**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents needs' as identified through resident assessments, and described in the plan of care for one of one resident (Resident #1) and 2 of 2 nurses reviewed for competent nursing staff. The facility failed to ensure nursing staff were properly trained and nursing staff failed to reported to management when they were unable to obtain the medication from the Omnicell Automated Medication Dispensing Systems. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings include: R1 is a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), diabetes, cognitive communication deficit, and difficulty in walking. Record review of Resident #1's MDS assessment, dated 07/13/23, revealed a BIMS score of five suggesting severe cognitive impairment, used a walker and a wheelchair, had a medically complex condition, had an active diagnoses of seizure disorder or epilepsy, and had a fall in the last month and a fracture related to a fall in the last six months. Resident #1's care plan focus initiated on 01/06/23 reflected that she is on anticoagulant (having the effect of retarding or inhibiting the coagulation of the blood) therapy, care plan focus on 01/10/23 revealed she has a diagnosis of a seizure disorder and had a fall post seizure activity on 09/20/23 with intervention ensure Keppra in Omnicell (ADMS) for back up. Review of MAR reflects medication order for Keppra Oral Tablet 1000 milligram (Levetiracetam) give 1.5 tablet by mouth two times a day for seizure disorder total dosage 1500 milligram. Review of medical record dated 09/20/34 revealed Resident #1 was at the hospital on [DATE] seen for seizure and head injury. Interview on 10/02/23 with LVN A at 12:38 pm revealed on Tuesday, 09/19/23 at approximately 8:00 am when LVN A tried to administer Resident #1 her medications, LVN A noticed Resident #1 did not have her Keppra (Levetiracetam) medication in the facility medication cart. When asked if the facility had an e-kit, LVN A revealed that the ADMS was the facility e-kit but when she went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the surveyor told her the DOW said that Keppra (Levetiracetam) was available at the facility in the ADMS LVN A revealed she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know how to get Resident #1's medication. When asked what could happen if a resident did not receive their dose of Keppra (Levetiracetam), she said that someone could die. LVN A administered Resident #1 her remaining prescribed medication and used the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam). LVN A revealed that she knew that the facility policy was to notify the NP or the DOW if a residents' medication was not available or something was missing. LVN A revealed it was a hectic morning and she just did not do it. LVN A revealed she knew Resident #1 was taking Keppra (Levetiracetam) for a seizure disorder and she learned the next day, on Wednesday 09/20/23, Resident #1 had a seizure. LVN A said she did not enter a note in the electronic medication administration record about Resident #1 not getting her am 1500 milligram dose of Keppra (Levetiracetam) but she said she did report it to the nurse who took over her shift, but she could not remember that person's name. Interview on 10/02/23 with LVN B at 2:55 pm revealed she worked 6:00 pm to 6:00 am and when she began administering Resident #1 her medication at approximately 8:00 pm, she realized Resident #1 was out of Keppra (Levetiracetam) and she ordered the medication using the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam) and saw that it was previously ordered earlier that day, but she reordered again. LVN B revealed she was unaware that Resident #1 did not receive her first dose of Keppra (Levetiracetam). LVN B went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the surveyor told her the DOW said that Keppra (Levetiracetam) was available at the facility in the ADMS LVN B revealed she received training on how to use the ADMS e-kit but she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know that Resident #1's medication was available at the facility. When asked what could happen if a resident did not receive Keppra (Levetiracetam), LVN B revealed the resident could possibly have a seizure, injury, and hospitalization. LVN B revealed that sometimes there are some mix-ups with getting medications from the pharmacy. LVN B revealed she knew that Keppra (Levetiracetam) was for seizures. LVN B said she had had a conversation with Resident #1 who told LVN B she has had seizures. LVN B revealed it is the facility policy to call the NP or the DOW if a resident is out of medication. LVN B revealed that she would be concerned that Resident #1 would have a seizure if she did not receive her Keppra (Levetiracetam) and she missed a step by not calling the NP or DOW. Interview on 10/02/2023 with the NP at 12:56 pm revealed that on 09/20/23 in the am she was speaking with a staff member in the hallway of the facility and heard a loud bang from Resident #1's room. She observed Resident #1 on the ground having a seizure. NP revealed Resident seized for 60 seconds afterwards was lethargic and had a contusion on her head (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). EMS was called and Resident #1 was taken to the hospital. NP revealed that Resident #1 was taking Plavix (an antiplatelet medication that stops platelets from clumping up together and forming blood clots) and it was important to watch Resident #1 for bleeding issues. NP revealed that, after the incident, she looked at Resident #1's medication administration record and found that on 09/19/23, the day prior to the seizure and fall, Resident #1 did not receive the two of her two daily doses of Keppra (Levetiracetam) 1500 milligrams each dose. NP revealed that Resident #1 had a history of falls, a stoke, is on a blood thinner and had other medical issues and she cannot attribute the lack of Keppra (Levetiracetam) to her seizure. NP revealed that Resident #1 was administered Keppra (Levetiracetam) for a seizure disorder. NP revealed she was not notified that Resident #1 did not receive either of her two Keppra (Levetiracetam) 1500 milligram doses for 09/19/23. Interview on 10/10/23 at 12:07 pm with the hospitial physician who treated Resident #1 revealed that he believed the missing doses of Keppra (Levetiracetam) were the most likely culprit for Resident #1's seizures and the lack of her receiving the Keppra (Levetiracetam) was his biggest concern. He revealed it is hard for him to say definitively that Resident #1 and a seizure then fell or fell and then had a seizure but the reisent should have been getting her Keppra (Levetiracetam) at the facility and thought that the Keppra could have prevented other issues had it been in her system. Interview on 10/02/23 with the DOW at 11:46 am who revealed that ADMS did contain Keppra (Levetiracetam) but neither LVN A nor LVN B knew to use the house stock medication order tab that listed all the medications stored in the ADMS. The ADMS had an override that was used when a nurse could not find an item on the scheduled medications or active medication order tab for a specific resident. The DOW revealed that the ADMS did not have Keppra (Levetiracetam) in Resident #1's 1500 milligram dose tablet size but the ADMS did have Keppra (Levetiracetam) stocked in other tablet quantities that could be requested from the ADMS to fulfill Resident #1's 1500 milligram dose. The DOW revealed that neither LVN A nor LVN B knew how to use this feature. The DOW revealed that the staff was trained on how to use the ADMS by the pharmacy staff who owned the ADMS. If the pharmacy staff was not available to train new staff when a new nurse was hired, facility staff trained the new staff. The DOW did not have any documents that reflected who or when the training occurred. She revealed that when the pharmacy staff who owned the ADMS trained the nurses, they went over the information very quickly . The DOW revealed that LVN A should have done a follow up call to the pharmacy when the pharmacy did not deliver the medication after LNVA requested it by electronic medication administration. The DOW confirmed Resident #1 missed two doses' of 1500 milligrams of Keppra (Levetiracetam), both her morning and her evening doses. The DOW revealed that Resident #1 had a seizure on 09/20/23 and in addition to the seizure, she fell and had a contusion on her head. The DOW revealed that Resident #1 has not had a seizure since she has resumed her Keppra (Levetiracetam). The DOW revealed that the calls to the NP and the DOW to alert them that Resident #1 was missing medication were not made and the DOW did not know Resident #1 missed two Keppra (Levetiracetam) until Resident #1 had the seizure and fell. The DOW revealed that she can't really state that not having the Keppra caused the seizure, but that the situation of Resident #1 missing 2 doses could have caused a seizure, could have been a lot worse and could have caused death. Review of nursing description in medication administration record dated 09/20/23 revealed Resident #1 was seen sitting on side of bed approximately 2-3 minutes prior to the incident. CNA heard a loud crashing sound and entered Residents #1's room. Resident was seen on floor, laying down in between bed and table with the table against her face. Resident was tense, non-responsive and shaking (less than one minute). NP entered the room and helped move Resident #1 away from objects. Lips noted to be blue, 15L 02 via non-rebreather mask given. 911 was called and Resident #1 started to respond with one work responses when the Emergency Medical Technicians arrived. Resident #1 was unaware of what happened when started to become more alert. Resident #1 unable to give description. Injuries observed at time of incident abrasion to top of scalp and face. Predisposing Physiological Factions recent change in medications/new Review of Resident #1's hospital records dated 09/20/23 revealed patient with prior history of seizures and a history of dementia which limited her ability to provide history but is assumed that she had a seizure as she was mildly postictal (lethargic). Patient's facility reports she was out of her Keppra (Levetiracetam) and had missed several doses, she typically takes 1500 milligrams twice a day. The patient (Resident #1) was provided with IV dose of Keppra (Levetiracetam) at patient's home dose rate. Patients had head injury, suspected seizure, and history of seizures, noncompliant with medication and ran out of them. Diagnoses seizure and head injury. CT maxillofacial impression small midline forehead contusion. Review of LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual last updated 01/04/23 reflected the facility may use an ADMD to access emergency medications, or medically necessary medications or routine orders and medications removed from the AMDS must have a corresponding Physician/Prescriber's order. The pharmacy will provide staff training and train-the-trainer programs as necessary. Facility should document staff training competencies on the use of the AMD S including: Content of the AMDS Accessing medications Facility should generate a refill report to identify those medications that require restocking and provide such refill report to the pharmacy. Review of facility Administering Medications policy revised date 07/01/12 reflected Policy: Medications will be administered in a timely manner and as prescribed [NAME] the residents' attending physician or the community's medical director. Purpose: To provide quality services regarding administering medications. The Director or Wellness (DOW) is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal ordered. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administrating the medication must initial and circle the medication administration record space provided for that drug. Any explanatory note on the reverse side of the medication administration record must be entered when drugs are withheld, refused, or given other than at scheduled time. (Note: the attending physician must be notified when a medication is refused or withheld per physician's order). Review of facility Medication Errors and Drug Reactions revision date 07/01/23 revealed Purpose: The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. Procedure: All medications errors and drug reactions must be promptly reported to the Director of Wellness (DOW) attending physician, resident/or family/POA and the pharmacist if applicable. An account of the incident must be recorded in the resident's medical record, such documentation must include, but is not limited to: a. The name, strength, and dosage of medication administered date and time. b. The date and time the physician was notified and his/her instructions. c. Date and time resident and/or party were notified. Residents receiving incorrection medication or having a drug reaction must be closely monitored. Any change in the resident's condition must be immediately reported to the Director of Wellness (DOW) and attending physician. The nurse discovering the error will be responsible for completing an incident report and submitting a copy to the Director of Wellness (DOW) and a copy to the administrator. All incidents reported related to medication errors and drug reactions will be reviewed by the QA community and pharmacy consultant. On 10/02/2023 at 6:10 pm, the ADM and the DOW were notified of the Immediate Jeopardy (IJ) due to the above failures and the IJ template was provided at that date and time. The following Plan of Removal was submitted by the facility and was accepted on 10/03/2023 at 3:17 pm: Plan of Removal Immediate Jeopardy On 10/02/23 an abbreviated survey was initiated at[The facility] . On 10/02/23 the surveyor provided an Immediate Jeopardy (IJ) template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F726- The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required. Action: All licensed nurses will be in-serviced, by end of day 10-03-23, with return demonstration, using a checkoff list, on the Omnicell operations. The Omnicell is a facility medication dispensing machine. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. Each nurse was provided with a quick reference guide to access the Omnicell, which was provided during this in-service. The pharmacy and the Regional Director of Wellness has in-serviced the DOW/ADOW on this issue prior to them in-servicing facility staff. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Action: All licensed nurses will be in-serviced , by end of day 10-03-23, on the refill process when a medication becomes low or is about to run out and who is to be notified (i.e. pharmacy, physician, DOW). This process will be monitored by the DOW/ADOW. All licensed nurses were also instructed to check the list of medications on the side of the Omnicell for availability in the Omnicell. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. The Regional Director of Wellness has in-serviced the DOW/ADOW on this issue. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Monitoring of the plan of removal from 10/04/23 through 10/04/23 included the following: Reviewed that all licensed nurses (with the exception of one LVN who was unavailable to attend because of a family emergency and would be in-serviced upon her return) were in-serviced by 10/03/23 demonstrated, using a checkoff list, the ADMS operations including refill process when medication runs low and instructed to check the list of medications on the side of the ADMS for availability of medication in the ADMS. The in-service for the nurses was completed by the ADOW. Reviewed the in-service conducted by The Regional Director of Wellness to the DOW/ADOW on these same issues prior to the DOW/ADOW in-servicing their nursing staff. Interviewed four LVNs between 10:52 am and 11:14 am 0n 10/04/23 who confirmed that they received the were in-serviced on and understood where to locate the list of available medications in the ADMS, the process of obtaining medications from the ADMS if a resident medication was low and the ADMS refill process. The ADM and DOW were informed the Immediate Jeopardy was removed on 10/04/23 at 12:05 pm, however the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, 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 interview and record review the facility failed to ensure residents were free of any significant medication errors for one of one resident (Resident #1) reviewed for medications. The facility failed to ensure nursing staff were properly trained and nursing staff failed to reported to management when they were unable to obtain the medication from the Omnicell Automated Medication Dispensing Systems. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. While the IJ was removed on 10/04/23, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), diabetes, cognitive communication deficit , and difficulty in walking. Record review of Resident #1's MDS assessment, dated 07/13/23, revealed a BIMS score of 5, which indicated severe cognitive impairment. Resident #1 used a walker and a wheelchair, had a medically complex condition, had an active diagnoses of seizure disorder or epilepsy, and had a fall in the last month and a fracture related to a fall in the last six months. Record review of Resident #1's care plan focus, initiated on 01/06/23, reflected she was on anticoagulant (having the effect of retarding or inhibiting the coagulation of the blood) therapy, care plan focus on 01/10/23 revealed she had a diagnosis of a seizure disorder and had a fall post seizure activity on 09/20/23 with intervention ensure Keppra in Omnicell (ADMS) for back up. Record review of Resident #1's MAR reflected medication order for Keppra Oral Tablet 1000 milligram (Levetiracetam) give 1.5 tablet by mouth two times a day for seizure disorder total dosage 1500 milligram. Record review of Resident #1's hospital medical record , dated 09/20/34, revealed Resident #1 was at the hospital on [DATE] seen for seizure and head injury. Interview on 10/02/23 with LVN A at 12:38 PM revealed on Tuesday, 09/19/23 at approximately 8:00 AM when she tried to administer Resident #1 her medications, LVN A noticed Resident #1 did not have her Keppra (Levetiracetam) medication in the facility medication cart. LVN A revealed the ADMS was the facility e-kit but when she went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser, the computer screen for the ADMS, said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the State Surveyor told LVN A the DOW said Keppra (Levetiracetam) was available at the facility in the ADMS, LVN A revealed she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know how to get Resident #1's medication. LVN A stated if a resident did not receive their dose of Keppra (Levetiracetam), they could die. LVN A administered Resident #1 her remaining prescribed medication and used the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam). LVN A revealed she knew the facility policy was to notify the NP or the DOW if a residents' medication was not available or something was missing. LVN A revealed it was a hectic morning and she just did not do it. LVN A revealed she knew Resident #1 was taking Keppra (Levetiracetam) for a seizure disorder and she learned the next day, on Wednesday 09/20/23, Resident #1 had a seizure. LVN A said she did not enter a note in the electronic medication administration record about Resident #1 not getting her AM 1500 milligram dose of Keppra (Levetiracetam) but she said she did report it to the nurse who took over her shift, but she could not remember that person's name. Interview on 10/02/23 with LVN B at 2:55 PM revealed she worked 6:00 PM to 6:00 AM and when she began administering Resident #1 her medication at approximately 8:00 PM, she realized Resident #1 was out of Keppra (Levetiracetam) and she ordered the medication using the electronic medication administration record to communicate with the pharmacy and ordered the Resident's Keppra (Levetiracetam) and saw it was previously ordered earlier that day, but she reordered it again. LVN B revealed she was unaware Resident #1 did not receive her first dose of Keppra (Levetiracetam). LVN B went to the ADMS and entered Residents #1's name and the name of Resident #1's medication the ADMS dispenser the computer screen for the ADMS said Keppra (Levetiracetam) 1500 milligram dose was unavailable. When the State Surveyor told LVN B the DOW said Keppra (Levetiracetam) was available at the facility in the ADMS, LVN B revealed she received training on how to use the ADMS e-kit but she was not trained on ADMS on how to obtain medication in other quantity amounts and she did not know Resident #1's medication was available at the facility. LVN B revealed if a resident did not receive Keppra, the resident could possibly have a seizure, injury, and hospitalization. LVN B revealed sometimes there were some mix-ups with getting medications from the pharmacy. LVN B revealed she knew Keppra (Levetiracetam) was for seizures. LVN B said she had had a conversation with Resident #1 who told LVN B she had seizures. LVN B revealed it was the facility policy to call the NP or the DOW if a resident was out of medication. LVN B revealed she would be concerned Resident #1 would have a seizure if she did not receive her Keppra (Levetiracetam) and she missed a step by not calling the NP or DOW. Interview on 10/202/23 with the NP at 12:56 PM revealed on 09/20/23 in the am she was speaking with a staff member in the hallway of the facility and heard a loud bang from Resident #1's room. She observed Resident #1 on the ground having a seizure. The NP revealed Resident seized for 60 seconds afterwards was lethargic and had a contusion on her head (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise). EMS was called and Resident #1 was taken to the hospital. The NP revealed Resident #1 took Plavix (an antiplatelet medication that stops platelets from clumping up together and forming blood clots) and it was important to watch Resident #1 for bleeding issues. The NP revealed after the incident, she looked at Resident #1's medication administration record and found on 09/19/23, the day prior to the seizure and fall, Resident #1 did not receive two of her two daily doses of Keppra (Levetiracetam) 1500 milligrams each dose. The NP revealed Resident #1 had a history of falls, a stoke, is on a blood thinner and had other medical issues and she could not attribute the lack of Keppra (Levetiracetam) to her seizure. The NP revealed Resident #1 was administered Keppra (Levetiracetam) for a seizure disorder. The NP revealed she was not notified Resident #1 did not receive either of her two Keppra (Levetiracetam) 1500 milligram doses for 09/19/23. Interview on 10/10/23 at 12:07 pm with the hospitial physician who treated Resident #1 revealed that he believed the missing doses of Keppra (Levetiracetam) were the most likely culprit for Resident #1's seizures and the lack of her receiving the Keppra (Levetiracetam) was his biggest concern. He revealed it is hard for him to say definitively that Resident #1 and a seizure then fell or fell and then had a seizure but the reisent should have been getting her Keppra (Levetiracetam) at the facility and thought that the Keppra could have prevented other issues had it been in her system. Interview on 10/02/23 with the DOW at 11:46 AM revealed the ADMS did contain Keppra (Levetiracetam) but neither LVN A nor LVN B knew to use the house stock medication order tab that listed all the medications stored in the ADMS. The ADMS had an override that was used when a nurse could not find an item on the scheduled medications or active medication order tab for a specific resident. The DOW revealed the ADMS did not have Keppra (Levetiracetam) in Resident #1's 1500 milligram dose tablet size but the ADMS did have Keppra (Levetiracetam) stocked in other tablet quantities that could be requested from the ADMS to fulfill Resident #1's 1500 milligram dose. The DOW revealed neither LVN A nor LVN B knew how to use this feature. The DOW revealed the staff were trained on how to use the ADMS by the pharmacy staff who owned the ADMS. If the pharmacy staff were not available to train new staff when a new nurse was hired, the facility staff trained the new staff. The DOW did not have any documents that reflected who or when the training occurred. She revealed when the pharmacy staff who owned the ADMS trained the nurses, they went over the information very quickly. The DOW revealed LVN A should have done a follow up call to the pharmacy when the pharmacy did not deliver the medication after LNVA requested it by electronic medication administration. The DOW stated Resident #1 missed two doses of 1500 milligrams of Keppra (Levetiracetam), both her morning and her evening doses. The DOW revealed Resident #1 had a seizure on 09/20/23 and in addition to the seizure, she fell and had a contusion on her head. The DOW revealed Resident #1 had not had a seizure since she had resumed her Keppra (Levetiracetam). The DOW revealed the calls to the NP and the DOW to alert them Resident #1 was missing medication were not made and the DOW did not know Resident #1 missed two Keppra (Levetiracetam) until Resident #1 had the seizure and fell. The DOW revealed she couldn't really state that not having the Keppra caused the seizure, but the situation of Resident #1 missing 2 doses could have caused a seizure, could have been a lot worse and could have caused death. Record review of the nursing description in the medication administration record, dated 09/20/23, reflected Resident #1 was seen sitting on the side of bed approximately 2-3 minutes prior to the incident. CNA heard a loud crashing sound and entered Residents #1's room. The resident was seen on floor, laying down in between the bed and table with the table against her face. The resident was tense, non-responsive and shaking (less than one minute). The NP entered the room and helped move Resident #1 away from objects. Lips noted to be blue, 15L 02 via non-rebreather mask given. 911 was called and Resident #1 started to respond with one work responses when the Emergency Medical Technicians arrived. Resident #1 was unaware of what happened when she started to become more alert. Resident #1 was unable to give a description. Injuries observed at time of incident abrasion to top of scalp and face. Predisposing Physiological Factions recent change in medications/new. Record review of Resident #1's hospital records, dated 09/20/23, revealed patient with prior history of seizures and a history of dementia which limited her ability to provide history but is assumed that she had a seizure as she was mildly postictal (lethargic). Patient's facility reports she was out of her Keppra (Levetiracetam) and had missed several doses, she typically took 1500 milligrams twice a day. The patient (Resident #1) was provided with IV dose of Keppra (Levetiracetam) at patient's home dose rate. Patients had head injury, suspected seizure, and history of seizures, noncompliant with medication and ran out of them. Diagnoses seizure and head injury. CT maxillofacial impression small midline forehead contusion. Record review of the LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual, last updated 01/04/23, reflected the facility may use an ADMD to access emergency medications, or medically necessary medications or routine orders and medications removed from the AMDS must have a corresponding Physician/Prescriber's order. The pharmacy will provide staff training and train-the-trainer programs as necessary. Facility should document staff training competencies on the use of the AMDS which include: Content of the AMDS Accessing medications Facility should generate a refill report to identify those medications that require restocking and provide such refill report to the pharmacy. Record review of the facility Administering Medications policy, revised date 07/01/12, reflected Policy: Medications will be administered in a timely manner and as prescribed by the residents' attending physician or the community's medical director. Purpose: To provide quality services regarding administering medications. The Director or Wellness (DOW) is responsible for the supervision and direction of all personnel with medication administration duties and functions. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal ordered. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administrating the medication must initial and circle the medication administration record space provided for that drug. Any explanatory note on the reverse side of the medication administration record must be entered when drugs are withheld, refused, or given other than at scheduled time. (Note: the attending physician must be notified when a medication is refused or withheld per physician's order). Review of facility Medication Errors and Drug Reactions revision date 07/01/23 revealed Purpose: The purpose of this procedure is to establish uniform guidelines in the reporting and recording of medication errors and drug reactions. Procedure: All medications errors and drug reactions must be promptly reported to the Director of Wellness (DOW) attending physician, resident/or family/POA and the pharmacist if applicable. An account of the incident must be recorded in the resident's medical record, such documentation must include, but is not limited to: a. The name, strength, and dosage of medication administered date and time. b. The date and time the physician was notified and his/her instructions. c. Date and time resident and/or party were notified. Residents receiving incorrection medication or having a drug reaction must be closely monitored. Any change in the resident's condition must be immediately reported to the Director of Wellness (DOW) and attending physician. The nurse discovering the error will be responsible for completing an incident report and submitting a copy to the Director of Wellness (DOW) and a copy to the administrator. All incidents reported related to medication errors and drug reactions will be reviewed by the QA community and pharmacy consultant. This was determined to be an Immediate Jeopardy (IJ) on 10/02/2023 at 6:10 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on 10/02/2023 at 6:10 pm. The following Plan of Removal was submitted by the facility and was accepted on 10/03/2023 at 3:17 PM: Accepted 3:17 pm Plan of Removal Immediate Jeopardy On 10/02/23 an abbreviated survey was initiated at [the facility]. On 10/02/23 the surveyor provided an Immediate Jeopardy (IJ) template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F760- The facility failed to ensure residents are free of any significant medication errors. Action: 100% audit was completed to determine the number of residents on anticonvulsant medication. The medication is available, both on the med cart and in the Omnicell. The audit was completed by the Regional Director of Wellness. The audit will be completed bi-weekly by the DOW/ADOW and will be an on-going process. One resident was found to be on this type of medication and the medication is in stock and available in the med cart and the Omnicell. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Action: All licensed nurse nurses will be in-serviced, by end of day 10-03-23, that if any resident missed a dose of an anticonvulsant medication, or any medication, the nurse is to immediately notify the physician, DOW and pharmacy. The nurses are also to check the quick reference guide on the side of the Omnicell for medication availability. The training will be completed by the DOW/ADOW and will be on-going for all current and newly hired staff. This will be an annual training for facility nurses. The facility does not use agency staff but if this occurs in the future, they will also be trained on this process by the DOW/ADOW, on hire. The DOW/ADOW were in-serviced by the Regional Director of Wellness prior to the facility staff being in-serviced. Start Date: 10-02-23 Completion Date: 10-03-23 Responsible: DOW/ADOW Monitoring of the plan of removal from 10/04/23 through 10/04/23 included the following: An audit was completed by Regional Director of Wellness, and it was determined Resident #1 was the only current resident in the facility on anticonvulsant medication. The medication was available, both on the med cart and in the ADMS Omnicell. Interviewed four LVNs between 10:52 AM and 11:14 AM on 10/04/23 revealed they received the in-serviced and understood where to locate the list of available medications in the ADMS and who and when to notify if anticonvulsant medication, or any medications, is missing . Record review of in-service taken by licensed nurses, by end of day on 10/03/23, (with the exception of one LVN who was unavailable to attend because of a family emergency and would be in-serviced upon her return) for any resident who missed a dose of an anticonvulsant medication, or any medication the MD/NP, pharmacist, and DOW would be notified. If the medication was missing the MD/NP, and family needed to be called and an incident report/medication error would need to be completed. The in-services included information for all nurses to check the quick reference guide on the side of the ADMS Omnicell for medication availability. The ADM and DOW were informed the Immediate Jeopardy was removed on 10/04/23 at 12:05 PM. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .