Code 201.14 (a) Responsibility of licensee 28 Pa Code 201.18 (a) Management 28 Pa Code 201.18 (b) (1) Management 28 Pa Code 201.18 (b) (3) Management 28 Pa Code 201.18 (d) Management 28 Pa Code 211.10 (a) Resident Care policies 28 Pa Code 211.10 (d) Resident Care Policies 28 Pa Code 211.12.(c) Nursing Services 28 Pa Code 211.12 (d) (3) Nursing Services 28 Pa Code 211.12 (d) (5) Nursing Services