**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, to promote healing and prevent infection for 1 of 5 residents (CR# 1) reviewed for pressure ulcers. The facility failed to prevent progression of CR # 1's Stage 4 Sacral Pressure Ulcer (a severe pressure injury that extends through all layers of skin,) that was not getting better and enlarged from 2.20 cm in length, 1.10 cm in width, 0.10 cm in depth and 2.42 cm in area on 8/19/2025 to 5.40 cm in length, 6.00 cm in width, 2.30 cm in depth, and 32.40 cm ( 2nd degree) in Area on 9/10/2025, had odor an exhibited signs of infection. The facility failed to administer CR # 1's antibiotics, Cefdinir, for the sacral ulcers and as ordered by the wound care Nurse Practitioner on 9/3/2025. An Immediate Jeopardy (IJ) was identified on 9/17/2025. The IJ Template was provided to the facility on 9/17/2025 at 5:00 pm. While the IJ was removed on 9/19/2025, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm at a scope of pattern. These failures could place residents at risk of pain, worsening of wounds, infection, hospitalization, and death. Findings Include: Record review of CR # 1's face sheet, dated 9/12/2025, revealed she was an [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction ( a medical condition where there is a blockage of blood flow to the brain, resulting in damage to brain tissue), non-traumatic intracerebral hemorrhage (a type of stroke caused by bleeding within the skull), hemiplegia and hemiparesis (conditions that cause weakness or paralysis on one side of the body), essential hypertension ( high blood pressure), peripheral vascular disease (a condition that affects the blood vessels outside of the heart), and pressure ulcer of sacral region( a skin breakdown that occurs over the sacrum, the triangular bone at the base of the spine). Record review of CR # 1's care plan 10/27/2021, revealed Focus: pain [CR # 1]is at risk for pain related to neuropathy (a condition that damages the nerves, leading to various symptoms), dorsopathies (conditions that affect the structure or function of the spine, encompassing a range of disorders from degenerative issues to inflammation and pain.), and pressure wound on sacrum(a skin breakdown that occurs over the bony prominence of the sacrum), Goal [ CR # 1} will voice an acceptable pain level within one hour of taking pain medication, and Interventions/Task [CR #1] administer apap prn for pain as ordered by physician, administer baclofen routinely for muscle spasms as ordered, assess for pain using 1-10 scale every shift, and ass to a position of comfort when in pain. Focus, revision 9/12/2025 [CR # 1) stage 4 pressure ulcer on sacrum and DTI to left heel. CR # 1 is at risk for further skin breakdown related to impaired mobility, incontinence, refusing repositioning, refusing baths and low albumin/protein levels.6/2/2025 - new stage 2 pressure ulcer on coccyx- healed 6/11/2025, 7/14/2025- pressure ulcer on coccyx reopened, 7/16/2025 pressure ulcer on coccyx staged 4 by Wound Care Physician. Goal [CR # 1] will remain free of any additional skin breakdown through the new review date; wound will show progress healing by decreasing in size weekly over the next 30 days. Interventions/Task[CR # 1] administer wound treatments routinely as ordered; ascorbic acid tablet 500 mg; assist to reposition at least every two hours; cleanse stage 4 sacral wound with vashe, apply Santyl ( topical ointment used to remove dead tissue from chronic skin ulcers )on vashe soaked hydro [NAME] blue and affected area, cover with silicone boarder dressing daily; encourage to be active and mobile; facility wound care physician to consult and treat weekly as clinically indicated, daily observation of skin with routine care; and low air loss mattress set at 180 lbs.Record review of CR # 1's Minimum Data Set (MDS), 6/23/2025, revealed: CR# 1 was: Dependent (helper does all of the effort or the assistance of 2 or more helpers is required for resident to complete task)C0500- Brief Interview for Mental Status (BIMS) - 14 (intact cognition)GG0120-used a wheelchair for mobilityGG0130-Self-care - dependent on staff for eating oral hygiene, toileting, shower, upper body dressing, lower body dressing, and personal hygieneGG0170-Mobility- dependent on staff for roll left to right; sit to lying; and tub shower transferH0300- Urinary Incontinence - Always incontinentH0400- Bowel Incontinence- Always incontinentM0100- Determinization of Pressure Ulcer/Injury Risk- CR # 1 has a pressure ulcer/injury, a scar over bony prominence, or non-removable dressing/devise. M1050- Risk of pressure ulcers/injuriesM0220- Unhealed pressure ulcers/injuriesRecord review of CR #1's Clinical Physician Orders, dated 9/16/2025, revealed: Tramadol HCL Tablet 50 mg - Direction- give 1 tablet by mouth every 24 hours as needed for pain; start date 9/9/2025 and no end date; Cleanse stage 4 sacral wound with vashe (cleanse, irrigate, moisten, and debride wounds, helping to promote healing by managing bacteria and biofilm, reducing odor, and preparing the wound bed), apply Santyl on vashe soaked hydro [NAME] blue and pack infected area cover with silicone boarder dressing- Direction- every day shift for wound care; start date 8/28/2025 and no end date; Low air loss mattress set at 180 lbs.- Direction - every shift; start date 8/8/2025 and no end date; Offload sacrum, turn and reposition -Direction -every shift for wound care; start date 6/2/2025 and no end date.Record review CR # 1's wound care physician notes, dated 8/27/2025, read in part [CR # 1] had a worsening stage 4 sacrococcygeal pressure injury. [CR # 1's] pressure injury had deteriorated measuring 2 cm in length, 1.6 cm in width and 1.3 cm in depth. The wound was exhibiting a small amount of purulent malodorous drainage. The wound bed consisted of approximately 80% yellow-brownish adherent slough. Undermining the present from 12 to 5 o'clock position. [CR # 1's] condition appeared to have worsened, as evidenced by the need for reassessment of wound dimension and care regimen. There were signs of potential infection, necessitating a wound culture. The malodorous nature of the wound was noticeable, potentially affecting [ CR #1's] social interaction and quality of life. The treatment plan included cleaning the wound and applying Santyl solution and Hydro [NAME] Blue dressing. Record review of CR # 1's wound care physician notes, dated 9/3/2025, read in part [ CR # 1's] stage 4 sacrococcygeal pressure injury worsened. CR # 1 pressure injury was characterized by purulent drainage, slough, and undermining. The wound measured 3 cm in length, 3.4 cm in width and 2.3 cm in depth. There was tunneling from 9'o'clock to 2'oclock with a depth of 4.1 cm. The wound was described as having 100% slough with purulent malodorous drainage. [CR # 1] had been takin Ciprofloxacin for the pressure injury localized infection, but it had not prevented the wound from worsening. Plan: changed antibiotic regimen to start Cefdinir 300 mg by mouth twice a day for 10 days, continue Ciprofloxacin 750 mg by mouth twice a day for an additional 10 days, continue probiotics for 14 days if not already started, continue Diflucan for prevention of Candidiasis infection, wound care, clean wound with saline wash, apply hydrocolloid dressing, use skin prep to peri wound area , change dressing daily, and positioning: maintain patient on side to reduce pressure on sacrococcygeal area.Record review of CR # 1's wound care progress notes written by the wound care nurse, dated 9/4/2025, read in part [CR # 1's] skin had been evaluated. Location: Sacrum; Issue type: pressure Ulcer/injury. Progress: stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4 pressure ulcer/injury-full thickness skin and loss tissue. Wound acquired in-house. Exact date: 7/14/2025 Staged by : Healthcare provider. Length (cm):3; Width (cm): 3.4; Depth (cm) 2.3. Undermining: No, Tunneling: yes; Number of tunnels: 1; cleaning solution: Sodium hypochlorite. Primary dressing: Antimicrobial. Secondary dressing: Foam, Secondary dressing: Silicone. Record review of CR # 1's wound care physician notes, dated 9/10/2025, read in part[CR # 1's] sacrococcygeal pressure injury has significantly worsened since the last visit. The wound exhibited copious amounts of malodorous purulent drainage, which indicated severe infection. The wound measurement revealed a length of 5.4 cm and with 6 cm, with tunneling at 1o'clock to depth of 6.4 cm. The wound bed consisted of approximately 90 % yellow-brownish slough with exposed bone, suggesting possible osteomyelitis (a bone infection that occurs when bacteria or other microorganisms invade and infect the bone). There is concern for undermining and slow healing. [CR # 1's] condition is further complicated by apparent non-compliance w9th the prescribed antibiotic regimen, as cefdinir was not started despite being ordered in the previous week. This delay in treatment may have contributed to the wound's deterioration and potential systemic infection. [CR #1's] vital signs were concerning, with a heart rate of 113 bpm recorded on 9/9/2025, and current difficulty in obtaining blood pressure and temperature measurement. [CR # 1] appears more withdrawn than usual, which, combined with the wound characteristics and vital sign abnormalities raises suspicion for sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). Plan: transfer [CR #1] to emergency room immediately for evaluation and management of suspected sepsis and osteomyelitis. Record review of CR # 1's Weekly pressure report, dated 9/5/2025, revealed CR # 1 had a stage 4 coccyx wound with an onset date of 8/7/2024 and measurements of 5.4 in length: 6.0 in width and 2.3 in depth. Treatment order included cleaning the wound and applying Santyl solution and Hydro [NAME] Blue dressing. CR # 1 was assessed by the MD on 9/10/2025. The family was notified on 9/10/2025. CR # 1 had a DTI left heal with an onset date of 9/3/2025- off load heal. CR # 1 was assessed by the MD on 9/10/2025. The family was notified on 9/10/2025. Record review of CR # 1's MAR, dated 9/2025, revealed: Cefdinir Oral Capsule 300 mg- Give 1 capsule by mouth two times a day for Rash for 3 days; start date 9/4/2025 at 7:00 am. An Immediate Jeopardy (IJ) was identified on 9/17/2025. The IJ Template was provided to the facility on 9/17/2025 at 5:00 pm. While the IJ was removed on 9/19/2025, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm at a scope of pattern. Record review of CR # 1's facility wound care progress note written by the wound care nurse, dated /8/27/2025, read in part[CR # 1's] skin had been evaluated. Location: Sacrum; Issue type: pressure Ulcer/injury. Progress: stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4 pressure ulcer/injury-full thickness skin and loss tissue. Wound acquired in-house. Exact date: 7/14/2025 Staged by : Healthcare provider, Length (cm): 2 Width (cm): 1.6 Depth (cm): 1.3 Undermining; No; Tunneling: Yes. Number of tunnels:1; Tunnel length (cm):1 Tunnel location; 1:2 o'clock. Cleaning solution: Sodium hypochlorite fiber. Primary dressing: Antimicrobial. Secondary dressing: Silicone.An interview at a local acute care hospital with Hospital Physician A on 9/12/2025 at 9:30 am stated that CR # 1 was admitted to the hospital with Stage 4 Sacral wound (Osteomyelitis). She stated it appeared that CR# 1 had not been repositioned enough. She stated based on the state of CR #1's sacral wound it appeared CR # 1 was not receiving wound care adequately. She stated CR # 1 was receiving antibiotics and had debridement of the sacral wound. She stated that some of the decomposition tissue could not be removed. She stated CR #1 needed surgery for additional debridement of the sacral wound. She stated that CR # 1 had decomposition, and the sacral wound was infected. She stated that CR # 1 was in severe pain. She stated that CR # 1's sacrum wound was severe and it had set up sepsis. She stated that in addition to the sacrum wound, CR # 1 had wounds on her heel and legs. Physician A stated that these wounds appeared to be stage one or two. In an interview with Family Member A on 9/12/25 she stated CR #1 was admitted to a local hospital due to a sacral wound infection. She stated when she asked facility staff about CR #1's medical condition she was told that CR # 1 was well. She stated CR # 1 is non-verbal; however, CR # 1 moaned when she was in pain. She stated that on 9/9/2025 she inquired about CR # 1's health and a staff member told Family member B that they needed to inquire about CR#1's sacral wound. Family member A stated that on 9/9/2025 she spoke with CR #1's nurse who said CR # 1 was fine. She stated that she also attempted to speak with the DON but was forwarded to voicemail. Family member A stated the DON contacted her and said CR # 1 was fine. Family member A stated on 9/10/2025 she received a call from the NF and she was told that CR # 1 was being transported to a local hospital. She stated when she arrived at the local hospital, and observed CR # 1's sacral wound, she was in disbelief as she observed a large hole on CR #1's sacral area. She stated CR # 1 was transferred to another hospital and required emergency debridement. She stated she was told CR # 1 would need surgery as they could not remove all the dead tissue in CR # 1's sacral area. In an interview with Wound Care Nurse on 9/15/2025 at 11:20 am who stated that if the floor nurse observed a wound on the weekend the nurse will call the MD for orders and then notify the Wound Care Nurse. Wound Care Nurse stated that CR # 1's wound orders were cleansing, packing with hydro [NAME] blue, Santyl, and silicone dressing She stated that she notified the Wound Care NP, but the Wound Care NP kept the same treatment. The Wound Care NP ordered a Xray of CR # 1s sacral area. She stated that ADON said the first Xray ruled out Osteomyelitis. She stated that another Xray of CR # 1's sacral was ordered on 9/8/2025 and showed that CR # 1 had Osteomyelitis. She stated that CR # 1 was sent to the hospital on 9/10/2025. The Wound Care Nurse stated that CR # 1's wound treatment was QD, and she never refused treatment. The Wound Care Nurse said she had been doing wound care for about a month. Observation of CR # 1 on 9/15/2025 at 1:30 pm revealed CR # 1 was lying in bed with her eyes open and she was moaning. Interview with Family member A present stated CR # 1 did not undergo surgery as planned due to the risk. She stated she and her family agreed to place CR # 1 on Hospice at another NF. In an interview with Family Member A on 9/15/2025 at 1:30 pm said she had no knowledge of how bad CR # 1's wound was. She stated that the NF kept telling her that CR # 1's sacral wound was small, and it was healing. She stated that CR # 1 refused medication and showers but if she had known CR # 1 was refusing wound treatment or antibiotics for her wound, given how bad it was, she would have gone to the NF to talk to CR # 1. She stated that she did not know how bad CR # 1's sacral wound was until she saw the wound at the hospital on 9/10/2025. She stated that CR # 1 would always say her bottom was burning, but she did not realize it was from a wound. She stated that she thought CR # 1 needed to be repositioned. In an interview with Hospital Physician A on 9/15/2025 at 1:45 pm at the hospital she stated that CR # 1 sacral wound looked horrible, and it was unacceptable for CR # 1 to have a wound looking like that. She said there was no way a wound would look like that if it was being treated. She stated that CR # 1 wound looked like it had not been treated for several days. She stated that she did not need to do a biopsy to know there was osteomyelitis. Hospital Physician A said she could see the bone and there was purulent drainage and had a foul odor. She stated that CR # 1 was hardly verbal so she could not see how CR # 1 could refuse any treatment. Hospital Physician A said she spoke with Family Member A about surgery for debridement and the process and what it would entail. She stated that Family Member A did not want CR # 1 to go through that and decided to place CR # 1 on hospice.In a telephone interview with Family Member B on 9/15/2025 at 11:40 am stated that in July 2025 CR # 1 had a sacral wound that healed. She stated that 2 months ago CR # 1's sacral wound returned and it progressively staged. She stated that she and Family Member A asked about CR # 1's condition and they were told that CR # 1 was well. Family Member B stated that she was aware of CR # 1's sacral wound but she did not know it was that bad. She stated that she observed CR # 1's sacral wound was large, smelly, discolored and had pus in it. She stated that this was why CR # 1 was in pain. She stated that she was told CR#1's sacral wound was not treated properly at the NF. In an interview with RN A on 9/16/2025 at 11:00 am stated that CR # 1 was bedridden and she was, totally care and required a Hoyer lift. She stated that CR # 1 had a sacrum pressure ulcer, and the wound was infected. She stated that she provided care to CR # 1 on 8/29/2025 and CR #1's sacrum wound was not open- no granulation tissue and no blood. She stated that the reason why CR # 1 sacrum wound staged was because she was not repositioned and off loaded. She stated that the last time she worked with CR # 1 she said, my butt, my butt. She stated that if a pressure ulcer was not treated properly the ulcer was infected and spread to sepsis. She stated that CR # 1 never refused care when she was caring for her. In an interview with the Wound Care Nurse on 9/16/25 at 12:00 pm stated CR # 1's wound was worsening. She stated CR # 1 never refused wound care and she received wound care daily. She stated she did not provide wound care to CR # 1 from 9/7/25-9/12/25. The wound care nurse stated that when she last treated CR #1 the peri wound was not around the sacral. She said CR #1 was ordered to have antibiotics on 9/3/25, but she refused the medication on 9/4/25 and 9/5/25. She stated that CR # 1's sacrum wound was worsening, but it was stable, and Osteomyelitis was not detected. She stated that Cr # 1 had holes near the sacrum area and there was no pus around the peri wound. She stated that she did not know why CR #1 ‘s wound was not healing. She stated CR#1 was at risk of infection or the worsening of the sacrum wound. She stated that CR #1 never refused care. In an interview with ADON on 9/16/25 at 12:10 pm stated that on 9/3/2025 CR # 1 had an X-ray which indicated there was no Osteomyelitis. She started on 9/8/25, a second x-ray revealed Osteomyelitis. The ADON stated CR # 1 would refuse care and would not allow staff to reposition her. The ADON stated CR # 1 would refuse wound care. She stated that CR #1 had a large slough (narcotic tissue) on the sacrum and the Wound Care NP debrided off the wound. She stated that if CR # 1 was not repositioned the sacrum wound would worsen and the risk could be infection., osteomyelitis and /or possible death. In an interview with LVN A on 9/16/2025 at 2:58 pm stated that she provided wound care to CR # 1 on 9/9/2025. She stated that CR # 1 sacrum wound looked horrible. She stated that CR # 1 was being seen by Wound Care NP or Physician once a week. She stated that CR # 1 was bed bound and total assist. She stated that she can't say if CR #1 sacrum wound was unavoidable or avoidable as there were many things that should be considered to include proper nutrition, daily medication, reposition every 2 hours and getting out of bed. She stated that when she provided wound care to CR # 1 on 9/9/2025 she had to use a depressor to clean out the slough that was on it. She stated that she was concerned with CR #1's sacrum wound as she could have sepsis, and the wound appeared to have some type of bacteria.In an interview with Wound Care NP on 9/17/2025 at 10:20 am she stated that CR # 1 had a stage 4 sacrum pressure injury. She stated that she visited CR # 1 on 9/10/2025 and the sacrum wound had deteriorated since her last visit on 9/3/2025. She stated CR # 1's sacrum wound had purulent drainage. She stated that on 8/27/2025 she saw CR # 1 and she noticed the sacral wound had deterioration. She stated that she took a culture and sensitivity, and CR # 1 was on broad spectrum of antibiotics. She stated that she ordered blood culture and continued wound care and Santanyl. She stated that on 9/3/2025 she ordered an X-ray, and she gave an order of Cefdinir 300 mg - 2 times a day for 10 days. She stated that she gave this order to Wound Care Nurse. She stated that Cr # 1's sacral wound continued to worsen. 9/10/2025 Cr # 1's sacral wound measured 5.4 cm by 6 cm with approximately 90% of the wound bed covered in yellow-brownish slough. She stated that the bone was exposed. She stated that CR # 1's heart rate was 110. She stated ordered for CR # 1 to be sent out to the local hospital. She stated that she noticed that was concerned about non-compliance with the prescribed antibiotics, Cefdinir. She stated that CR # 1 was supposed to start the Cefdinir (to treat bacterial infections in many different parts of the body) a on 9/3/2025, but CR # 1 was not given the medication as prescribed. She stated that the facility did not adhere to the wound care protocol. She stated this may have contributed to CR # 1's wound care deterioration and potential systemic infection. She stated that CR # 1's wound sacral wound was worsening, and she was concerned that CR # 1 had sepsis and possible Osteomyelitis. Wound Care NP stated that she could not say as to whether this was unavoidable or avoidable. She stated that with wound you just don't know. She stated that she can't say how a resident will heal. She stated that the wound care nurse will let her know if the resident have any changes. She stated that she did not know if the CR # 1 was repositioned; she stated that she had any issues with this. She stated that she was told CR # 1 would refuse care. She stated that CR #1 never refused care while she was treating her. In a telephone interview with Wound Care Physician. He stated that CR # 1's sacral pressure injury. She stated that this sacral wound was infected. He stated that a broad spectrum of antibiotics was administered to CR # 1. He stated that bacteria took over the sacral infection . He stated that sometimes the wound will heal and sometime the wound will not heal. He stated CR # 1 was given a broad spectrum of antibiotics for resistant bacteria and the infection was rapidly taking control of the sacral pressure injury. Wound Care Physician stated that all antibiotics work the right way they will put broads he stated that this will not guarantee it will control the infection. The infection will take over the area and will cause deterioration. Wound Care Physician stated they tried to find the correct antibiotics - broad spectrum had enough sensitivity. The Wound Care Physician would say if this deterioration was unavoidable or avoidable as he stated that there are several things that could be factors to include turning, eating properly, blood glucose each patient is different, and commodity is different.In an interview with the Wound Care Nurse on 9/17/2025 at 11:00 am stated that Wound Care NP gave an order for CR # 1 on 9/3/2025 for Cefdinir 300 mg-2 times a day for 3 days for sacral wound. She stated that the order was given verbally, and she wrote the order as she heard it from Wound Care NP. She stated that Wound Care NP did not give her (Wound Care Nurse) an order for Cefdinir- 300 mg- 2 times a day for 10 days for the sacral wound. On 9/17/2025 at 5:00 pm., the Administrator was notified of the Immediate Jeopardy due to the above failures. The IJ template and plan of removal was emailed to the Administrator. The plan of removal was requested at this time. The following Plan of Removal (POR) was submitted by the facility and accepted on 9/18/2025 at 3:26 pm: Immediate Jeopardy Citation called on 9/17/25 @ 5:00 PM PORFacility failed to ensure CR #1 received the care services to prevent the development and deterioration of a stage 4 sacrococcygeal pressure ulcer[ CR #1 is no longer a resident of the facility and has been moved to a different facility. Immediate Action:Upon notification of the deficient practice, a 100% skin sweep and audit was completed to ensure that no other resident had any wound care issues that were not documented on and to ensure that orders matched as they should. Nurse Administration, DON, ADON, Wound Care Nurse, Admissions Nurse and MDS nurse have conducted the 100% skin sweep on each unit. Which was completed on 9/17/25. The skin sweep included looking for signs and symptoms of infection, 1 Resident was noted to have some redness, it was addressed with TAO and dry dressing, and MD was notified for any additional direction. No substantial wounds or open areas that had not already been addressed and documented on. Care plans for all wounds noted were reviewed on 9/18/25 and all RP's[ were given a weekly update on current wound status on 9/17 and 9/18/ 25. 100% wound care orders are being audited to ensure that all patients with wounds are being properly cared for as per the MD orders to be completed 9/18/25. Performance Improvement plan was put in place 9/17/25 to drill down on underlying issues that led to the alleged deficient practice. Wound Care policy was reviewed on 9/17/25 by the Administrator and DON no changes were made to the policy. Protocol regarding wound order taking is being altered to ensure orders are clarified and signed on the day the order is given, or we will change wound care providers to accommodate that new protocol. These changes will take effect immediately and be verified 9/24/25. Facilities Plan to Ensure compliance quickly: Through the skin sweep facility was able to check for any residents at risk for pressure ulcers. One resident was found with a red area. Evaluation and treatment was given. Wound Care Nurse is the designated LVN to cover the wound care system. Wound care nurse will round on wounds daily to ensure that turning and repositioning is happening as necessary. DON and administrative nurse designees will monitor direct care staff compliance with respect to any new interventions. All direct care staff members are being in-serviced, which began 9/17/25 and is ongoing to be completed by 9/19/25. DON and ADON's are carrying out training and education to all direct care staff. No staff member can provide direct care until they have been in-serviced on the below topics. To ensure facility will prevent worsening existing pressure sores. Facility will have wound care rounds daily, and weekly wound care practitioner visits. Staff will be educated as to signs and symptoms of skin break down so to be able to report to charge nurse and wound care nurse. All education and monitoring begin 9/17/25. Although we continue to do weekly practitioner rounds and daily wound care rounds, the way in which we conduct these rounds will be different as there will be written orders and signed the day of. All nursing staff is being educated on change of condition and reporting guidelines. DON, ADON, MDS Nurse and other designated nurses by the DON will keep care plans updated with any new interventions or changes of condition regarding wounds. With regard to any changes to treatments, medications, and with respect to wounds family and MD will be notified immediately and family will be updated weekly after wound care physician groups have rounded. Daily in morning stand up DON or designee will ensure that orders are in place and family members have been contacted. Weekly in standard of care meeting facility will go over wound care for the week and ensure orders are in place and family members have been notified of changes. Direct care staff will be alerted of changes via in-service and education along with alerts on EMR dashboard. All training regarding the in-services noted below, change of condition, ANE, Following MD orders, and reporting change of condition. All training is being done by DON or ADON's. If the resident refuses care, several interventions will be put in place such as updated care plan, work with family to gain resident agreement with compliance. Work with wound care practitioners and wound care nurse to help persuade residents to accept wound care. Check for any barriers that keep the resident from accepting wound care such as pain, discomfort or other irritants, then address those issues to gain compliance. If the resident chooses to continue to refuse, the refusal will be documented by the wound care nurse in the EMR the facility may no longer be able to meet that resident's needs, and a different level of care may be needed such as inpatient wound care or acute care. This decision will be made with resident, family members and IDT in a comprehensive care plan meeting. These steps were placed in QAPI plan for residents who refuse 7/18/25. The Medical Director and Wound Care Physician group were notified by DON as to the need for performance improvement plan on 9/17/25 with respect to wound care to gain counsel and to educate them on the need for written orders when in house rather than verbal orders. Wound Care nurse will be 1 on 1 in-serviced by DON as to new protocol surrounding getting written orders instead of verbal orders. All nursing staff were in-serviced on the following:- General Wound Care with Competency and return Demonstration. - Abuse, Neglect, Exploitation prohibition. - Following MD Orders- Reporting Change of ConditionThe above in-services were initiated on 9/17/25 and are ongoing until all direct care staff has signed to be completed by 9/19/25. No one can provide direct care until they have had the in-service training given by the DON and or ADON's. In-servicing was initiated 9/17/25 and is ongoing. No staff member will be able to provide direct care until they have been educated on the above topics. DON and ADON's will provide proper training. An Ad Hoc QAPI meeting will be conducted on 9/18/25 at 9AM to review audit results and to ensure that the education given is covering the pertinent topics pertaining to this particular alleged deficient practice.DON and administrative nurses will have a collaborative effort with respect to wound care orders and implementation of those orders, and weekly during standard of care meetings on going indefinitely and will be reviewed by QAPI committee monthly for 6 months to ensure compliance. Ongoing daily monitoring by DON or designee, to review any new pressure issues or other types of wounds and to ensure that the MD order is in place and being followed. Standard orders for any noted skin issues will be applied as per MD recommendation. Facility will be adding wound care competency check offs beginning 9/17/25 and ongoing for current and newly hired nurses and then annually ongoing. DON or designee will be responsible for competencies and check offs. No staff will be allowed to provide care to residents until they have received the noted training and appropriate check offs. Wound Care Physician group will be signing orders in house moving forward to ensure dictation of all orders are correct and clarified. This will be both a part of our POR and POC upon receipt of legal documents. Monitoring of POR: Record review of facility Resident Rights policy, dated December 2016, read in part Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be notified of his or her medical condition and of any changes in condition in his or her condition. Record review of the facility's Change of Condition policy, not dated, read in part observe, record and report any condition change to the physician so proper treatment can be implemented. Procedure included notifying resident's responsible party.Record review of the facility's Inservice Training Reporting Change, dated 9/17/2025, read in part [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. While the IJ was removed on 02/07/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk for adverse side effects, overdose, hospitalization, and death. The findings included: Record review of CR #1's admission Record, dated 01/10/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included age-related osteoporosis with current pathological (broken bone) fracture, left femur (thigh bone), asthma (narrowing of the airways), and muscle weakness. Record review of CR #1's MDS Assessment, dated 12/31/24, revealed a BIMS score of 3, indicating severe cognitive impairment. Further review revealed resident was dependent (the assistance of 2 or more helpers was required for the resident to complete the activity) with toileting, shower/bathe, and upper and lower body dressing. Section J - Health Conditions, Pain Management indicated CR #1 received scheduled and PRN pain medication, pain was present, experienced frequently, and resident verbalized intensity as moderate (scale 2) over the last 5 days. Record review of CR #1's baseline care plan, dated 12/27/24, revealed the resident was alert, cognitively intact, and incontinent. Further review revealed CR #1 was taking psychotropic, antibiotics, anticoagulants, opioids, and black box medications. Record review of CR #1's MAR dated, 01/01/2025-01/31/2025, revealed an order for morphine sulfate oral tablet 15 mg, 1 tablet by mouth every 12 hours for pain (8:00 a.m. and 2000 (8:00 p.m.)), start date 12/30/24, end date 01/03/25. Further review revealed an order for Norco oral tablet, 7.5-325 mg, 1 tablet by mouth three times a day (8:00 a.m. 1300 (1:00 p.m.), and 1800 p.m. (6:00 p.m.)) for pain, start date 12/30/24, end date 01/01/25. On 01/01/25, CR #1 was administered a morphine tablet and Norco tablet at 8:00 a.m. Record review of physician orders, dated 12/30/24, revealed an order for morphine sulfate oral tablet 15 mg, give 1 tablet by mouth every 12 hours for pain, start date 12/30/24. Further review revealed an order for Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen), give 1 tablet by mouth three times a day for pain, do not exceed 3 GM in 24 hours, start date 12/30/24. Record review of CR #1's progress notes, dated 01/01/25 at 12:20 p.m., revealed upon entering resident room to assist CNA in brief change and repositioning, this nurse [Nurse A] noted resident to be lethargic. Pupils pinpoint and barely reactive, speech unclear, unable to follow commands, respiratory rate decreased. Doctor and 911 called and RP notified. Record review of CR #1's hospital records, report date 01/29/25, revealed resident was given 1 injection and 2 syringes of NARCAN (used to treat an opioid overdose emergency). Further review read in part .ED course as of 01/01/25 .Narcan given helps with RR and now making more noise, gives her name when asked .Narcan ordered with some improvement[,] wore off quickly, will redose .After narcan pt is now yelling call the police and they are drugging me .She was given Narcan by EMS and her symptoms improved. She was recently given morphine for pain which has probably been too strong for the patient .was admitted for acute encephalopathy in setting of accidental narcotics overdose .presented to the hospital for acute encephalopathy in the setting of accidental opiate overdose that resolved while here at the hospital .treated with IV ceftriaxone yet her encephalopathy did not improve .developed acute respiratory failure with hypoxia during hospice admission .pronounced dead at 2:57 PM . Resident was admitted to inpatient hospice care on 01/04/25 and passed away on 01/09/25 from acute toxic encephalopathy. During a telephone interview on 01/10/25 at 10:28 a.m., CR #1's family member said on two separate visits, 12/28 and 12/29, resident was overmedicated, and she asked nurses not to administer anything other than what the hospital had given her and to talk with her before any medication changes. During an interview on 01/10/25 at 1:20 p.m., Nurse A said on the 01/01/25 CR #1 was the same as 12/31/24, refusing care all morning. She said a CNA came to her and told her the resident did not want her brief to be changed by the CNA. She said she thinks it was CNA C that notified her and so she went in the room with CNA C and noticed a change in condition. She said she noticed CR #1 had slurred speech, was lethargic, her pupils were pinpoint, altered mental status, and said that was all she could remember off the top of her head, and that it was noticeable. She said she immediately called Doctor and reported the change of condition, and she gave the order to send the resident to the hospital. She said she called 911 for transport, assessed her vitals, EMS arrived, and once she was leaving with them, she notified the family member and explained her change of condition and that she was going to the hospital. She said the medication aides pass the medications including narcotics. She said the CNA on 01/01/25 was CNA C. She said the resident may have gone out to the hospital sometime after breakfast or lunch. She said she had taken the residents vitals earlier that morning between 6:45 a.m. and breakfast. She said she cannot recall what her vital signs were off the top of her head but if they were not within normal limits for resident, the doctor would have been notified. She said she did not receive any notifications about a change in condition from the CNA before assisting her with the brief changing. She said that she knew with all the medications she got, she was still in pain. On 01/10/25 at 2:00 p.m., a telephone call made to CNA B but received message saying the subscribers number was not in service. On 01/10/25 at 2:18 p.m., a telephone call made to CNA C, but call went unanswered. Left a voicemail requesting a return phone call. During an interview on 01/01/25 at 3:22 p.m., the DON said she knew CR #1 went out to the hospital and was admitted with acute encephalopathy related to UTI, dehydration, acute kidney injury, and they suspected a possible stroke and CT showed some stenosis to the carotid artery but could not completely rule that out. She said Nurse A described the resident as failure to thrive and that she had been refusing to eat and drink and medications at times. She said the Doctor made a recent pain medication adjustment a couple days before the resident went out to the hospital. She said the resident was not seeing a pain management doctor. She said the resident came to the facility because she had a recent hip fracture and was not a surgical candidate. She said she was on hydrocodone, but it was not managing her pain so the Doctor prescribed morphine twice a day and CR #1 could have hydrocodone 3 times a day if she needed it. She said If the pain was not being managed, they notify the doctor and go from there and always try to do things like repositioning and non-medication interventions such as therapy and a hot pack. On 02/04/25 at 10:18 a.m. and 11:24 a.m., called CNA B but at two different numbers provided by the facility but received the following messages: the subscriber you have called is not in service, please check the number and try your call again; your call cannot be completed as dialed please check the number and try again. During a telephone interview on 02/04/25 At 12:32 pm, the Doctor said morphine was used for pain management. She said CR #1 had excruciating left hip pain. She said she had started her on Morphine because CR #1 complained of pain score of 10/10. She said Norco was for pain management as well. She said she was on Norco but said Norco was not helping. She said she ordered Morphine Sulfate 15 mg, 1 tablet to be administered by mouth to be schedule for every 12 hours. She said she told them she can also have Norco as needed. Norco was the breakthrough pain medication. She said despite the two medications, CR #1 was still in pain. She said she had a femur fracture and was in a lot of pain. She said Norco was to be administered every 6 hours as needed for pain. She said CR #1 refused food, and care due to pain. She wanted Morphine. She said when a medication was ordered for three times a day, it should be administered at, 8 a.m., 2 p.m., and 9 p.m. bedtime. She said she never writes orders in the Electronic Medication Administration Record (eMAR) the nurses do. She said she sees the orders because she signs any order under her name. She said after you give Morphine, you wait, if the resident was still in pain, then you give the Norco. She said wait for at least 2 hours to administer a second pain medication. She said the consequences of administering two opioids were: constipation, drossiness, altered mental status, pupils' constriction, dizziness, vomiting, nausea, confusion, and changes in pupils. She said the elderly population were frail. Surveyor mentioned that the hospital mentioned accidental opioid overdose, the Dr., said the hospital did not know what they were doing. During an interview on 02/04/25 at 1:38 p.m., the DON said she was not at the facility when CR #1 was transported to the hospital. She said Nurse A told her the resident had a decrease in responsiveness. She said she was not aware of what pain medication CR #1 was taking until after she went out to the hospital. She said Nurse A said she was also concerned that it could be her pain medication. She said she looked at the hospital site and they had encephalopathy, UTI, and dehydration. She said she was not aware of the hospital notes about opiate overdose, but she did call the Doctor to let her know she was transferred to the hospital and what the hospital's notes were at that time. She said Nurse A was concerned it was about the medications because of how she found the resident before she sent her out. She said she did not know CR #1's order for Norco and morphine were together at 8:00 a.m. She said when starting to manage breakthrough pain you start with one and space out the other at least a couple of hours. She said the Doctor ordered the morphine in addition to the Norco because Norco was not helping with pain. During follow-up interview on 02/05/25 at 9:46 a.m., Doctor/Medical Director/Physician said when the EMS comes, to be on the safe side, they will give Narcan even with the slight suspicion of overdose. She said hospital gave Narcan because probably EMS told them. The Doctor said in spite of being on the schedule morphine 2 times a day CR #1 was still needing the Norco because she was still in pain. The Doctor said because CR #1 was yelling and in pain, she thinks that was why they gave it to her. She said CR #1 was admitted with an order for PRN Norco, then scheduled Norco and morphine was added. She said for this patient it would be okay to give her scheduled morphine and Norco. She said Narcan was used to reverse narcotic overdose. She said some effects of giving the two medications at the same time could be constipation, drowsiness, dizziness, nausea, and pinpoint pupils. During a telephone interview on 02/05/25 at 10:30 a.m., MA B said CR #1's name sounded familiar, but she could not put a face to her. She said she did not remember what she gave the resident on 01/01/25. She said to be honest it would help it she could see a picture of the resident. She said she did not remember what time she gave the medication, but she works with the nurse, and they were the ones who usually monitor the pain of the resident. She said she administers PRN narcotics. She said administration times were determined by what the nurse enters in the system. Record review of the facility's Administering Medications policy, revised April 2019, read in part .8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss concerns . Professional Reference accessed 02/24/25 - Hydrocodone and morphine Interactions - Drugs.com Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death. Talk to your doctor if you have any questions or concerns. Your doctor may be able to prescribe alternatives that do not interact, or you may need a dose adjustment or more frequent monitoring to safely use both medications. Do not drink alcohol or self-medicate with these medications without your doctor's approval, and do not exceed the doses or frequency and duration of use prescribed by your doctor. Also, because these medications may cause dizziness, drowsiness, difficulty concentrating, and impairment in judgment, reaction speed and motor coordination, you should avoid driving or operating hazardous machinery until you know how they affect you. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. Professional Reference - Toxic Encephalopathy - https://pharos.nih.gov/diseases/Toxic%20encephalopathy#diseaseSummary A group of neurologic disorders caused by damage to the nervous system following exposure to pharmacologic, biologic, and chemical agents. Examples of neurotoxins include chemotherapy agents, radiation treatment, heavy metals, pesticides, and food additives. The Administrator was notified on 02/05/25 at 9:26 a.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 02/06/25 at 1:20 p.m.: Plan of Removal Immediate Jeopardy Citation called on 2/5/25 @ 9:26 AM F- 755 Pharmacy Services [] Immediate Action: Upon notification of the deficient practice, a 100% audit of all residents with orders for scheduled narcotic pain medications, hospice pain medications and any breakthrough pain medications including all opioid medication is being completed to ensure that no other resident had scheduled pain medications with the parameters that were closer than 2 hours apart on the medication administration record. None were found to have any parameters that were closer than 2 hours apart as of 2/5/25. Audit was completed on 2/5/25 by DON [] RN, ADON [], LVN [], LVN. In addition, In-servicing and education will be provided to all licensed or registered nursing staff and prescribing medical doctors regarding opioid use and parameters to do with any other scheduled narcotic pain medications that could cause accidental overdosing. This education and in-service will be initiated on 2/5/25 and will become a part of [] onboarding and ongoing education. All medication aides, charge nurses, nursing administration and medical doctors will be in-service and educated effective immediately beginning 2/5/25 and ongoing. Initial in-services and education was provided and completed on 2/5/25 conducted by ADON [], LVN and [] LVN. Policies were reviewed and there was no changes to the policy. Education regarding Opioid use and signs and symptoms of opioid use was initiated on 2/5/25 and is being conducted by [], LVN ADON, [], RN DON and [], LVN. Nurses and Medication Aides have been educated in all areas including Opioid use and signs of overdose and it was completed on 2/6/25. Facilities Plan to Ensure compliance quickly: An Ad Hoc QAPI meeting will be conducted on 2/5/25 at 2PM to review audit results and to ensure that the education given is covering the pertinent topics pertaining to this particular alleged deficient practice. DON and administrative nurses will have a collaborative effort with respect to monitoring medications upon admission, and weekly during standard of care meetings on going indefinitely and will be reviewed by QAPI committee monthly for 6 months to ensure compliance. Ongoing daily monitoring by DON or designee, to review medications for compliance. [] will also be adding Opioid abuse education to our onboarding and our annual in-servicing. On 02/06/25-02/07/25, surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed on 02/06/25, the facility completed an audit of all residents in the facility with orders for scheduled narcotic pain medications, hospice pain medications and any breakthrough pain medications including all opioid medication. Review revealed 38 residents had an order(s) for narcotic(s). 12 of these residents had one or more of their narcotic medication(s) discontinued. Record review revealed on 02/05/25, in-service was initiated with nursing staff and MAs on Pharmacy Services and Opioid Use, Administering Medications, Checking 7 Rights, and Medication Labeling; 28 staff were in-serviced. Interviews were conducted from 02/06/25 to 02/07/25 with staff from all shifts (6:00 a.m.to 2:00 p.m., 6:00 a.m. to 6:00 p.m., 7:00 a.m. to 7:00 p.m., 6:00 p.m. to 6:00 p.m., and 10:00 p.m. to 6:00 a.m.): DON, Nurse A, B, C, D, E, F, G, and H, and MAs A, B, C, and D. All licensed Nursing staff and MAs interviewed, verbalized an understanding of the information presented during the in-service trainings. The Administrator was informed the Immediate Jeopardy was removed on 02/07/2025 at 2:37 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that its residents were free of any significant medication errors resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. While the IJ was removed on 02/07/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could place residents at risk for adverse side effects, overdose, hospitalization, and death. The findings included: Record review of CR #1's admission Record, dated 01/10/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included age-related osteoporosis with current pathological (broken bone) fracture, left femur (thigh bone), asthma (narrowing of the airways), and muscle weakness. Record review of CR #1's MDS Assessment, dated 12/31/24, revealed a BIMS score of 3, indicating severe cognitive impairment. Further review revealed resident was dependent (the assistance of 2 or more helpers was required for the resident to complete the activity) with toileting, shower/bathe, and upper and lower body dressing. Section J - Health Conditions, Pain Management indicated CR #1 received scheduled and PRN pain medication, pain was present, experienced frequently, and resident verbalized intensity as moderate (scale 2) over the last 5 days. Record review of CR #1's baseline care plan, dated 12/27/24, revealed the resident was alert, cognitively intact, and incontinent. Further review revealed CR #1 was taking psychotropic, antibiotics, anticoagulants, opioids, and black box medications. Record review of CR #1's MAR dated, 01/01/2025-01/31/2025, revealed an order for morphine sulfate oral tablet 15 mg, 1 tablet by mouth every 12 hours for pain (8:00 a.m. and 2000 (8:00 p.m.)), start date 12/30/24, end date 01/03/25. Further review revealed an order for Norco oral tablet, 7.5-325 mg, 1 tablet by mouth three times a day (8:00 a.m. 1300 (1:00 p.m.), and 1800 p.m. (6:00 p.m.)) for pain, start date 12/30/24, end date 01/01/25. On 01/01/25, CR #1 was administered a morphine tablet and Norco tablet at 8:00 a.m. Record review of physician orders, dated 12/30/24, revealed an order for morphine sulfate oral tablet 15 mg, give 1 tablet by mouth every 12 hours for pain, start date 12/30/24. Further review revealed an order for Norco oral tablet 7.5-325 mg (hydrocodone-acetaminophen), give 1 tablet by mouth three times a day for pain, do not exceed 3 GM in 24 hours, start date 12/30/24. Record review of CR #1's progress notes, dated 01/01/25 at 12:20 p.m., revealed upon entering resident room to assist CNA in brief change and repositioning, this nurse [Nurse A] noted resident to be lethargic. Pupils pinpoint and barely reactive, speech unclear, unable to follow commands, respiratory rate decreased. Doctor and 911 called and RP notified. Record review of CR #1's hospital records, report date 01/29/25, revealed resident was given 1 injection and 2 syringes of NARCAN (used to treat an opioid overdose emergency). Further review read in part .ED course as of 01/01/25 .Narcan given helps with RR and now making more noise, gives her name when asked .Narcan ordered with some improvement[,] wore off quickly, will redose .After narcan pt is now yelling call the police and they are drugging me .She was given Narcan by EMS and her symptoms improved. She was recently given morphine for pain which has probably been too strong for the patient .was admitted for acute encephalopathy in setting of accidental narcotics overdose .presented to the hospital for acute encephalopathy in the setting of accidental opiate overdose that resolved while here at the hospital .treated with IV ceftriaxone yet her encephalopathy did not improve .developed acute respiratory failure with hypoxia during hospice admission .pronounced dead at 2:57 PM . Resident was admitted to inpatient hospice care on 01/04/25 and passed away on 01/09/25 from acute toxic encephalopathy. During a telephone interview on 01/10/25 at 10:28 a.m., CR #1's family member said on two separate visits, 12/28 and 12/29, resident was overmedicated, and she asked nurses not to administer anything other than what the hospital had given her and to talk with her before any medication changes. Observation of CR #1's narcotics blister packs revealed one for HYDROcod/APAP tab 7.5/325MG, 1 tablet by mouth every twelve hours as needed for pain and one for morphine ER TAB 15MG, 1 tablet by mouth every twelve hours. During an interview on 01/10/25 at 11:06 a.m., Nurse A said she knew CR #1 had scheduled pain medication but still complained of pain. She said that was one of the main reasons she would refuse care. She said if there was ever a refusal or discrepancy in medications, she or the charge nurse at the time would be notified. During a follow-up interview on 01/10/25 at 1:20 p.m., Nurse A said on the 01/01/25 CR #1 was the same as 12/31/24, refusing care all morning. She said a CNA came to her and told her the resident did not want her brief to be changed by the CNA. She said she thinks it was CNA C that notified her and so she went in the room with CNA C and noticed a change in condition. She said she noticed CR #1 had slurred speech, was lethargic, her pupils were pinpoint, altered mental status, and said that was all she could remember off the top of her head, and that it was noticeable. She said she immediately called Doctor and reported the change of condition, and she gave the order to send the resident to the hospital. She said she called 911 for transport, assessed her vitals, EMS arrived, and once she was leaving with them, she notified the family member and explained her change of condition and that she was going to the hospital. She said the medication aides pass the medications including narcotics. She said the CNA on 01/01/25 was CNA C. She said the resident may have gone out to the hospital sometime after breakfast or lunch. She said she had taken the residents vitals earlier that morning between 6:45 a.m. and breakfast. She said she cannot recall what her vital signs were off the top of her head but if they were not within normal limits for resident, the doctor would have been notified. She said she did not receive any notifications about a change in condition from the CNA before assisting her with the brief changing. She said that she knew with all the medications she got, she was still in pain. On 01/10/25 at 2:00 p.m., a telephone call made to CNA B but received message saying the subscribers number was not in service. On 01/10/25 at 2:18 p.m., a telephone call made to CNA C, but call went unanswered. Left a voicemail requesting a return phone call. During an interview on 01/01/25 at 3:22 p.m., the DON said she knew CR #1 went out to the hospital and was admitted with acute encephalopathy related to UTI, dehydration, acute kidney injury, and they suspected a possible stroke and CT showed some stenosis to the carotid artery but could not completely rule that out. She said Nurse A described the resident as failure to thrive and that she had been refusing to eat and drink and medications at times. She said the Doctor made a recent pain medication adjustment a couple days before the resident went out to the hospital. She said the resident was not seeing a pain management doctor. She said the resident came to the facility because she had a recent hip fracture and was not a surgical candidate. She said she was on hydrocodone, but it was not managing her pain so the Doctor prescribed morphine twice a day and CR #1 could have hydrocodone 3 times a day if she needed it. She said If the pain was not being managed, they notify the doctor and go from there and always try to do things like repositioning and non-medication interventions such as therapy and a hot pack. On 02/04/25 at 10:18 a.m. and 11:24 a.m., called CNA B but at two different numbers provided by the facility but received the following messages: the subscriber you have called is not in service, please check the number and try your call again; your call cannot be completed as dialed please check the number and try again. During a telephone interview on 02/04/25 At 12:32 pm, the Doctor said morphine was used for pain management. She said CR #1 had excruciating left hip pain. She said she had started her on Morphine because CR #1 complained of pain score of 10/10. She said Norco was for pain management as well. She said she was on Norco but said Norco was not helping. She said she ordered Morphine Sulfate 15 mg, 1 tablet to be administered by mouth to be schedule for every 12 hours. She said she told them she can also have Norco as needed. Norco was the breakthrough pain medication. She said despite the two medications, CR #1 was still in pain. She said she had a femur fracture and was in a lot of pain. She said Norco was to be administered every 6 hours as needed for pain. She said CR #1 refused food, and care due to pain. She wanted Morphine. She said when a medication was ordered for three times a day, it should be administered at, 8 a.m., 2 p.m., and 9 p.m. bedtime. She said she never writes orders in the Electronic Medication Administration Record (eMAR) the nurses do. She said she sees the orders because she signs any order under her name. She said after you give Morphine, you wait, if the resident was still in pain, then you give the Norco. She said wait for at least 2 hours to administer a second pain medication. She said the consequences of administering two opioids were: constipation, drossiness, altered mental status, pupils' constriction, dizziness, vomiting, nausea, confusion, and changes in pupils. She said the elderly population were frail. Surveyor mentioned that the hospital mentioned accidental opioid overdose, the Dr., said the hospital don't know what they are doing. During an interview on 02/04/25 at 1:38 p.m., the DON said she was not at the facility when CR #1 was transported to the hospital. She said Nurse A told her the resident had a decrease in responsiveness. She said she was not aware of what pain medication CR #1 was taking until after she went out to the hospital. She said Nurse A said she was also concerned that it could be her pain medication. She said she looked at the hospital site and they had encephalopathy, UTI, and dehydration. She said she was not aware of the hospital notes about opiate overdose, but she did call the Doctor to let her know she was transferred to the hospital and what the hospital's notes were at that time. She said Nurse A was concerned it was about the medications because of how she found the resident before she sent her out. She said she did not know CR #1's order for Norco and morphine were together at 8:00 a.m. She said when starting to manage breakthrough pain you start with one and space out the other at least a couple of hours. She said the Doctor ordered the morphine in addition to the Norco because Norco was not helping with pain. During follow-up interview on 02/05/25 at 9:46 a.m., Doctor/Medical Director/Physician said when the EMS comes, to be on the safe side, they will give Narcan even with the slight suspicion of overdose. She said hospital gave Narcan because probably EMS told them. The Doctor said in spite of being on the schedule morphine 2 times a day CR #1 was still needing the Norco because she was still in pain. The Doctor said because CR #1 was yelling and in pain, she thinks that was why they gave it to her. She said CR #1 was admitted with an order for PRN Norco, then scheduled Norco and morphine was added. She said for this patient it would be okay to give her scheduled morphine and Norco. She said Narcan was used to reverse narcotic overdose. She said some effects of giving the two medications at the same time could be constipation, drowsiness, dizziness, nausea, and pinpoint pupils. During a telephone interview on 02/05/25 at 10:30 a.m., MA B said CR #1's name sounded familiar, but she could not put a face to her. She said she did not remember what she gave the resident on 01/01/25. She said to be honest it would help it she could see a picture of the resident. She said she does not remember what time she gave the medication, but she works with the nurse, and they were the ones who usually monitor the pain of the resident. She said she administers PRN narcotics. She said administration times were determined by what the nurse enters in the system. During a follow-up interview on 02/05/25 at 10:50 a.m., the DON said the medication administration times were picked by the nurses. She said one unit might have a maximum of 30 residents so they may start medication pass at 7:00 a.m. and space out from there because not everyone could be done at the same time. She said someone who wants to sleep in might be given their medication at 9:00 a.m. She said their computer system would flag when there were any medications that were contraindicated which in that case they checked with the physician. She said medication start times were 7:00 a.m., 8:00 a.m., and 9:00 a.m., which was pretty routine. Record review of the facility's Administering Medications policy, revised April 2019, read in part .8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss concerns . Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy, dated 2001, read in part .Treatment/Management .4. The staff and physician will identify and address unexpected, unintended, undesirable or excessive responses to a medication based on the severity of underlying conditions, the seriousness of any adverse drug reactions, risk of worsening of medical conditions, and other factors. a. This may include changing doses, changing times of administration, switching to another medication, or stopping one or more medications. Professional Reference accessed 02/24/25 - Hydrocodone and morphine Interactions - Drugs.com Using narcotic pain or cough medications together with other medications that also cause central nervous system depression can lead to serious side effects including profound sedation, respiratory distress, coma, and even death. Talk to your doctor if you have any questions or concerns. Your doctor may be able to prescribe alternatives that do not interact, or you may need a dose adjustment or more frequent monitoring to safely use both medications. Do not drink alcohol or self-medicate with these medications without your doctor's approval, and do not exceed the doses or frequency and duration of use prescribed by your doctor. Also, because these medications may cause dizziness, drowsiness, difficulty concentrating, and impairment in judgment, reaction speed and motor coordination, you should avoid driving or operating hazardous machinery until you know how they affect you. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor. Professional Reference - Toxic Encephalopathy - https://pharos.nih.gov/diseases/Toxic%20encephalopathy#diseaseSummary A group of neurologic disorders caused by damage to the nervous system following exposure to pharmacologic, biologic, and chemical agents. Examples of neurotoxins include chemotherapy agents, radiation treatment, heavy metals, pesticides, and food additives. The Administrator was notified on 02/05/25 at 9:26 a.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 02/06/25 at 1:20 p.m.: Plan of Removal Immediate Jeopardy Citation called on 2/5/25 @ 9:26 AM F- 755 Pharmacy Services [] Immediate Action: Upon notification of the deficient practice, a 100% audit of all residents with orders for scheduled narcotic pain medications, hospice pain medications and any breakthrough pain medications including all opioid medication is being completed to ensure that no other resident had scheduled pain medications with the parameters that were closer than 2 hours apart on the medication administration record. None were found to have any parameters that were closer than 2 hours apart as of 2/5/25. Audit was completed on 2/5/25 by DON [] RN, ADON [], LVN [], LVN. In addition, In-servicing and education will be provided to all licensed or registered nursing staff and prescribing medical doctors regarding opioid use and parameters to do with any other scheduled narcotic pain medications that could cause accidental overdosing. This education and in-service will be initiated on 2/5/25 and will become a part of [] onboarding and ongoing education. All medication aides, charge nurses, nursing administration and medical doctors will be in-service and educated effective immediately beginning 2/5/25 and ongoing. Initial in-services and education was provided and completed on 2/5/25 conducted by ADON [], LVN and [] LVN. Policies were reviewed and there was no changes to the policy. Education regarding Opioid use and signs and symptoms of opioid use was initiated on 2/5/25 and is being conducted by [], LVN ADON, [], RN DON and [], LVN. Nurses and Medication Aides have been educated in all areas including Opioid use and signs of overdose and it was completed on 2/6/25. Facilities Plan to Ensure compliance quickly: An Ad Hoc QAPI meeting will be conducted on 2/5/25 at 2PM to review audit results and to ensure that the education given is covering the pertinent topics pertaining to this particular alleged deficient practice. DON and administrative nurses will have a collaborative effort with respect to monitoring medications upon admission, and weekly during standard of care meetings on going indefinitely and will be reviewed by QAPI committee monthly for 6 months to ensure compliance. Ongoing daily monitoring by DON or designee, to review medications for compliance. [] will also be adding Opioid abuse education to our onboarding and our annual in-servicing. On 02/06/25-02/07/25, surveyor confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed on 02/06/25, the facility completed an audit of all residents in the facility with orders for scheduled narcotic pain medications, hospice pain medications and any breakthrough pain medications including all opioid medication. Review revealed 38 residents had an order(s) for narcotic(s). 12 of these residents had one or more of their narcotic medication(s) discontinued. Record review revealed on 02/05/25, in-service was initiated with nursing staff and MAs on Pharmacy Services and Opioid Use, Administering Medications, Checking 7 Rights, and Medication Labeling; 28 staff were in-serviced. Interviews were conducted from 02/06/25 to 02/07/25 with staff from all shifts (6:00 a.m.to 2:00 p.m., 6:00 a.m. to 6:00 p.m., 7:00 a.m. to 7:00 p.m., 6:00 p.m. to 6:00 p.m., and 10:00 p.m. to 6:00 a.m.): DON, Nurse A, B, C, D, E, F, G, and H, and MAs A, B, C, and D. All licensed Nursing staff and MAs interviewed, verbalized an understanding of the information presented during the in-service trainings. The Administrator was informed the Immediate Jeopardy was removed on 02/07/2025 at 2:37 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.