**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for resident rights. 1. The facility failed to notify the MD or NP when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to notify the MD or NP when Resident #1, with a BIMS score of 15, began exhibiting erratic behaviors, changes in mental status, confusion, and agitation. 3. The facility failed to notify the MD, NP, or abuse coordinator when Resident #1 presented with bruises on her abdomen, back, legs, arms, and forehead . The failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/13/24 at 2:49 PM. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delay in medical treatment, decline in health, and death. Findings included: Review of Resident #1's admission MDS assessment dated [DATE], reflected Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including left hemiplegia following cerebral infarct (weakness or paralysis on the left side of the body after a stroke), chronic kidney disease, muscle weakness, seizures, anxiety (intense and excessive worry and fear), and abnormalities of gait. The primary medical condition category was listed as stroke. Section B (Hearing, Speech, and Vision) reflected the resident's speech was clear and she made herself understood. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section E (Behavior) reflected no hallucinations (an experience involving the apparent perception of something not present) or delusions (Fixed, false conviction in something that is not real). Section E also reflected no verbal behaviors directed towards others, and no physical behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Section H (Bladder and Bowel) reflected the resident was continent of bowel and bladder. Section N (Medications) reflected the resident received anticoagulant and antiplatelet medications. Review of Resident #1's comprehensive care plan reflected a focus, initiated 10/30/24, of depressive symptoms with an intervention, Observe and report any changes in mental status, notify MD if any changes in mood, behavior and/or psychosocial status is observed. A focus, initiated 10/25/24, of risk for falls with interventions including, Follow facility fall protocol and, review information on past falls and attempt to determine cause of falls. Record possible root causes . A focus, initiated 10/25/24, reflected potential alteration in nutrition and hydration with interventions including, Monitor/document/report PRN any s/s of dehydration: decreased or no urine output and new onset confusion. A focus, initiated 10/25/24, for antianxiety medication reflected interventions including, Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: .Confusion, impaired thinking and judgement, mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A focus, initiated 10/25/24, for anticoagulant therapy reflected an intervention, Monitor/document/report PRN adverse reactions .sudden changes in mental status. The care plan did not address the resident's kidney disease. A focus initiated 11/04/24 reflected, The resident has a behavior problem of repeatedly putting herself on the floor (purposeful), throwing items on floor and breaking (plates, cups, etc.), yelling out loud, clogging toilet with paper towels. Goals included, Resident will show a decrease in negative behaviors by next review date and Will exhibit socially appropriate behaviors during review period. Interventions included, Approach resident appropriately when resident is hallucinating, delusional or expressing potentially harmful suspicions . Ask resident if these hallucinations/delusions are harmful to themselves in any way .Document resident's inappropriate behaviors when it occurs . If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident . Intervene as necessary to protect the rights and safety of others . Review of Resident #1's progress note dated 10/31/24 at 4:31 AM, written by LVN D reflected, .resident was sitting on the floor, states she woke up needing to use the restroom and was attempting to get up too quickly; bed was in low position with call light in reach, resident aware to call for help, VS WNL, denies pain, no s/s LE rotation, current anticoag rx [sic] on hold, denies hitting head, on neuro checks. Review of Resident #1's progress note dated 11/1/24 at 1:25 AM, written by LVN D, reflected Guest c/o 'not being able to urinate', bladder scan performed with no residual, noted in 24-hour report for in house NP. Review of Resident #1's progress note dated 11/1/24 at 9:44 PM reflected, fall f/u day 2/3: resident observed propelling self in hallway on unit, resident observed clogging toilets (toilet in her room and empty rooms) with paper towels, resident redirected multiple times nurse manager notified, maintenance order placed. Review of Resident #1's progress note dated 11/02/24 at 8:00 PM (created 11/03/24 at 1:03 AM), written by LVN K, reflected in part, .resident observed yelling out for help . Review of Resident #1's progress note dated 11/02/24 at 9:35 PM, written by LVN K (created 11/03/24 at 5:37 AM) reflected, Day 3/3 fall f/u bruises noted to abd, lower back, ble, bue, and forehead. The note does not reflect that the provider was notified of the bruises. Review of Resident #1's progress note dated 11/03/24 at 2:59 PM, written by LVN B, reflected in part, Guest noted from previous shift not having a good sleep yelling all night and breaking things and putting herself to the floor many times .the next day the pt continue breaking things and breakfast plates and cup and pulling the call light off the wall and continue throwing herself on the floor and yelling and the NP was called and the pt call 911 by herself and she was sent out for AMS and the pt has scattered bruising all over . Review of Resident #1's progress notes from 11/02/24 through 11/03/24, reflected no documentation that the provider was notified of bruising until the resident was sent out with EMS around 2:51 PM on 11/03/24. Additionally, there was no further information regarding her genitourinary status or that the provider was notified of the change in urinary status. There was no documentation that the provider was notified of the change in mental status or behaviors, or that Resident #1 was yelling out, yelling out all night, clogging toilets, breaking things, putting herself on the floor many times. The notes did not reflect that the provider was notified when the behaviors of throwing things, breaking things, pulling the call light off the wall, and throwing herself to the floor, and yelling continued to the next day. Review of an incident report dated 10/31/24 at 4:31 AM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, Resident aware and reeducated to call for assistance when needing help . Mental Status reflected only the oriented to person box was checked. Predisposing Physiological Factors reflected the boxes for confused and impaired memory were checked. Predisposing Situation Factors reflected the boxes for behavior issues, during transfer and, ambulating without assist were checked. No notifications to the physician or responsible party were documented. Review of Resident #1's shower sheet dated 11/02/24, reflected scattered fading bruises. The time of the note is left blank. Lines on the body diagram indicated bruises on the abdomen, arms, and left leg. The form was signed by a CNA and a nurse. The nurse's signature is illegible. Review of Resident #1's Task: Bladder Continence, the resident was marked as continent five times from 10/26/24 through 10/30/24. On 11/01/24, she was marked as incontinent of bladder. Review of Resident #1's Transfer Form dated 11/03/24 at 2:59 PM reflected the resident was incontinent of bladder. Review of photos of Resident #1 taken in the ER on [DATE] between 4:35 PM and 4:39 PM reflected the following: Face - two red bruises on her forehead and one on her left eyebrow. Abdomen - one purple/red bruise just below her umbilicus (belly button) and extending down towards the pubic bone, unable to visualize the bottom of the bruise due to positioning. The bruise is about 6 inches wide. A large deep purple hematoma (bruise) on the right abdomen flank is about 14 inches in width Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. It starts at about the level of the umbilicus, about 5 inches are visible, the bottom edge of the hematoma is covered by clothing. There was a tape measure visible lying across the wound in the in picture. Right upper leg - about 11 purple bruises on lateral (outside)/posterior (back) view. Right lower leg - about 8 purple bruises on posterior view Left lower leg - a purple bruise that starts a few inches below her knee and extends to just above the ankle, about 10 inches on anterior (front) view, tape measure visible in the photo. About 7 purple bruises are visible on the medial (inside) aspect of the leg and the large bruise on the anterior view extends to the medial aspect. Right foot - about 10 purple/red bruises on medial, lateral, dorsal (top), and plantar (bottom) surfaces. Laceration on dorsal surface. Left foot - about 6 purple/red bruises on lateral and dorsal surfaces. Right arm - about 3 purple bruises and one large deep purple/red bruise visible. Review of Resident #1's Emergency Provider Report from the ER, dated 11/03/24 at 5:52 PM, reflected in part, Presentation Chief Complaint - Altered Mental status. Stated complaint Left hip pain/confusion per EMS . presents with altered mental status and scattered bruising . speech nonsensical and unable to communicate effectively . Primary Impression: Altered Mental Status. Secondary Impressions: Anemia, Ecchymosis, History of completed stroke. Review of Resident #1's physician progress notes from the acute hospital dated 11/11/24 at 11:48 AM reflected in part, Patient was agitated on arrival to emergency room, required several doses of sedatives for agitation in emergency room. Per EMS report nursing staff at facility reported patient was hitting her own head against the wall and had frequent falls CT chest abdomen, and pelvis shows significant bladder distention. Markedly enlarged bilateral kidney with innumerable cyst . Hematoma in the subcutaneous fat in the lateral right mid to lower abdomen measuring 8.3 x 3.8 x 7.6 cm. Hemoglobin 6.1 on admission. Patient underwent 2 units of PRBC transfusion from extensive bruising all over the body. No evidence of GI bleed. Eliquis was discontinued, aspirin and Plavix continued. Acute metabolic encephalopathy resolved. Resident has some urinary retention, and a catheter was placed . Urinary tract infection, received Ceftriaxone 1 gram IV every 24 hours. Review of Resident #1's EMR including MDS assessment, progress notes, evaluations, and MARs dated from 10/25/24 through 11/03/26, did not reflect the physician was notified of a change in mental status, changes in mood, behavior and/or psychosocial status. There was no documentation that the physician was notified of hallucinations or delusions. During a telephone interview on 11/06/24 at 8:16 AM, Resident #1's FM stated the resident had called her on 11/02/24 and said she thought she had a UTI because she was not peeing, and she did not feel right. She stated they were on speaker phone and there was a staff member in the room. She stated she asked the other person in the room if the doctor was coming to see the resident and the other person replied, Yes. She stated she did not know if a doctor ever saw the resident about her complaint of not urinating. She stated she saw the resident the next day in the ER. She stated the resident went to the ER for altered mental status and multiple falls. She stated she was never notified of the falls. She stated she noticed, during phone calls and texts, the resident being more confused and irritable for the few days prior to going to the ER. She stated Resident #1 started having trouble writing a coherent text message. She stated the decline went on for days before Resident #1 called 911 to go to the hospital. During an interview on 11/06/24 at 2:28 PM, the VPCO stated the post fall assessment would have the documentation regarding the resident's status. She stated the nurses would document in the progress notes when a bruise was observed or noticed. She stated they would definitely investigate any bruises that could not be explained. She stated if an alert and oriented resident had falls and a change in behavior, her first thought was to get a UA as changes were often a sign of infection. During an interview on 11/07/24 at 10:33 AM, the MD stated she saw Resident #1 on 10/28/24. She stated she did not look under the clothes but there were no bruises on the visible skin. She stated she was not aware of extensive bruising. She stated the resident was on 3 different medications that could have caused her to bruise easily. She stated Resident #1's hemoglobin was 8.8 (hemoglobin, part of the blood, helps carry oxygen to all the vital organs, 12-17 is a normal level) on 10/23/24 at the acute hospital prior to her admission at this facility. She looked but did not see any blood results from the time the resident was in the facility. She stated she was not aware that the resident complained of not being able to urinate. She stated the resident had chronic kidney disease, but she had been urinating, as far as she knew, while at the facility. She stated the resident may not have been drinking enough, or her kidney disease may have worsened. She stated she expected to be notified of changes in condition when they occurred. She stated the resident was a good historian and would have been able to talk about the bruises and any problems with urination. She stated she was not notified of any erratic behavior other than the resident being upset that her daughter did not answer the phone. During an interview on 11/07/24 at 11:11 AM, the NP stated bruising may not occur right away if a resident fell or sustained an injury. The NP stated if a resident were on blood thinners and hit their head, to be safe, the resident would be sent out for evaluation. After viewing the picture of the abdominal bruise, the NP stated that bruise should have been reported immediately as the resident was on blood thinners. The NP stated she was not aware that the resident had complained of not being able to urinate. She stated she was not aware of the facility 24-hour report. She stated the on-call providers kept a report of the calls received. She reviewed the notes and stated she did not see an entry for Resident #1's urinary complaint. The NP stated she was notified of the erratic behavior when the nurse called her at 2:25 PM on 11/03/24. During an interview on 11/07/24 at 12:33, LVN B stated she had worked at the facility for about three years. She stated she first saw bruises on Resident #1's arm on 10/29/24 but did not work on the resident's hall until 11/01/24. She stated she noticed bruises on Resident #1's abdomen on 11/01/24. She stated because the resident was on blood thinners, she figured the resident was on anticoagulant injections while in the acute hospital and that was the reason for the bruises. She stated because they were old bruises, she did not report them. She stated the resident had scattered bruises all over her body. She stated on Saturday, 11/02/24, the resident was yelling and pulled the call light off the wall. She stated the resident was trying to call her daughter and was yelling about it. LVN B told the resident she would help her call her daughter shortly. When she returned to the room to help, the resident began yelling again and pushed her tray all the way out of her room; the yelling continued. LVN B stated she did not notify the doctor as the resident was just mad about her daughter not answering the phone. She stated on Sunday morning 11/03/24, she was told in report that Resident #1 had yelled all night. She stated the resident continued to yell, kept putting herself on the floor, and hit herself in the head with the phone. She stated it was very different behavior for this resident, but the resident was mad at her daughter. LVN B stated in the afternoon she explained to the resident that she would notify the provider to have her sent out. LVN B stated shortly after she got to the nursing station, the front desk called and asked her if she had called 911. The front desk told her 911 was on the phone about Resident #1 and she told them to come get her. LVN B stated, She heard me say I was going to send her out, so she went ahead and called 911. During an interview on 11/07/24 at 2:00 PM with the VPCO and CNO, the VPCO stated on 10/31/24, she was called to the room after Resident #1 was found sitting on the floor. She stated there was no facial bruising at that time. After seeing the picture of the bruise on Resident #1's abdomen/trunk/back, the CNO stated the bruise was from anticoagulant injections due to its location. The VPCO stated it was a new bruise because it had not changed colors. She stated she could not tell when or where the picture was taken so she could not verify the bruise was present while the resident was at the facility. During a telephone interview on 11/07/24 at 2:38 PM, Resident #1 stated she fell when she was at the facility. She stated, I tried to get help and they said they would be right back, and it was an hour. Resident #1 stated she was crawling around on her butt trying to get help. She stated they took their time to help. She stated one staff member told her they were going to kick her out if she kept acting up. She stated she had bruises on her arms which she sustained during the falls. She said she fell and hit her back. She stated the big bruise hurt and stated an ice pack would have helped. She stated she did not feel right and had trouble urinating, I thought I had a UTI. During an interview on 11/07/24 at 5:05 PM, the GM stated the nursing documentation should reflect the work they were doing. He expected documentation to be accurate and timely. He stated he expected the nurse to contact the MD, NP, or CNO if there was a change in condition or mental status. During an interview on 11/12/24 at 4:17 PM with the ACNO, he stated he had recently provided training on customer service, change of condition, and assessment. After review of Resident #1's abdominal flank bruise, he stated he expected the provider would have been notified of a bruise of that size. He stated if he saw the resident having behaviors, he would not necessarily notify the doctor if those behaviors caused the bruising. He stated if the resident was on blood thinners, he should notify the provider. He stated the provider should be notified if a resident had a change in status. During a telephone interview on 11/13/24 at 11:49 AM, CNA A stated on 10/31/24, Resident #1 was somewhat confused, so she checked on the resident every 30 minutes. She stated that was a change for the resident. She stated the resident had bruises, but the nurse had already assessed them. She stated there was just a small bruise on the resident's arm that the resident said came from a fall earlier in the day. The CNA stated she reported that bruise to the nurse, but the nurse said it would not show up that fast so it must have been an old bruise. During an interview on 11/13/24 at 1:06 PM, LVN B stated the change in Resident #1's mental status did not occur until Sunday 11/03/24. On Saturday (11/02/24) morning report, which she received from LVN D, she was told the resident was found on the floor. On Sunday morning in report, she was told other residents were mad because Resident #1 was making so much noise all night. She stated the resident had complained of pain the night before and they got a hip x-ray. She stated she did not remember ever being told in report that Resident #1 complained of not being able to urinate. She stated on the morning of 11/03/24 Resident #1 continued to yell and break things and throw herself on the floor. She stated the resident had bruises all over and she notified the provider to send the resident out. She stated she assessed the resident, and it was because her daughter did not answer the phone, that she was mad. Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. The VPCO was notified on 11/13/24 at 2:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/14/24 at 4:32 PM: Allegation of Credible Compliance F684 11/13/2024 November 13th, 2024 Immediate Interventions: 1. Notifications made to the Medical Director on 11/13/24 at approximately 4:00pm of the immediate jeopardy citation 2. Emergency meeting conducted with action plan developed. This occurred at 4:30pm on 11/13/24 Attendees: RN, VP of Clinical Operations Administrator RN, Assistant Director of Nursing Action Plan: Licensed nursing staff, certified medication aides, and certified nursing assistants in-serviced immediately on the facility policy and procedure for notification of change of condition and the abuse and neglect policy and procedure. Resident #1 has discharged from the facility and therefore a plan of correction cannot be accomplished. Current residents were assessed by licensed nursing staff for any changes of condition, including but not limited to their physical (including but not limited to skin integrity), mental and emotional status. No negative outcomes were obtained from these assessments. A root cause analysis was completed by the VP of Clinical Operations and incorporated into staff training and in-servicing, which includes notification of change of condition, and abuse and neglect policies and procedures. 3. Licensed nursing staff, certified medication aides, and certified nursing assistants were in-serviced on the change of condition policy and procedure, including but not limited to: changes in resident behavior, skin integrity changes, increased confusion, and genitourinary changes. The assistant director of nursing and nursing supervisor have provided in-service, education and compliance training with staff. - Changes of condition must be reported to the provider timely (within 30 min) if no response within 30 minutes the Medical Director will be notified. If the Medical Director does not respond within 30 minutes, the Director of Nursing will be contacted. - Documentation of changes of condition will be documented in the medical record within the nurse's shift. - Signs and symptoms of abuse or neglect, the Administrator will be notified immediately. - Allegations of abuse and neglect will be reported to all appropriate state and local entities by the Administrator in accordance with all state and federal regulations. 4. Meeting with the following managers to review Immediate Jeopardy on 11/13/24. We reviewed the notification of changes of condition policy and procedure, as well as the abuse and neglect policy and procedure. - Administrator - VP of Clinical Operations - Director of Rehabilitation - Assistant Director of Nursing - Nursing Supervisor - MDS Coordinator - Dietary Manager - Social Services Training: 1. RN Director of Nursing, to be in-serviced by RN [NAME] President of Clinical Operations. [Name] will be in-serviced on the notification of changes of condition policy and procedure, and the abuse and neglect policy and procedure. The VP of Clinical Operations ensures in-servicing and training tasks are provided and compliance is achieved. 2. An immediate in-service was initiated on 11/13/2024 by VP of Clinical Operations on change of condition notification and abuse and neglect. 3. Beginning 11/13/24 and on-going: A post-test will be completed by direct care nursing staff to ensure competency on notification of changes of condition and abuse and neglect. Staff must answer all questions correctly before returning to work. 4. New staff will receive in-servicing prior to orientation on the floor. PRN staff will not be allowed to work in the facility until they have completed in-service training and post-test. 5. A payroll report listing current employees will be used to track in-service completion. The VP of Clinical Operations will ensure this task is completed. Monitoring: 1. Nursing Administration (Director of Nursing, Assistant Director of Nursing) will interview and conduct skin assessments at random for residents residing in the facility, as well as review the electronic medical record to ensure compliance with the facility's abuse and neglect and notification of changes of condition policies to ensure compliance. This will occur daily for one week, then twice weekly for four weeks, and monthly thereafter. 2. Administrator, or appointed designee, will review this plan in its entirety in the Clinical Meeting scheduled 5 times per week (Monday through Friday) to monitor for compliance, and to make changes based on the interdisciplinary team's review and decision. This will be on-going. [Facility] requests that the measures we have implemented be reviewed and that our allegation of removal of jeopardy be accepted as of 11/13/24. The investigator monitored the Plan of Removal on 11/14/24 as followed: During interviews conducted on 11/14/24 between 4:39 PM and 7:00 PM, 3 CNAs, 2 LVNs, and 2 RNs from both shifts stated they were in-serviced on Abuse and Neglect and Change in Condition. Some staff reported they had the training on 11/13/24, while others reported the training on 11/14/24 prior to starting their shift. All staff stated the abuse coordinator was the GM. Staff stated any abuse had to be reported immediately. Staff reported taking a written test about abuse and neglect. Staff reported in-service and a written test regarding notification of changes. The staff stated the in-service covered reporting any change such as bruises, skin tears, complaints of difficulty urinating, behaviors, or pain. Staff stated the provider needed to be notified immediately. If the provider did not respond within 30 minutes, the medical director was notified. If no response from the medical director within 30 minutes, the CNO was notified. Documentation was to be completed as soon as possible but no later than the end of the shift. The staff stated the test was a multiple-choice test. They stated questions included, Which of the following incidents requires notification to the MD/NP? and, If the resident experiences a significant change, what actions must the nurse take? Review of the facility's Ad Hoc meeting agenda dated 11/13/24, reflected the Medical Director was notified. The VPCO, RN Supervisor, Director of Rehab, MDS Coordinator, DM, SS, and DCE attended the meeting. Review of the post-tests to ensure competency on notification of changes of condition and abuse and neglect was conducted. The test for change of condition contained seven multiple-choice questions. A sample of questions included, A charge nurse must notify the physician of the following: circle all that apply, Which of the following requires notification to the MD/NP? and, If a resident experiences a significant change in their physical, mental, or psychosocial status, which action must the charge nurse take? The Abuse post-test contained 10 True or False questions. A sample of the questions included, Everyone in the facility is responsible for watching for and reporting abuse. Taking away a resident's call light is considered a form of abuse. It is okay to swear in front of a resident if they are swearing too. The tests were taken by direct care nursing staff as well as staff from other departments. The tests reviewed were all passed with no concerns identified. Review of the Abuse in-service given by the VPCO, dated 11/13/24 reflected Notification to Abuse Coordinator (GM). The in-service contained 43 signatures. The Abuse & Neglect policy was attached. Review of the Change of Condition notification in-service given by the VPCO, dated 11/13/24 reflected Assessment and notification must be completed on any physical, mental or emotional changes. The Change of Condition Policy was attached. The sign-in sheet contained 43 signatures. Review of the payroll report listing current employees was reviewed. 18 nursing staff had completed the training. 4 general administrative staff had completed the training. An interview and skin assessment were conducted on all residents in house. A sample of 5 residents medical records reflected the residents were interviewed and a head-to-toe assessment was completed. No significant findings noted. The CNO was out of town but per the VPCO, he was trained verbally during a telephone call and would take the tests when he returned to duty. The VPCO was notified on 11/14/24 at 7:19 PM that the IJ had been removed. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #1) of 6 residents reviewed for quality of care. 1. The facility failed to assess the resident or notify the provider when Resident #1, who has a diagnosis of stage 5 kidney failure, complained of not being able to urinate. 2. The facility failed to assess Resident #1, notify the provider or the abuse coordinator when Resident #1, who was taking blood thinners and had a BIMS score of 15, presented with bruises all over her body, and began throwing herself on the floor, hitting herself on the head, yelling, and exhibiting erratic behaviors . 3. The facility failed to follow the care plan and notify the MD of changes in mental status, confusion, and agitation. 4. The facility failed to assist Resident #1 to transfer to the hospital on [DATE], before she called 911 and waited 27 minutes on the phone until EMS arrived. The failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/13/24 at 2:49 PM. While the IJ was removed on 11/14/24 at 7:19 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for not receiving intervention in a timely manner and a decline in health and hospitalization. Findings included: Review of Resident #1's admission MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including left hemiplegia following cerebral infarct (weakness or paralysis on the left side of the body after a stroke), chronic kidney disease, muscle weakness, seizures, anxiety (intense and excessive worry and fear), and abnormalities of gait. The primary medical condition category was listed as stroke. Section B (Hearing, Speech, and Vision) reflected the resident's speech was clear and she made herself understood. Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section E (Behavior) reflected no hallucinations or delusions. Section E also reflected no verbal behaviors directed towards others, and no physical behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). Section H (Bladder and Bowel) reflected the resident was continent of bowel and bladder. Section N (Medications) reflected the resident received anticoagulant and antiplatelet medications. Review of Resident #1's comprehensive care plan reflected a focus, initiated 10/30/24, of depressive symptoms with an intervention, Observe and report any changes in mental status, notify MD if any changes in mood, behavior and/or psychosocial status is observed. A focus, initiated 10/25/24, of risk for falls with interventions including, Follow facility fall protocol and, review information on past falls and attempt to determine cause of falls. Record possible root causes . A focus, initiated 10/25/24, reflected potential alteration in nutrition and hydration with interventions including, Monitor/document/report PRN any s/s of dehydration: decreased or no urine output and new onset confusion. A focus, initiated 10/25/24, for antianxiety medication reflected interventions including, Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: .Confusion, impaired thinking and judgement, mania, hostility, rage, aggressive or impulsive behavior, hallucinations. A focus, initiated 10/25/24, for anticoagulant therapy reflected an intervention, Monitor/document/report PRN adverse reactions .sudden changes in mental status. The care plan did not address the resident's kidney disease. A focus initiated 11/04/24 reflected, The resident has a behavior problem of repeatedly putting herself on the floor (purposeful), throwing items on floor and breaking (plates, cups, etc.), yelling out loud, clogging toilet with paper towels. Goals included, Resident will show a decrease in negative behaviors by next review date and Will exhibit socially appropriate behaviors during review period. Interventions included, Approach resident appropriately when resident is hallucinating, delusional or expressing potentially harmful suspicions . Ask resident if these hallucinations/delusions are harmful to themselves in any way .Document resident's inappropriate behaviors when it occurs . If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to the resident . Intervene as necessary to protect the rights and safety of others . Review of Resident #1's admission Nursing Evaluation, dated 10/25/24 at 7:29 PM, reflected normal skin color on the resident's face, upper extremities, and lower extremities. The assessment note redness on the sacrum but no other skin integrity concerns. Review of Resident #1's physician order dated 10/25/24 reflected, Skin Checks Weekly every day shift every Saturday - Must open and document Skin Evaluation for each assessment (including no new areas found). Review of Resident #1's Medication/Treatment Administration Record for November 2024, reflected LVN B signed the Weekly Skin Evaluation as completed on 11/02/24. Review of Resident #1's Evaluation log from 10/25/24 through 11/03/24 reflected no Weekly Skin Evaluation was completed. Review of Resident #1's Order Summary Report for active orders as of 11/03/24, reflected the following medication orders: 10/28/24 Apixaban oral tablet 5mg by mouth two times a day for DVT PPX unsupervised self-administration. 10/25/24 Aspirin oral capsule 81mg by mouth on time a day for analgesics. 10/25/24 Clopidogrel Bisulfate oral tablet 75mg by mouth one time a day for hematological agents 10/25/24 Buspirone HCl oral tablet 5mg by mouth two times a day for antianxiety agents. Review of Resident #1's shower sheet dated 11/02/24, reflected scattered fading bruises. The time of the note is left blank. Lines on the body diagram indicated bruises on the abdomen, arms, and left leg. The form was signed by a CNA and a nurse. The nurse's signature is illegible. Review of Resident #1's progress note dated 10/31/24 at 4:31 AM, written by LVN D reflected, .resident was sitting on the floor, states she woke up needing to use the restroom and was attempting to get up too quickly; bed was in low position with call light in reach, resident aware to call for help, VS WNL, denies pain, no s/s LE rotation, current anticoag rx [sic] on hold, denies hitting head, on neuro checks. Review of Resident #1's progress note 10/31/24 at 12:30 PM (created 11/01/24 at 8:35 AM) written by the VPCO, reflected, . Staff member was informed guest called to say she fell in her room, upon entering room guest was observed sitting in an upright position on her buttock . no apparent injuries, no redness, swelling, bruising or abnormalities .denies hitting her head or any other area of her body . educated guest to call for assistance with any further transfers .verbalized understanding. Guest is her own r/p, clinical manager and MD notified as well. Review of Resident #1's progress note dated 11/1/24 at 1:25 AM, written by LVN D, reflected Guest c/o 'not being able to urinate', bladder scan performed with no residual, noted in 24-hour report for in house NP. Review of Resident #1's progress note dated 11/1/24 at 9:44 PM reflected, fall f/u day 2/3: resident observed propelling self in hallway on unit, resident observed clogging toilets (toilet in her room and empty rooms) with paper towels, resident redirected multiple times nurse manager notified, maintenance order placed. Review of Resident #1's progress note dated 11/02/24 at 8:00 PM, written by LVN K, reflected in part, .resident observed yelling out for help . The note did not reflect the provider being notified that the yelling out behavior was a change in mental status from being alert and oriented, with a BIMS score of 15, and able to make her needs known. Review of Resident #1's progress note dated 11/02/24 at 9:35 PM, written by LVN K (created 11/03/24 at 5:37 AM) reflected, Day 3/3 fall f/u bruises noted to abd, lower back, ble, bue, and forehead. The note does not reflect that the provider was notified of the bruises. Review of Resident #1's progress note dated 11/03/24 at 2:59 PM, written by LVN B, reflected in part, Guest noted from previous shift not having a good sleep yelling all night and breaking things and putting herself to the floor many times .the next day the pt continue breaking things and breakfast plates and cup and pulling the call light off the wall and continue throwing herself on the floor and yelling and the NP was called and the pt call 911 by herself and she was sent out for AMS and the pt has scattered bruising all over . Review of Resident #1's progress notes from 11/02/24 through 11/03/24, reflected no documentation that the bruises were assessed, or the provider notified of bruising until the resident was sent out with EMS around 2:51 PM on 11/03/24. Review of the incident report log from 08/01/24 through 11/06/24, reflected Resident #1 had two falls. The throwing herself to the floor was not documented on the incident list. Review of an incident report dated 10/31/24 at 4:31 AM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, Resident aware and reeducated to call for assistance when needing help . Mental Status reflected only the oriented to person box was checked. Predisposing Physiological Factors reflected the boxes for confused and impaired memory were checked. Predisposing Situation Factors reflected the boxes for behavior issues, during transfer and, ambulating without assist were checked. No notifications were documented. Review of an incident report dated 10/31/24 at 12:30 PM, reflected Resident #1's fall from the same date and time. Immediate actions taken included, educated guest to call for assistance with any further transfers to decrease the risk of a fall. Page 1 of the report reflected the guest was alert and oriented x4. Page 2 of the report reflected the mental status as only oriented to person. No Predisposing Environmental or Physiological factors checked. Review of a text message from Resident #1 to a FM sent 11/01/24 at 10:30 PM, the resident texted, In short my pan s, I shit, I'm in sa diaper but, I'm in a dia diaper [sic] Review of Resident #1's Task: Bladder Continence, the resident was marked as continent five times from 10/26/24 through 10/30/24. On 11/01/24, she was marked as incontinent of bladder. Review of an undated document received in an email on 11/15/24 by the VPCO, regarding Resident #1's complaint of not being able to urinate, reflected in part, .The day shift licensed nurse worked with the resident has documented vital signs along with a pain assessment documented in the resident medical record. The resident did not verbally express any further concerns. As such, there was no indication from the residents or the nurse that additional follow-up was necessary at the time. The transfer form, included in the email, reflected the resident required assistance with toileting and was incontinent of bladder. Review of Resident #1's progress notes from 11/01/24 through 11/03/24, reflected no assessment of the cause for the incontinence and no further information regarding her genitourinary status. Review of Resident #1's progress notes dated 11/01/24 through 11/03/24 reflected no documentation that the provider was notified of the change in mental status or behaviors. The notes did not reflect that the nurse manager who was notified, followed up on the resident's change in mental status. Review of Resident #1's progress notes dated 10/31/24 through 11/03/24, up until the final entry, reflected no documentation that the provider was notified of yelling out, yelling out all night, clogging toilets, breaking things, putting herself on the floor many times. The notes do not reflect that the provider was notified when the behaviors of throwing things, breaking things, pulling the call light off the wall, and throwing herself to the floor, and yelling continued to the next day. Review of a screen shot from Resident #1's phone dated 11/03/24, reflected a phone call placed to 911 at 1:59 PM. The call lasted 27 minutes. Review of photos of Resident #1 taken in the ER on [DATE] between 4:35 PM and 4:39 PM reflected the following: Face - two red bruises on her forehead and one on her left eyebrow. Abdomen - one purple/red bruise just below her umbilicus (belly button) and extending down towards the pubic bone, unable to visualize the bottom of the bruise due to positioning. The bruise is about 6 inches wide. A large deep purple hematoma (bruise) on the right abdomen flank is about 14 inches in width extending across her low back. It starts at about the level of the umbilicus, about 5 inches are visible, the bottom edge of the hematoma is covered by clothing. There was a tape measure visible lying across the wound in the in picture. Right upper leg - about 11 purple bruises on lateral (outside)/posterior (back) view. Right lower leg - about 8 purple bruises on posterior view Left lower leg - a purple bruise that starts a few inches below her knee and extends to just above the ankle, about 10 inches on anterior (front) view, tape measure visible in the photo. About 7 purple bruises are visible on the medial (inside) aspect of the leg and the large bruise on the anterior view extends to the medial aspect. Right foot - about 10 purple/red bruises on medial, lateral, dorsal (top), and plantar (bottom) surfaces. Laceration on dorsal surface. Left foot - about 6 purple/red bruises on lateral and dorsal surfaces. Right arm - about 3 purple bruises and one large deep purple/red bruise visible. Review of Resident #1's Emergency Provider Report, dated 11/03/24 at 5:52 PM, reflected in part, Presentation Chief Complaint - Altered Mental status. Stated complaint Left hip pain/confusion per EMS . presents with altered mental status and scattered bruising . speech nonsensical and unable to communicate effectively . Primary Impression: Altered Mental Status. Secondary Impressions: Anemia, Ecchymosis, History of completed stroke. Review of Resident #1's physician progress notes from the acute hospital dated 11/11/24 at 11:48 AM reflected in part, Patient was agitated on arrival to emergency room, required several doses of sedatives for agitation in emergency room. Per EMS report nursing staff at facility reported patient was hitting her own head against the wall and had frequent falls CT chest abdomen, and pelvis shows significant bladder distention. Markedly enlarged bilateral kidney with innumerable cyst . Hematoma in the subcutaneous fat in the lateral right mid to lower abdomen measuring 8.3 x 3.8 x 7.6 cm. Hemoglobin 6.1 on admission. Patient underwent 2 units of PRBC transfusion from extensive bruising all over the body. No evidence of GI bleed. Eliquis was discontinued, aspirin and Plavix continued. Acute metabolic encephalopathy resolved. Resident has some urinary retention, and a catheter was placed . Urinary tract infection, received Ceftriaxone 1 gram IV every 24 hours. Review of Resident #1's EMR including MDS assessment, progress notes, evaluations, and MARs dated from 10/25/24 through 11/04/26, did not reflect the resident was assessed for a change in mental status, changes in mood, behavior and/or psychosocial status, s/s of dehydration, reactions to anti-anxiety or anticoagulant medications. There was no documentation that the resident was assessed for hallucinations or delusions after the initial MDS assessment, or for possible causes of the altered mental status. During a telephone interview on 11/06/24 at 8:16 AM, Resident #1's FM stated the resident had called her on 11/02/24 and said she thought she had a UTI because she was not peeing, and she did not feel right. She stated they were on speaker phone and there was a staff member in the room. She stated she asked the other person in the room if the doctor was coming to see the resident and the other person replied, Yes. She stated she did not know if a doctor ever saw the resident about her complaint of not urinating. She stated she saw the resident the next day in the ER. She stated the resident went to the ER for altered mental status and multiple falls. She stated she was never notified of the falls. She stated she noticed, during phone calls and texts, the resident being more confused and irritable for the few days prior to going to the ER. She stated Resident #1 started having trouble writing a coherent text message. She stated the decline went on for days before she called 911 to go to the hospital. During an interview on 11/06/24 at 2:28 PM, the VPCO stated the post fall assessment would have the documentation regarding the resident's status. She stated the nurses would document in the progress notes when a bruise was observed or noticed. She stated they would definitely investigate any bruises that could not be explained. She stated if an alert and oriented resident had falls and a change in behavior, her first thought was to get a UA as changes were often a sign of infection. During an interview on 11/07/24 at 10:33 AM, the MD stated she saw Resident #1 on 10/28/24. She stated she did not look under the clothes but there were no bruises on the visible skin. She stated she was not aware of extensive bruising. She stated the resident was on 3 different medications that could have caused her to bruise easily. She stated Resident #1's hemoglobin was 8.8 (hemoglobin, part of the blood, helps carry oxygen to all the vital organs, 12-17 is a normal level) on 10/23/24 at the acute hospital prior to her admission at this facility. She looked but did not see any blood results from the time the resident was in the facility. She stated she was not aware that the resident complained of not being able to urinate. She stated the resident had chronic kidney disease, but she had been urinating, as far as she knew, while at the facility. She stated the resident may not have been drinking enough, or her kidney disease may have worsened. She stated she expected to be notified of changes in condition when they occurred. She stated the resident was a good historian and would have been able to talk about the bruises and any problems with urination. She stated she was not notified of any erratic behavior other than the resident being upset that her daughter did not answer the phone. During an interview on 11/07/24 at 11:11 AM, the NP stated for any unwitnessed fall, she expected the staff to ask the resident if they had hit their head. She stated bruising may not occur right away if a resident fell or sustained an injury. The NP stated if a resident was on blood thinners and hit their head, to be safe, the resident would be sent out for evaluation. After viewing the picture of the abdominal bruise, the NP stated that bruise should have been reported immediately as the resident was on blood thinners. She stated the bruise looked fresh and it may have happened when she threw herself on the floor. The NP stated she was not aware that the resident had complained of not being able to urinate. She stated she was not aware of the facility 24-hour report. She stated the on-call providers kept a report of the calls received. She reviewed the notes and stated she did not see an entry for Resident #1's urinary complaint. The NP stated she was notified of the erratic behavior when the nurse called her at 2:25 PM on 11/03/24. During an interview on 11/07/24 at 12:33, LVN B stated she had worked at the facility for about three years. She stated she first saw bruises on Resident #1's arm on 10/29/24 but did not work on the resident's hall until 11/01/24. She stated she noticed bruises on Resident #1's abdomen on 11/01/24. She stated because the resident was on blood thinners, she figured the resident was on anticoagulant injections while in the acute hospital and that was the reason for the bruises. She stated because they were old bruises, she did not report them. She stated the resident had scattered bruises all over her body. She stated on Saturday, 11/02/24, the resident was yelling and pulled the call light off the wall. She stated the resident was trying to call her daughter and was yelling about it. LVN B told the resident she would help her call her daughter shortly. When she returned to the room to help, the resident began yelling again and pushed her tray all the way out of her room. The yelling continued. LVN B stated she did not notify the doctor as the resident was just mad about her daughter not answering the phone. She stated on Sunday morning 11/03/24, she was told in report that Resident #1 had yelled all night. She stated the resident continued to yell, kept putting herself on the floor, and hit herself in the head with the phone. She stated it was very different behavior for this resident, but the resident was mad at her daughter. LVN B stated in the afternoon she explained to the resident that she would notify the provider to have her sent out. LVN B stated shortly after she got to the nursing station, the front desk called and asked her if she had called 911. The front desk told her 911 was on the phone about Resident #1 and I told them to come get her. LVN B stated, She heard me say I was going to send her out, so she went ahead and called 911. During an interview on 11/07/24 at 2:00 PM with the VPCO and CNO, the VPCO stated on 10/31/24 she was called to the room after Resident #1 was found sitting on the floor. She stated there was no facial bruising at that time. After seeing the picture of the bruise on Resident #1's abdomen/trunk/back, the CNO stated the bruise was from anticoagulant injections due to its location. The VPCO stated it was a new bruise because it had not changed colors. She stated she could not tell when or where the picture was taken so she could not verify the bruise was present while the resident was at the facility. During a telephone interview on 11/07/24 at 2:38 PM, Resident #1 stated she fell when she was at the facility. She stated, I tried to get help and they said they would be right back, and it was an hour. She stated she was crawling around on her butt trying to get help. They took their time to help me. She stated one staff member told her they were going to kick me out if I kept acting up. She stated she had bruises on her arms which she sustained during the falls. She said she fell and hit her back. She stated the big bruise hurt and stated maybe an ice pack would have helped. She stated she did not feel right and had trouble urinating, I thought I had a UTI. During an interview on 11/07/24 at 5:05 PM, the GM stated there were no competencies for the bladder scan . He stated there was a manual for the bladder scan machine itself. He stated nursing documentation varies from person to person. He stated the nursing documentation should reflect the work they were doing. He expected documentation to be accurate and timely. He stated the clinical management team was responsible to monitor documentation. He stated he expected the nurse to contact the provider or CNO if there was a change in condition or mental status. During an interview on 11/12/24 at 4:17 PM with the ACNO, he stated he had recently provided training on customer service, change of condition and assessment. He stated he had not provided any training on bladder scans. He stated if a resident complained of not being able to urinate, the nurse reached out to the provider, performed a straight cath, bladder scan, or whatever the provider ordered. He stated it would be case by case, but voiding should occur at least every 4-8 hours. He stated signs and symptoms of UTI could be itching, burning, frequency, or new onset confusion. He stated if there was a bladder scan with no residual, there was no need for follow up. He stated if it was him, he would have rescanned to ensure the initial reading was correct. He stated skin assessments were done upon admission and he believed the wound care nurse was responsible to complete the skin assessment. He stated the skin assessments were completed, he thought, weekly per the policy. He stated CNAs documented in the electronic record and completed shower sheets. The CNAs were expected to document and report any skin issues such as bruises, skin tears, or red areas. He stated residents could get bruised many ways and they could be self-inflicted if the resident was having behaviors. After review of Resident #1's abdominal flank bruise, he stated she may have sustained the bruise when she fell or threw herself on the floor. He expected the provider to be notified of a bruise of that size. He stated it looked new as he did not see any yellow or other signs of aging. He stated if he saw the resident having behaviors, he would not necessarily notify the doctor if those behaviors caused the bruising. He stated if the resident was on blood thinners, probably, he should notify the provider. During an interview on 11/13/24 at 11:08 AM, LVN C stated she was trained on performing a bladder scan when she worked at a hospital, but she had not had any recent training on the bladder scan. She stated the last time she worked with Resident #1, on 10/31/24, she was alert and oriented, and wheeling herself to the coffee shop in the lobby. She stated she completed a skin assessment that day as she helped the resident get dressed. She did not notice any bruises or skin impairment. She stated she did not document that skin assessment. During a telephone interview on 11/13/24 at 11:49 AM, CNA A stated on 10/31/24, Resident #1 was somewhat confused, so she checked on the resident every 30 minutes. She stated they had the bed in the low position, and she told her several times to call for assistance before getting up, but the resident kept getting up. She stated that was a change for the resident. She stated the resident had bruises, but the nurse had already assessed them. She stated there was just a small bruise on the resident's arm that the resident said came from a fall earlier in the day. The CNA stated she reported that bruise to the nurse but the nurse said it would not show up that fast so it must have been an old bruise. During an interview on 11/13/24 at 1:06 PM, LVN B stated the change in Resident #1's mental status did not occur until Sunday 11/03/24. On Saturday (11/02/24) morning report, which she received from LVN D, she was told the resident was found on the floor. On Sunday morning in report, she was told other residents were mad because Resident #1 was making so much noise all night. She stated the resident had complained of pain the night before and they got a hip x-ray. She stated she did not remember ever being told in report that Resident #1 complained of not being able to urinate. She stated on the morning of 11/03/24 Resident #1 continued to yell and break things and throw herself on the floor. She stated the resident had bruises all over and she notified the provider to send the resident out. She stated she assessed the resident, and it was because her daughter did not answer the phone, that she was mad. Multiple attempts to contact LVN D by telephone were made between 11/07/24 and 11/13/24. No return call was received prior to exit from the facility. Review of the Change in Resident Condition policy revised 06/2022, reflected in part, To provide guidance on notification of the physician when there is a change of condition. 1. Should there be a significant change in the resident's physical, mental or emotional status, the attending physician should be notified. 2. If the attending physician does not respond within 30 minutes, contact the Medical Director. 3. If the Medical Director does not call within 30 minutes, contact the DON. Review of the Post-Fall policy revised 05/2023, reflected in part, The LPN/RN will assess the resident for injury and give care/treatment needed at that time. Evaluating the resident's need for: First aid needs, Assessment will include vital signs, skin assessment, neurological assessment, ROM .pain .The LPN/RN notifies the physician of the fall and findings from his/her assessment. The physician makes the clinical decision to transfer resident to hospital or monitor and treat in facility. The Administrator and DON are notified of fall. Document circumstances, notification of medical doctor, family or responsible party, Administrator and Director of Nursing and findings from the assessment in the clinical record . Review of the Bladder Scan Protocol revised 09/2024 reflected, To ensure bladder scan orders are followed in accordance with physician orders. Policy/ Procedure: 1. Bladder scans may be initiated for residents experiencing signs and symptoms of urinary retention and/or recent catheter removal at the licensed nurse's discretion, provider notification will occur for abnormal results. 2. Post void residuals will be completed via a bladder scan device if available in accordance with physician orders . Review of the Skin Policy & Procedure dated 03/2020, reflected in part, The nurse will perform a full-body initial skin assessment to identify if the resident is at risk for a pressure ulcer within 24 hours of admission to the facility and weekly .The nurse will conduct a full-body skin assessment for each resident weekly to ensure no risks have developed .Each Direct Care Provider will examine each resident's total body skin with each bathing experience and will report any abnormalities to the nurse using the Skin Sheet. The VPCO was notified on 11/13/24 at 2:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 11/14/24 at 4:32 PM: Allegation of Credible Compliance F684 11/13/2024 November 13th, 2024 Immediate Interventions: 1. Notifications made to the Medical Director on 11/13/24 at approximately 4:00pm of the immediate jeopardy citation 2. Emergency meeting conducted with action plan developed. This occurred at 4:30pm on 11/13/24 Attendees: RN, VP of Clinical Operations Administrator RN, Assistant Director of Nursing Action Plan: Licensed nursing staff, certified medication aides, and certified nursing assistants in-serviced immediately on the facility policy and procedure for notification of change of condition and the abuse and neglect policy and procedure. Resident #1 has discharged from the facility and therefore a plan of correction cannot be accomplished. Current residents were assessed by licensed nursing staff for any changes of condition, including but not limited to their physical (including but not limited to skin integrity), mental and emotional status. No negative outcomes were obtained from these assessments. A root cause analysis was completed by the VP of Clinical Operations and incorporated into staff training and in-servicing, which includes notification of change of condition, and abuse and neglect policies and procedures. 3. Licensed nursing staff, certified medication aides, and [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to inform the resident's Physician or Nurse Practitioner when there was a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on 07/12/2024. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (Emergency Room) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admission date to the hospital on [DATE], with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on 07/12/2024. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (Emergency Room) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admission date to the hospital on [DATE], with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident was free of any significant medication errors for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given ceftriaxone (antibiotic used to treat bacterial infections) for a total of 4 times within the dates of 07/09/2024 to 07/11/2024, staff did follow up with the pharmacy for the antibiotics, staff did not communicate with the NP of the lack of antibiotics and missed medications, and staff did not communicate the missed doses to the administration. This failure resulted in the Resident #1's being sent to the hospital to have consistent antibiotic treatment, and to treat Bacteremia (bacteria in the blood stream) and ventriculitis (inflammation of the ventricles in the brain). An IJ was identified on 07/18/2024. The IJ Template was provided to the facility on [DATE] at 06:35 p.m. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings Included: Review of Resident #1's face sheet, dated 07/18/2024, revealed a [AGE] year-old-female. admitted to the facility on [DATE] and discharged on 07/12/2024. Resident #1's face sheet further revealed diagnoses of other Encephalitis (An inflammation of the brain usually caused due to infection that causes flu like symptoms), Encephalomyelitis (term for inflammation of the brain and spinal cord), and Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Record review of Resident #1's orders, dated 07/18/2024, revealed two discontinued orders for: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024, start date: 07/09/2024 Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024, order date: 07/09/2024, start date: 07/09/2024, end date: 07/18/2024 Record review of Resident #1's July MAR (Medication Administration Record), dated 07/18/2024, revealed: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy), order date: 07/09/2024 1038 (10:38 a.m.), D/C (Discontinued) Date: 07/10/2024 0608 (06:08 a.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Tuesday 07/09/24 a charting code of 09 at 2100 (09:00 p.m.) Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.), D/C (Discontinued) Date: 07/12/2024 at 1548 (03:48 p.m.). With administer times at 0900 (09:00 a.m.) and 2100 (09:00 p.m.). Further review revealed: Wednesday 07/10/2024 a charting code of 09 at 0900 (09:00 a.m.), and 2100 (09:00 p.m.) Thursday 07/11/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of a check mark 2100 (09:00 p.m.) Friday 07/12/2024 a charting code of (x) at 0900 (09:00 a.m.), and a charting code of (x) at 2100 (09:00 p.m.) Further review of Resident #1 July MAR (Medication Administration Record) revealed a Chart Codes/Follow up table, a charting code of a check mark is listed as administered. Additional review of Resident #1's July MAR (Medication Administration Record), on page 30: Ceftriaxone Sodium Intravenous Solution Reconstituted, scheduled time: 07/11/2024 2100 (09:00 p.m.), administered time: 07/11/2024 2320 (11:20 p.m.), administered by LVN B, route intravenously, and location of Admin arm-right. Record review of Resident #1's July MAR revealed Resident #1 was administered Ceftriaxone Sodium Intravenous one time from the dates of 07/09/2024 to 07/12/2024. Record review of Resident #1's Progress Notes, dated 07/18/2024, revealed: Note, effective date: 07/09/2024 2022 (08:22 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) pending pharmacy delivery. Note, effective date: 07/10/2024 1007 (10:07 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) PT (patient) pulled IV (Intravenous) line out. Note, effective date: 07/10/2024 1600 (04:00 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) pending pharmacy delivery. Note, effective date: 07/10/2024 2253 (10:53 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Medication pending arrival to facility. Note, effective date: 07/11/2024 1810 (06:10 p.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) Not Available. Note, effective date: 07/12/2024 0947 (09:47 a.m.), type: Emar (electronic medication administration), note text: Ceftriaxone Sodium Intravenous Solution Reconstituted (Ceftriaxone Sodium) Use 2000 mg (milligrams) intravenously every 12 hours for abt (Antibiotic Therapy) until 07/18/2024 23:59 (11:59 p.m.) med order pending, call pharmacy. Record review of Resident #1's NP Progress note, dated 07/12/2024, revealed an HPI (History of Present Illness) Related to this Visit, notified this AM (Morning) by nursing staff that pt (Patient) has not received IV (Intravenous) abx (Antibiotic) ceftriaxone since admission d/t (Determine that) Pharmacy carrier not delivering med to facility. No previous staff or nursing notified this NP (Nurse Practitioner) that med had not been delivered since pt's (Patient's) admission. This NP (Nurse Practitioner) called and notified attending MD (Medical Doctor) and notified her of the situation. pt (Patient) sent to ER (Emergency Room) to ensure pt restarted on abx (Antibiotic). Spoke to pt's Family #1 in pt's room and notified family that pt has not received her IV (Intravenous) abx and will be sending pt back to ER. MD stated his frustrations with facility and wanted pt immediately sent out, which this NP explained was already in the process. Record review of Resident #1's hospital records, dated 07/18/2024, revealed Resident #1 an admission date to the hospital on [DATE], with no discharge date , with a chief complaint missed antibiotic. Further review of Resident #1's hospital records revealed an Assessment/Plan note: this 91-yeard-old female with past medical history of diabetes type 2 dementia, and haemophiles influenza (bacteria that can cause severe infection) on ceftriaxone was brought from skilled nursing facility. 1. Bacteremia (the presence of bacteria in the bloodstream)/ventriculitis inflammation of ventricles in the brain). Continue ceftriaxone 2 g (grams) every 12 hour till (until) 7/20 Interview on 07/18/2024 at 11:24 a.m., RN A stated that she worked the day shift when Resident #1 arrived on 07/09/2024, Resident #1 arrived between 3pm to 4pm. RN A stated that she remembered Resident #1 because of her antibiotics (Ceftriaxone) and she was scheduled to receive her medications twice, 9am and 9pm as that was how the orders was listed. RN A stated she admitted Resident #1, her antibiotics were not in house, RN A stated she ordered them from the pharmacy, as Resident #1's admitting records from the hospital revealed Resident #1 received her first dose of the antibiotic and Resident #1 next dose would be at 9pm. RN A stated she passed this information down to the next nurse on shift, as she would be off duty from 07/10/2024 to 07/12/2024. RN A returned to work on 07/12/2024 and reviewed Resident #1 medication administration and discovered that Resident #1 had missed doses of Ceftriaxone and had only received one dose on 07/11/2024 at 9pm. RN A stated when she inquired on the missed antibiotics, she was told the medications have not arrived in the facility. RN A stated she informed the ACNO, and NP of the missed doses. RN A stated that staff should have followed up with the pharmacy for the medications, inform the DON or ACNO, and notify the MD or NP of the missing antibiotics to look for alternatives. RN A stated that there we risk associated with the missed dosages as it could lead to an infection in Resident #'s blood. RN A stated Resident #1 was sent to the ER per the NP orders as the NP was seriously concerned of Resident #1 not receiving the antibiotics. Interview on 07/18/2024 at 12:27 p.m., LVN A stated she worked the floor as a charge nurse during Resident #1 stay on 07/11/2024. LVN A stated that Resident #1 antibiotics (Ceftriaxone) were not available that day. LVN A stated she checked the Ekit that day and there was no Ceftriaxone available. LVN A stated she marked it on the MAR as a 9, listed as other because the antibiotic was not available. LVN A stated that if there are missed doses, we contact the MD or NP, there is a procedure to follow up with the pharmacy and notify the DON or ACNO. LVN A stated, I screwed up, I admit it, I did not call the pharmacy because I thought it would be delivered later that day, and I did not call the NP. It was so busy that day, I'm sorry. LVN A stated the risks of Resident #1 not having her antibiotics would be the increased risk of infection. Interview on 07/18/2024 at 01:48 p.m., LVN B stated she worked during Resident #1's time at the facility and remembered her. LVN B confirmed that Resident #1 antibiotics are administered intravenously. LVN B stated that on Wednesday night (07/10/2024), she did not see Resident #1's Ceftriaxone in the cart, LVN B added she did not look in the Ekit that night. LVN B stated in Resident #1's MAR she coded it as 9 as she did not want to lie and say she administered the Ceftriaxone. LVN B stated on Thursday night (07/11/2024) Resident #1 did not have her Ceftriaxone in the cart, LVN B asked another nurse to look in the Ekit, and a dose of Ceftriaxone was available. LVN B stated she successfully administer Resident#1's antibiotic (Ceftriaxone), that is why she marked it with a checkmark. LVN B stated, I take full accountability, didn't check the ekit, and didn't call, I didn't call the pharmacy, I was thinking it (Ceftriaxone) was on its way here, I was thinking it was, that's why I put a medication pending arrival in the progress note, I didn't call the NP, the DON or ACNO, I should have but it was busy those nights. LVN B stated the risk of not Resident #1 not having her Ceftriaxone was, the risk of not getting better, of not healing, the risk of infection, and the risk of the resident (Resident #1) not going home as planned, I'm sorry. Interview on 07/18/2024 at 03:09 p.m., NP stated that she was only told that Resident #1 did not receive the scheduled antibiotic Ceftriaxone on 07/12/2024, the day I sent her to the ER. NP stated she was informed by RN A. NP stated she informed the MD, we were not happy, because staff did not give her Ceftriaxone, and we were not informed. NP added Resident #1 missed many doses, and when she was informed, I wanted to assure Resident #1 received her Ceftriaxone, that is the reason she had to send her to the ER. NP stated, the antibiotics (Ceftriaxone) was important for this patient, this was the main reason she was here to treat her infection, she had an infection in her brain that was treated at hospital, to assure that the infection won't come back and keep ravaging this patient, the antibiotics (Ceftriaxone) had to be consistent, and continued at the facility. the NP added, even with one dose she (Resident #1) received it could lead to serious harm, she (Resident #1) could have gone septic, sending to her hospital was ensuring she doesn't go septic and have drastic harm done to her (Resident #1). Interview on 07/18/2024 at 04:00 p.m., DON stated staff were required to look in the Ekit, if medications are not available staff are to notify the resident's providers, to look for alternative medications or treatments, or to make appropriate adjustments. The DON stated that the process and procedures are here to keep residents safe and to also offer options for our facility to treat residents. The DON confirmed she was not notified of Resident #1's missed doses (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. Interview on 07/18/2024 at 04:13 p.m., ACNO stated if no medications are available in the medication cart or the Ekit, staff should follow up with pharmacy, there two routes of delivery. If the medication does not come in from pharmacy, and there is no reason given from the pharmacy, staff are supposed to tell the DON, ADM, GM, ACNO. ACNO stated staff are supposed to follow up and call doctor or NP to see if there are alternatives. ACNO stated she recalled Resident #1 because she was on antibiotics (Ceftriaxone). ACNO stated she was informed on Friday (07/12/2024) approximately at 10:40 a.m., she informed the GM, and a pharmacy follow up would be completed. ACNO stated that she was informed that Resident #1 had missed two days without her (Resident #1) antibiotics. ACNO stated that staff should have notified, her, DON, GM that first day the Ceftriaxone had not come in and if Resident #1 did not receive the antibiotic. ACNO stated she verbally educated LVN A on the process of calling administration on 07/12/2024, but no in-services completed. ACNO stated, The antibiotic (Ceftriaxone), was important, if there were missed doses, it would interfere with her (Resident #1's) healing. Interview on 07/18/2024 at 05:39 p.m., GM stated staff are to contact the providers if there are no medications available for any reason, providers are to offer adjustments or alternatives for the missing medications, staff are to contact the pharmacy directly as well to work with them to have those medications delivered. GM added if the pharmacy is not able to deliver the medication, staff are to contact his or her supervisors and inform them of the situation. GM stated if the process is not followed, there are risk to residents not receiving the desired and appropriate treatments. GM stated she was not informed by staff of Resident #1 missed dosages of antibiotics (Ceftriaxone) within the dates of 07/09/2024 to 07/11/2024. GM stated she was informed by the ACNO on 07/12/2024, and she immediately followed up with the pharmacy that day. Record Review of the Facility's Medication Ordering and Receiving from Pharmacy/Ordering and Receiving Non-Controlled Medications, dated 01/23, reflected the Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate reds of medication order and receipt. Procedures: 1. Section E: New Medications, expect for emergency or stat medications, are ordered as follows: If the first dose of medication is scheduled to be given before the next regularly scheduled pharmacy delivery, please telephone or transmit the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. 1. Section F: Stat and emergency medications; except for Controlled Substances are ordered as follows: During regular pharmacy hours, the emergency or stat order is transmitted to the pharmacy immediately upon receipt. Such medications are delivered and administer in a timely manner. Emergency/STAT medication order then medication is not available in the emergency kit: An emergency/STAT order is placed with the provider pharmacy and the pharmacy is called by nursing staff to request the STAT. The requested medication(s) will be delivered in a timely manner. Subsequent doses are scheduled according to nursing care center policy on medication administration. Record Review of the Facility's Administration of Medications, dated 04/2023, revealed General statement, All medications are administered safely and appropriately to aid resident to and help overcome illness, relieve and prevent symptoms and help in diagnosis. The GM was notified on 07/18/2024 at 06:35 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The POR (Plan of Removal) was accepted on 07/19/2024 at 03:37 p.m., and included: On 7/18/24 an abbreviated survey was initiated on 7/18/24 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - The facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of a resident, this resulted in Resident #1 missing dosages of ceftriaxone. 1. Corrective Action for residents affected by the deficient practice: a. Resident #1 had been discharged from the facility on 7/12/2024. 2. How other residents having the potential to be affected be identified and what corrective action(s) will be taken: a. Residents admitted to the facility have the potential to be affected by the identified deficient practice. Education was given to DON and GM by Chief Clinical Officer on 7/18/2024. Inservice will start 7/18/2024 and be completed by all fulltime staff by 7/19/2024 and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA). Training for all new hires, PRN and part time employees will be completed prior to start of shift. Post test will be conducted after Inservice. Topic will include: i. Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider ii. Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - 1. Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs. 2. Contact pharmacy immediately. Nurses & CMAs. 3. Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs. 4. Within 1 hour after notifying DON and/or GM, notify physician to request for alternative orders. ONLY for nurses 5. Document and carry out provider's instructions immediately. ONLY for nurses iii. Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - 1. DON Contact information is posted in med room 2. Contact GM Contact information is posted in Med Room 3. Contact assigned provider ONLY for nurses iv. Contents of medication dispensing machine and IV E-kits - see Attachment A b. Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message. Inservice will be required to be completed prior to start of shift. There will be post test given and graded by CNO and/or GM c. Nursing staff initiated a MAR-to-Cart audit of all in-house residents on 7/18/2024 to ensure medications are available and to order/reorder medications that are not available in the medication carts. This will be completed by 7/19/2024. 3. Measures that will be put in place or systemic changes that will be made to ensure the deficient practice(s) does not recur: a. The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee starting 7/20/2024 and will be ongoing process. Medications should be available by next delivery period and/or within 24 hours of order entry. If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine. Then follow regular delivery for the next dose. If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery. List of medications available on the medication dispensing machine was posted by DON on 7/18/2024 in the medication rooms. 4. Monitoring performance: a. DON and/or designee will complete a daily audit of medications for new admissions, starting 7/20/2024 until 8/1/2024. Then will be reduced to weekly x 2 weeks ending 8/15/2024. Then move to random new admit medication audits until 8/30/2024. b. If there is missing medication, DON and/or designee will ensure that the notification tree was activated beginning 7/18/2024 and will be ongoing process. c. Findings will be discussed weekly starting 7/19/2024 between GM, DON and/or designee and VP of clinical operations and will continue weekly until 8/15/2024. There was an ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called. Findings will also be presented during monthly QAPI meeting x3 months. The Survey Team monitored the Plan of Removal on 07/19/2024 Observations on 07/19/2024 from 08:30 a.m. to 03:30 p.m., revealed nursing staff received in-service training from GM and DON on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Record review on 07/19/2024 revealed daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents. Record review on 07/19/2024 revealed ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical Record review on 07/19/2024 revealed in-services completed for 12 staff on topics of Proper ordering/reordering medications process, contacting administration, and systematic changes to assure accuracy of orders and medications. Further record review revealed graded post-test for staff, no failures. Interview on 07/19/2024 at 03:41 p.m., LVN C stated she has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN C stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 03:47 p.m., RN B stated he has taken in-services on 07/18/2024 at PM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. RN B stated he has taken the post-test and confirmed completion and passed. Observation and interview on 07/19/2024 at 03:53 p.m., LVN D was observed calling the pharmacy on medications delivery. LVN D stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN D stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:09 p.m., CMA A stated she he has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, notifying nurses to follow process of provider notifications to seek immediate interventions and alternatives. CMA A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:36 p.m., ACNO stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. ACNO stated she has taken the post-test and confirmed completion and passed. ACNO stated daily audit of medications for new admissions, and MAR-to-Cart audit of all in-house residents completed and will continue. Phone call Interview on 07/19/2024 at 04:39 p.m., LVN B stated she has taken in-services on 07/19/2024 over phone with DON, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN B stated she has taken the post-test and confirmed completion and passed. Phone call Interview on 07/19/2024 at 04:43 p.m., LVN A stated she has taken in-services on 07/19/2024 at AM shift, on topics of Proper ordering/reordering medications process, contacting administration, providers to inform of any missing medications to seek immediate interventions and alternatives, and systematic changes to assure medications and orders accuracy. LVN A stated she has taken the post-test and confirmed completion and passed. Interview on 07/19/2024 at 04:49 p.m., the DON stated the Chief Clinical Officer educated her and the GM on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. Interview on 07/19/2024 at 04:59 p.m., GM stated Chief Clinical Officer educated her and DON on topics of Proper ordering/reordering medications process on 7/18/2024, ADHOC QAPI meeting held on 7/18/2024 with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, and in-service started 07/18/2024 after IJ identified on topics of [NAME] ordering/reordering medications process, for all Fulltime, part time, PRN nurses and certified medication aides (CMA), as needed for all new hires, PRN and part time employees will be completed prior to start of shift. DON stated daily and random audits will continue to assure compliance. The GM was notified on 07/19/2024 at 05:27 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 07/19/2024, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of (Resident # 1) 1 residents reviewed for suicidal ideation in that: The failed to monitor Resident #1 closely after verbalizing to multiple staff members that she wanted to die on 06/26/2023 and Resident #1 attempted suicide on 06/26/2023 at about 2:50 p.m. and was sent to the local hospital ER. An Immediate Jeopardy (IJ) situation was identified on 07/07/2023 at 5:20 p.m. While the IJ was removed on 07/11/2023 at 13:5012 p.m., the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for accidents, a diminished quality of life and suicide. Findings included: Review of Resident #1's undated face sheet revealed a [AGE] year-old female with admission date of 06/22/2023. Diagnoses included altered mental status, unspecified, urinary tract infection, and depression. Review of Resident #1's physician order dated 06/22/2023 reflected: Psychologist or Psychiatrist to evaluate and treat as needed. Review of Resident #1's 5-days MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated severe cognitive impairment. Review of Resident #1's care plan dated 06/23/2023 revealed the resident had an ADL self-care performance deficit and limited physical mobility, the resident had a psychosocial wellbeing problem, and was a full code (f a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive). The care plan also reflected the resident was having adjustment issues and voiced she wanted to die, staff witnessed guest attempting to harm self when entered room initiated on 06/26/2023. Review of Resident #1's Progress note dated 06/23/2023 at 12: 37 p.m. written by the OT reflected During OT evaluation, patient stated to OT I don't want to live and refused to use oxygen despite education and reflected of recommended medical intervention. Review of Resident #1's NP progress notes dated 06/23/2023 written by NP B reflected: Notified by therapy that patient is refusing to wear oxygen and is saying that she is ready to die. She is satting (oxygen level) in the 80s without nasal cannula, does not appear to be short of breath, however. Patient has very poor English, but she is telling me that she is old and should not have lived this long anyway. Extensive emotional support offered. We discussed that she should be able to make progress and go back home but she says she does not want to try. Denies any plans of actively hurting herself. PHQ-9 Screening: In the past two weeks, how often have you been bothered by any of the following problems? 0 = not at all 1 = several days 2 = more than half the days 3 = nearly every day 1. little interest or pleasure in doing things? 3 2. Feeling down, depressed, or hopeless? 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way? 2 Review of Resident #1's PHQ9 (The 9-question Patient Health Questionnaire is a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression. It rates depression based on the self-administered Patient Health Questionnaire) assessment conducted by the social worker dated 06/26/2023 at 9:34 a.m. reflected a score of 15, Moderately Severe Depression (staff Observation). It was also reflected Resident #1 answered yes to the question state that life isn't worth living, wishes for death, or attempts to harm self-symptom presence and state that life isn't worth living, wishes for death, or attempts to harm self-symptom presence 2-6 days. Review of Resident #1's Progress notes dated 06/26/2023 at 12:02 pm written by LVN A reflected Guest requested to speak with family. Called guest family for guest to speak. Left room with guest sitting in wheelchair on the phone with speaking with family. Then observed guest banging phone on bedside table repeatedly stating get me out of here. why am I here. I'm going to kill myself. I just want to die. Reported to DONNCO. Guest still on phone with family member. NCO states will notify social work. Review of Resident #1's incident report dated 06/26/2023 at 2:50 p.m. reflected Resident #1 was found by social services sitting in a wheelchair in her bathroom with the call light cord wrapped and tied around her neck. The Resident was unable to give description of incident. Continuously states she wants to kill herself. Review of Resident #1's progress notes dated 06/26/2023 at 2:56 pm written by the Social Worker reflected: This writer was walking down the hallway and noticed that guest's light was red, this writer knocked and then entered the room. This writer called out and didn't see the guest in bed- as I turned into the bathroom this writer found the guest with the emergency cord wrapped and tied around her neck. The writer ran into the hallway and found two therapists to come assist. The two therapists followed this writer into the guest's room/bathroom where they untied her cord. This writer informed DON that guest needed to be sent out for a Psych Eval. Review of Resident #1's progress notes dated 06/26/2023 at 2:57 p.m. written by the PT reflected: entered pt's room approximately 10:40AM pt. stating Give me a knife, I want to kill myself, throw me out the window. Reported to DOR who then immediately reported at 10:50AM to social worker and administration. Later in the day passing by pt.'s room approx. 2:55PM social worker asking for help due to pt. wrapping call light cord around neck in bathroom. Review of Resident #1's progress notes dated 06/26/2023 at 3:01 p.m. written by the DOR reflected: At 10:50am PT notified me that pt. made reports of wanting to kill herself and just die. Immediately notified SW and GM about guest's reports and ensured a referral had been made to psychology services and for following up. Review of Resident #1's MDS dated [DATE] reflected It was noted Resident #1 was discharged on 06/26/2023. During an interview on 07/07/2023 at 11:04 a. m. the PT stated Resident #1 expressed not wanting to live during therapy initial evaluation on 06/23/2023 and the Director of Rehabilitation was notified immediately. The PT stated the DOR notified the GM, DON and Social Services. The PT stated on 06/26/2023 Resident #1 asked her (PT) to give her a knife or throw her out through the window along with the trash, and Resident #1 stated she wanted to kill herself. The PT stated, she left Resident #1 in the room by herself to notify the Director of therapy. The PT stated, I guess it was not safe to leave her (Resident #1) by herself in the room. The PT stated later that day, at about 2:55 p.m. she was approached by the Social Worker asking for help for Resident #1. The PT stated when she walked into Resident #1's room, Resident #1 had the cord from the call light around her neck, but not completely. The PT stated she then wheeled Resident #1 to the nurse's station and notified LVN A of the incident. During an interview on 07/07/2023 at 11:21 a.m. LVN A stated on 06/26/2023 at about 08:00 am was the first day she heard Resident #1 verbalize wanting to die. LVN A stated while Resident #1 was on the phone with family, she heard Resident #1 telling family she wanted to kill herself. LVN A stated she notified the DON and the ADON about Resident #1's behavior. LVN A stated staff were going back and forth to Resident #1's room due to Resident #1 being agitated, banging the phone on the table, yelling, and screaming out loud. LVN A stated everyone knew about Resident #1's behavior and Resident #1's room door was kept opened. LVN A stated she was on her break when the Social Worker found Resident #1 in the restroom with the cord from the call light around her neck. LVN A stated Resident #1 was taken to the nurse's station after the incident and Resident #1 made multiple attempts hitting her forehead, motion of stabbing herself and attempts to hit staff. During an interview on 07/07/2023 at 11:49 a.m. the Social Worker stated on 6/26/23, she saw a flashing red light from Resident #1's room. The social worker stated she called out Resident #1's name and she did not respond. The social worker stated Resident #1 was found in the restroom in her room with the cord from the call light in the restroom around her (Resident #1) neck and the resident was pulling on the cord. The Social Worker stated she ran out for help and saw 2 therapy staff one of which was the PT. The Social worker stated the therapy staff took the cord from around Resident #1's neck. The Social Worker stated maybe 2 hours prior to the incident, the DOR sent a group text to she (social Worker) and the GM that Resident #1 made a statement of wanting to die. The Social worker stated she was going to make a referral to Psych but Resident # 1 attempted suicide before she could. The social Worker stated during her initial assessment with Resident #1, Resident #1 had depression noted. During an interview on 07/07/2023 at 12:19 p.m. the DOR stated she was notified by the PT on 06/23/2023 that Resident #1 expressed being depressed and she immediately notified the Social Worker and the GM. The DOR stated during one of Resident #1's treatment sessions, on the morning of 06/26/2023 Resident #1 asked that the PT give her a knife and throw her out with the trash. The DOR stated she immediately notified the GM and the social worker. If a resident says she does not want to live, it should be taken seriously that is serious. The DOR stated usually the first time a resident expressed wanting to harm themselves the DON and NP were notified. The DOR stated, You know it is not uncommon for people to express the need of wanting to kill themselves, I just make my report and those who are trained to take care of it, takes care of it. On the day she was sent out, that was the day she was expressing more of a direct suicidal ideation. During an interview on 07/07/2023 at 12:35 p.m. the DON stated she was made aware of the initial statement made by Resident #1 on 06/23/2023 and she assessed Resident #1, but she did not document her assessment. The DON stated she was made aware the second time Resident #1 verbalized she wanted to die on 06/26/2023. The DON stated staff were monitoring the resident by making frequent rounds. The DON stated the facility did not provide one on one monitoring due to staffing. The DON stated she could not say why Resident #1 was not sent out after verbalizing the second time that she wanted to die since the facility was not able to provide one on one monitoring. During an interview on 07/07/2023 at 3:42 p.m. NP B stated she was notified on 06/23/2023 by therapy and nursing that Resident #1 verbalized not wanting to live. NP B stated she assessed Resident #1, and Resident stated she did not want to live. NP B stated Resident # 1 had no plan, was weak at the time, could not move, had no strength, and could not carry out what she was saying. NP B stated Resident #1's statement was passive and had no plan and if Resident #1 had a plan, she would have spoken to the DON to follow the facility's protocols regarding suicide. During an interview on 07/07/2023 at 5:29 p.m. the GM stated she only heard about Resident #1 wanting to die on 06/26/2023. The GM stated the procedure to follow for a resident with suicidal ideation was reflected on the behavior monitoring policy. The GM stated, I did not know she had said it earlier. Now I am understanding why it was an IJ. We have the behavioral monitoring policy, if a resident has a plan, we will send them to the hospital for evaluation and monitoring. During an interview on 07/10/2023 at 10:48 a.m. NP C stated NP B informed her on 06/23/2023 sent her a communication that Resident #1 wanted to die but had no plans. NP C stated she worked on 06/26/2023 and was not made aware Resident #1 continued to have suicidal ideation until after the incident. NP C stated if she was made aware, she would have assessed Resident #1, and if she was suicidal, she would have sent Resident #1 to the ER for immediate psychiatric consult. NP C stated they can try to monitor but this was not the right setting for them, and sending the resident out was better. NP C stated Resident #1 should have been assessed; it was not the best thing to leave Resident #1 by herself in the room. During an interview on 07/10/2023 at 11:13 a.m. the ADON stated on 06/23/2023 he was told by the PT Resident #1 did not want to wear her oxygen. He stated he went to assess Resident #1 and she was sating (oxygen level) in 93-94% on room air and the family stated Resident #1 did not wear oxygen at home. The ADON stated LVN A did not notify him on 06/26/2023 about Resident #1 verbalizing that she wanted to die. The ADON stated the next time he heard of Resident #1 wanting to die was after she attempted to kill herself. The ADON stated, If I had known prior, I was going to notify the GM, DON made sure Resident #1 was safe, have someone to watch her, initiate one on one visit, notify the physician, family, if she got violent, we would activate 911. Review of the facility's policy titled BEHAVIOR EMERGENCY POLICY revised 04/2023 reflected: The goal of the facility is to provide a safe, secure environment. To foster a safe environment, a consistent staff approach to behavioral problems and emergencies are necessary. Responsible Party: Nursing Staff, Social Services, GM. Policy The goal is to use the least restrictive behavioral interventions and move through the steps at increments necessary to maintain a safe environment. No forms of seclusions are permitted, however, separation from other residents or staff is allowed for a short period of time to reduce agitation. Staff should remain calm and professional at all times. Demonstrate empathy and offer reassurance of safety: I understand your situation, you are safe here, you don't need to be afraid, etc. Set verbal limits: please keep your voice down, stop swinging your arms, etc. Escort to private area - a quiet room with decreased external stimulation for a short amount of time may help calm the resident and provides privacy. Initiate 1:1 observation/monitoring as needed until the resident is calm. Offer medication - utilize physician order for a medication explaining to the resident how the medication will help them. Notify physician for transfer to emergency room for evaluation of behavioral disturbance. If resident becomes violent to staff or others, call 911 for outside intervention. After the incident, document in the nursing notes: a. The president's behavior and/or symptoms at the onset. b. The events and/or reasons potentially contributing to the president's behavior. c. An assessment of the resident. d. Each intervention utilized. e. Notification of family/physician and subsequent orders Review of the facility's policy titled Behavioral Monitoring dated July 2020 reflected: To ensure behavioral monitoring is completed in accordance with all state and federal requirements. Responsible Party: GM, DON Policy/Procedure: 1. Residents that are exhibiting behaviors, and/or that are receiving psychotropic medications will have behavioral monitoring completed by licensed facility nursing staff. 2. Behavioral monitoring may be completed on paper or within the facility electronic medical record. 3. Behavioral monitoring may include but isn't limited to the type(s) of behaviors being exhibited, non-pharmacological interventions attempted prior to administering medications, and the outcome of the non-pharmacological and/or pharmacological interventions. 4. Residents who are exhibiting new and/or increased behaviors that are not improving with non-phar-macological and/or pharmacological interventions may be referred to psychiatric and/or psychology services for further treatment interventions. 5. In the event the resident is exhibiting suicidal and/or homicidal ideations, the physician will be notified and increased intensive staff monitoring implemented until the resident can be transferred to a higher level of care. This was determined to be an Immediate Jeopardy (IJ) on 07/07/2023 at 5:20 p.m. The General Manager and DON were notified. The General Manager was provided with the IJ template on 07/07/2023 at 5:20 p.m. The following Plan of Removal submitted by the facility was accepted on 07/10/2023 at 3:12 p.m.: Plan of Removal Immediate Jeopardy On 07/07/2023 an abbreviated survey was initiated at the facility. On 07/07/2023 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Threat states as follows: F742-The facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of (Resident # 1) one residents reviewed for suicidal ideation. Action: Resident #1 was sent to the emergency room for further psychiatric evaluation on 6/26/2023. She did not recall the incident during her ER evaluation. She was not admitted and transferred to another SNF on that same day. Action: All active residents currently in the facility had PHQ-9 (Patient Health Questionnaire) screening done by Director of Care Transitions and/or Designee. Any resident scoring 10 or higher (which indicates moderate depression) has been referred to psych services on July 10th, by Director of Care Transitions and/or Designee. On July 10th, Director of Care Transitions or nurse/designee notified physician, responsible party, Director of Nursing and GM. Behavior Monitoring Policy and/or Behavior Emergency Policy were followed based on specific resident behaviors. These team members will be involved in setting up a safe plan if resident voices suicidal ideations voiced during PHQ-9 intake that would include 1:1 monitoring until resident is transferred to hospital and removing any items that could be used by resident as harm (silverware, shoelaces, call light cords, etc.). Staff to be notified of resident safety plan requirements until discharged . The PHQ-9 is a questionnaire that is administered with MDS Assessment cycle which includes change of condition. It can be used at any time to determine if resident is experiencing depression and there is not a requirement on who is able to conduct the PHQ-9 with residents. Start Date:7/8/2023 Completion Date: 7/8/2023 by midnight Responsible: Director of Care Transitions (Social Worker) and/or Designee Action: All staff including GM and Director of Nursing have received training on reporting of resident threat to self/voicing suicidal ideations immediately utilizing our Behavior Emergency Policy and Behavioral Monitoring Policy by 7/8/23. Any staff on leave/agency/prn to be in-serviced prior to return to duty. The Behavior Emergency Policy and the Behavior Monitoring Policy will be followed when residents experience suicidal ideation. Start Date: 7/8/2023 Completion Date: 7/8/2023 Responsible: GM and Director of Nursing Services (trained by Regional Clinical Support for the facility prior to training facility staff) Action: Director of Nursing has conducted health and welfare rounds on all in house residents on 7/8/2023 and then will continue completing health and welfare rounds on all in house residents by DON/designee: daily for 2 weeks, weekly for 1 month, and randomly thereafter. DON was trained by Regional Clinical Support on 7/8/2023. All results reported to monthly QAPI committee on July 10th, for review of trends and action as needed. If suicidal ideations are voiced during rounds, DON/Designee will notify physician, responsible party, the GM and Director of Care Transitions immediately. The Behavior Emergency Policy and the Behavior Monitoring Policy will be followed when residents voice suicidal ideations. These team members will be involved in setting up a safe plan when resident voices suicidal ideations voiced during health and wellness rounds or at any time to any staff member that would include 1:1 monitoring until resident is transferred to hospital and ensuring a safe environment removing any items that could be used by resident as harm (silverware, shoelaces, call light cords, etc.). QAPI Committee includes, Medical Director, DON, GM, Social Services, Environmental Services, HR, Pharmacist. Any residents that have suicidal ideations during initial rounds on 7/8/2023 will be discussed with the GM, DON, and Directors of Care Transitions for safety plan. Care plans to be initiated and physician and responsible party to be notified immediately. Start Date: 7/8/2023 Completion Date: 7/8/2023 for initial rounds; then ongoing Responsible DON/Designee Action: All residents admitted with a diagnosis of depression and/or psychotropic medications will be referred to psych services within 72 hours of admitting by Director of Nursing or Director of Care Transitions or designee. Prior to psych services referral, Director of Care Transitions or DON or designee will notify physician, responsible party and GM immediately if resident is voicing suicidal ideations. These team members will be involved immediately in setting up a safe plan based which could include but are not limited to referral to psych services, 1:1 monitoring, transfer to hospital and ensuring a safe environment for resident. Psych services typically visit on a weekly basis for neuropsych evaluations can be expedited as needed. Any resident voicing suicidal ideations will be provided with 1:1 monitoring until transferred to hospital and will remain in a safe environment in which any items that could be used as harm will be removed (silverware, shoelaces, call light cords, etc). Start Date: 7/8/2023 Completion Date: ongoing Monitoring of the plan of removal was completed on 07/11/2023 and revealed the following: During an interview on 07/11/2023 at 11:26 a.m. LVN A stated she was on what serviced on what to do in a suicidal situation. LVN A stated they were to notify the DON and the GM. LVN A stated the Resident was not to be left alone, they should be placed on 1:1 care/monitoring. LVN A stated the resident should be in an environment that is safe and free from anything that could be used potentially to harm themselves. During an interview on 07/11/2023 at 11:54 a.m. LVN D stated she was in-serviced on 07/10/2023 on suicidal ideations. LVN D stated when a resident was having suicidal ideation, she would call the DON and the GM, and notify the doctor and the social worker for psych evaluation. LVN D stated she would continue to monitor the resident, make sure the resident is given plastic silverware only, the call light would be taken away from the resident, and the resident would be monitored visually. monitoring. LVN D stated she would not leave the resident in a room when they were expressing to harm themselves. LVN D stated, you cannot assume a resident would not kill themselves after they have verbalized it. During an interview on 07/11/2023 at 12:17 p.m. CNA E stated she was in-serviced on 07/10/2023 on suicidal ideations. She stated she had to make sure she stayed with the resident and called the DON. During an interview on 07/11/2023 at 12:35 p.m. CNA F stated she was in-serviced on 07/10/2023 on who to notify when a resident verbalized harming self and how to keep a resident safe. CNA F stated If someone made a statement to harm themselves or physically harm themselves, they would be put on one-on-one supervision in a safe area in their room. She stated she would try to get more information from the resident and call her supervisor to intervene but would never leave the resident alone. During an interview on 07/11/2023 at 12:46 p.m. the Social Worker stated she was in-serviced on 07/10/2023 on Residents with suicidal ideations. The social Worker stated if a resident verbalized wanting to kill self or not wanting to be here, she would ask the resident if they had a plan. The social worker stated it was important for whoever getting the information to alert the DON, ADON, the GM and her (Social Worker). The Social Worker stated, when alerted by another staff of a resident having suicidal ideation, she would discuss feelings with the resident and based on the findings the resident would be transferred to the ER. During an interview on 07/11/2023 at 12:58 p.m. the DOR stated on 07/10/2023 she was in-serviced on the Behavior monitoring policy, and how to respond to the resident when they were having suicidal or homicidal ideation. The DOR stated she would try to figure out the trigger., and seclude the resident as needed. The DOR stated for residents with suicidal ideations, no seclusion was needed, empathy, least restrictive modification. The DOR stated they were trained who to notify by following the tree/chain of command, including the GM, DON, ADONANCO, and social workers. The DOR stated she was responsible to in-service therapy staff as they got back to work. The DOR stated the DON and GM were in-servicing other staff as they came back to work. During an interview on 07/11/2023 at 1:54 p.m. the PT stated she was in-serviced by the DOR on 07/10/2023 regarding the behavioral modification process. The PT stated if a resident expressed suicidal ideation, the DOR, GM and the DON were to be notified, and do not leave the resident by themselves. Record review of the facility's Inservice, dated 07/07/2023, reflected the following trainings were instructed by the DOO and participants were the DON and the GM. Suicidal Ideation and Behavioral Monitoring During an interview on 07/11/2023 at 1:23 p.m. the DON stated she and the GM were in-serviced on 07/07/2023 by the DOO regarding Behavioral monitoring and Residents with suicidal ideation, the process and mechanism of action and her responsibilities when a Resident verbalized suicidal ideation. The DON stated she initiated the in-services for all other staff on 07/08/2023. The DON stated she, the GM, the DOR and the ADON were responsible to make sure all staff were in-serviced prior to working their shifts. The DON stated she completed Health and Welfare Resident Audits on all Residents on 07/08/2023, 07/09/2023, and 07/10/2023; and the ones for 07/11/2023 were in progress. During an interview on 07/11/2023 at 1:38 p.m. the GM stated she and the DON were in-serviced on 07/07/2023 by the DOO regarding Behavioral monitoring and Residents with suicidal ideation, the process, and her responsibilities when a Resident verbalized suicidal ideation. The GM stated the 2 policies were reviewed, when a resident verbalized suicidal ideation, the staff would call for help and never leave the resident alone. The GM stated the nurses would assess the resident and notify the RP, Physician, and initiate one-on-one monitoring until the resident was transferred to the ER. Record review of the facility's Inservice, dated 07/08/2023, reflected the following trainings were instructed by the DON and the GM and the participants were all other staff in the facility. Behavioral Emergency Policy. Adequate supervision and assistance to prevent accidents Record review of facility's POR documentations reflected Health and Welfare Resident Audits were completed on all Residents on 07/08/2023, 07/09/2023, and 07/10/2023 by the DON. Record review of facility's POR documentations reflected 36 Residents BIMS and PHQ9 assessments were completed by the Social Worker The GM was informed the Immediate Jeopardy was removed on 07/11/2023 at 1:50 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.