**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to immediately inform the resident, consult with the resident physician, and notify the resident's representative when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when R#1's abnormal skin condition was identified on 09/09/23. R#1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated. The findings included; Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as per protocol. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder because she forgot. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. RN A said she thought she had called Resident #1's physician to ask for orders that addressed the disocloration on Resident #1. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. CNA J said she was told that LVN B already knew about the discoloration on 09/11/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation so they could make a decision as soon as possible. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CNA G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment becsue she forgot. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. RN A said she had not called Resident #1's FM M. Interview on 09/14/23 at 2:29 pm with Resident #1's FM M revealed the facility had not contacted them on 09/09/23 when Resident #1 was noted with discoloration on her inner thigh. FM M said she was not contacted until 09/10/23 in the evening when it the nurse called her to inform her that Resident #1 now had dark purplish color on her left toes. Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified by facility staff whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. Record review of the facility policy in section Quality of Care, titled Significant Change in Condition, Response dated 12/2022 reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical and mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning reports. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction. F580 Notification of Change Plan of Removal September 19,2023 This plan of removal is written and submitted on behalf of in response to the citation and findings related to F580 for failure to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. This deficient practice was identified during a complaint visit survey conducted on 9/15/2023. 9-19-2023 Per IJ template, facility failed to notify the residents physician when R#1 abnormal skin condition was identified on 09/09/23. Immediate Action 1. Medical Director on 9-19-23. 2. Residents #1, is no longer in the facility. 3. IDT consisting of DON, MDS, Infection Preventionist, Director of Rehab, RN clinical resource to Audit all residents with skin condition, current care plan, Braden scores to identify high risk residents that may develop skin issues and verify notification to MD this will be completed on 9-19-2023. 4.In-service/Education begun for Nurses and CNAs by DON on reporting all identified skin issues to the Director of Nursing immediately. In-service will be completed 9/20/23. Inservice/Education initiated with all staff on change of condition recognition, reporting and monitoring. 09/20/2023 Any employee not in facility will receive in service via phone, any employee who has not received in service will not be allowed to work until in service has been received. In-service will be general and resident specific. 5.All staff will complete competency on change of condition initiated 09/19/2023.This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 8.All residents will have a head-to-toe assessment completed on 9/19/23, any resident identified with skin issue will have MD notified immediately and orders put in place 9. QA meeting regarding items in the IJ template completed 09/19/2023. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. 10.The DON, ADON, QA Nurse, or Clinical Resource will verify staff competency by various change in condition scenarios with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2 weeks x 2 months then a random 5 nurses per month on going. 11.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the POR included the following; Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff on interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying and verifying the COC made. Staff interviews were conducted on 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration for approximately 39 hours. Resident #1 was transferred to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated. The findings included; Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as needed. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. RN A said she thought she had called Resident #1's physician to ask for orders that addressed the discoloration on Resident #1. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. CNA J said she was told that LVN B already knew about the discoloration on 09/11/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation so they could make a decision as soon as possible. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CAN G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. RN A said she had not called Resident #1's FM M. Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. Record review of the facility policy in section Quality of Care, titled Significant Change in Condition, Response dated 12/2022 reflected It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical and mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning reports. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction. The following plan of removal submitted by the facility was accepted on 09/22/23 at 11:57 am: F684 Quality of Care Plan of Removal September 19,2023 This plan of removal is written and submitted on behalf of in response to the citation and findings related to F684 483.25 for failure to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. This deficient practice was identified during a complaint visit survey conducted on 9/15/2023. F684 - Quality of Care Immediate actions 1. RN DON initiated in-services with nurses 09/19/23 at 6:15pm. Education for ALL facility staff consisted of timely identification and reporting Changes in Condition, Nursing Services, Resident Rights and Quality of Care. Ongoing education will be focused on the following areas: Identification and reporting of changes in condition to Primary Care Physician, Director of Nursing, Resident Representative/Designee and/or Medical Director Training to be provided addressing written communication to oncoming shift in the 24-hour written report. 2. Medical Director, notified of Immediate Jeopardy on 09/19/2023 at 6:37pm. Procedure implemented to prevent for a similar situation from reoccurring. The DON an ADON have immediately (9/19/2023) began to monitor all changes in condition daily on weekdays and weekends via review of electronic 24-hour report on PCC for all units, progress notes, new orders, new medication orders, change in condition assessments, hospital transfers and nursing documentation. The daily monitoring by the Director of Nursing and the Assistant Director of Nursing began 9/19/2023 and will be ongoing. Changes in condition will be reviewed daily and the Medical Director will be consulted for any recommendations or suggestions. The Administrator, DON, ADON, MDS and/or designee to attend weekly clinical meetings to include review of residents with skin conditions, changes in conditions, hospital transfers and update of care plan interventions, notifications of Resident Responsible Parties as necessary. All residents will have a head-to-toe assessment completed on 9/19/2023, any resident identified with skin issue will have MD notified. Procedure for new staff Inservice Current staff will be in serviced by Administrative Nursing staff and sister facility DON's by 09/20/2023. New staff will be in serviced by DON or designee upon hire during orientation and prior to working the floor. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. Training for the staff Director of Nursing/Assistant Director of Nursing/Designee will conduct training for the clinical staff. Any employee not in facility will receive Inservice via phone. Any employee who has not received the Inservice will not be allowed to work until in-service has been received. In-service will be general and resident specific. Monitoring Quality Assurance meeting regarding items in the IJ template completed 9/19/2023. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. The Don, ADON, QA Nurse or Clinical Resource will verify staff competency by reviewing changes in condition and interventions, with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2weeks x 2 months then a random 5 nurses every 2 weeks per month ongoing. Summary of IJ and corrective Action to be reviewed by QAPI Committee x 4 weeks or until substantial compliance established and continue monthly 90 days to ensure ongoing compliance. Monitoring of the POR included the following; Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying, and verifying the COC made. Staff interviews were conducted onn 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report, and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to 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 assessments for one resident (Resident #1) of 5 residents reviewed for care. RN A's failure to document, monitor, and assess R#1's abnormal skin discoloration for approximately 39 hours resulted in R#1's transfer to the hospital with acute ischemia for impending loss of limb or possible placement in hospice. This failure could affect residents with acute ischemia by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 09/19/23 at 6:10 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated. The findings included: Record review of the admission record for Resident #1 dated 09/15/23 reflected Resident #1 was a [AGE] year-old female that was admitted to facility on 03/17/21 with the diagnosis of diabetes mellitus (sustained blood sugar levels), cognitive communication deficit (memory loss), need for assistance for personal care and hypertensive heart disease (complication of high blood pressure) without heart failure. Record review of the quarterly MDS dated [DATE] reflected Resident #1's cognitive status was severely impaired, required extensive assistance by two persons for bed mobility, transfers, dressing and toilet use. Record review of the care plans dated 12/03/21 for Resident #1 reflected those resident needs included assistance with activities of daily living, transfer, toileting, and bed mobility. Interventions included required skin inspection, observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. Interview on 09/19/23 at 1:15 pm with CNA G revealed she had worked on Resident#1's hall on 09/08/23 from 10:00 pm to Saturday 09/09/23 at 6:00 am. CNA G said while changing Resident #1's brief she noticed Resident #1 had about a two-inch dark discoloration on resident's left inner thigh. CNA G said she reported the discoloration to RN A right away at approximately 6:00 am at the end of her shift on 09/09/23. RN A came to assess Resident #1 right away. CNA G said she knew it was her responsibility to report any abnormal skin conditions to the charge nurse immediately. Interview on 09/15/23 at 4:46 pm with RN A revealed that CNA G had informed her on 09/09/23 at about 6:00 am at the end of both of their shifts, from 10:00 pm to 6:00 am that while changing the resident CNA G noticed Resident #1 had a medium size purple discoloration to the resident's left inner thigh. RN A said she was at the end of her shift and did not complete a change of condition as needed or called her Director of Nurses as needed. RN A said she did not complete the 24-hour report (computerized form) and print the general notes (24-hour report) as she should have done to communicate to incoming shift in the Resident #1's hall binder. RN A said she thought she had verbally communicated to LVN B when LVN B came into his shift on 09/09/23 regarding of the discoloration to Resident #1. RN A said LVN B was coming into his shift on 09/09/23 and she did not remember what time he came to his shift on 09/09/23. RN A said she had made a documentation on her progress notes on 09/09/23 at 6:11 a.m. Review of R#1's progress notes dated 09/09/10 at 6:11 am reflected RN A had been notified by CNA G that Resident #1 had medium dark discoloration to her inner thigh. Record review on 09/15/23 of Resident#1's clinical records revealed no change of condition had been completed or evidence in the 24-hour report. Interview on 09/15/23 at 5:22 pm with LVN B revealed he worked on Saturday 09/09/23 from 10:30 am to 7:00 pm on Resident #1's hall. LVN B said he did not recall RN A telling him that Resident #1 had a discoloration to her left inner thigh. LVN B said he did not see any change of condition or general notes (24-hour report) completed for this discoloration on Resident #1. LVN B said he had not looked at the progress notes completed by RN A for Resident #1 on 09/09/23 because he would not open the progress notes for all his residents but would look for a change of condition or general notes on the binder for Resident #1. LVN B said he did not go to monitor or assess Resident #1's discoloration because he did not know this information. LVN B said none of the CNAs working in this hall had reported anything to him. Interview on 09/15/23 at 2:00 pm with CNA J revealed she provided care to Resident #1 on Saturday 09/09/23 from 6:00 am to 2:00 pm. CNA J said she did not see any discoloration on Resident #1's left inner thigh or on her feet. CNA J said she had not provided care to Resident #1 again until 09/11/23 when she was told by CNA K that Resident #1 had left foot discolorations found on 09/10/23. Interview on 09/15/23 at 5:12 pm with CNA L said she provided care to Resident #1 on 09/09/23 from 6:00 am to 2:00 pm. CNA L said Resident #1 up did want to get up from bed during her shift. During incontinent care, she did not see if Resident #1 had a pink discoloration on her left inner thigh. CNA L said she thought that charge nurse LVN B knew about the discoloration and did not report it to LVN B. CNA L said she was off from work on 09/10/23. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked on Resident #1's hall from 7:00 pm to 10:00 pm on 09/09/23. When she came into her shift, LVN B did not mention that Resident #1 had discoloration. LVN C said she did not see a change of condition or general notes for Resident #1, so she did not monitor or assess Resident #1's discoloration on her left inner thigh. Interview on 09/15/23 at 5:52 pm with LVN F revealed she worked on Saturday 09/09/23 from 10:30 pm to 6:30 am Sunday morning. LVN F said she did not see any change of condition report or general notes (24-hour report) on Resident #1's discoloration. LVN F said she did not monitor or assess Resident #1's discoloration during her shift on 09/09/23. Interview on 09/18/23 at 2:20 pm with LVN B revealed he worked on Sunday 09/10/23 from 6:30 am to 3:00 pm and LVN C took over his shift from 3:00 pm to 10:00 pm. LVN B said he did not go monitor or assess Resident #1's left leg discoloration during this shift because he had not seen a change of condition or in the 24-hour report. Interview on 09/19/23 at 1:59 pm with CNA H revealed she said she reported to LVN C at about 9:00 pm on 09/10/23 that Resident #1 had medium dark purplish discoloration to the top of the left foot and close to the toes. The rest of the left extremity did not have any discoloration. CNA H said she had not noticed any discoloration on Resident #1's inner left inner thigh. Interview on 09/18/23 at 3:05 pm with LVN C revealed she worked from 3:00 pm to 10:00 pm on Sunday 09/10/23. LVN C said at about 9:00 pm CNA H came to report that Resident #1 had dark discoloration from her left toes up to below her knee. LVN C said she went to assess, completed a change of condition, and called Resident #1's Nurse Practitioner and got orders for an x-ray and doppler test. LVN C said she also called Resident #1's family members and was able to contact them. Record review of the x-rays for left foot report for Resident #1 dated 09/11/23 reflected no acute fracture or discoloration of the left foot, left knee, or left toes. Record review of the radiology report dated 09/11/23 for Resident #1 reflected the procedure completed was for extremity veins US-Unilateral Lower. This report reflected DVT in the left lower extremity. Interview on 09/15/23 at 11:23 am with RN D revealed Resident #1 was sent to her physician's office for evaluation of left lower extremity on 09/11/23. RN D said Resident #1 came back to facility with orders from physician. Record review of Clinical Referral (doctor's orders) for Resident #1, dated and signed by Resident #1's physician on 09/11/23 reflected resident was sent for checkup due to purple /maroon discoloration to left foot calf and inner aspect of knee-cold to touch. Unknown days with acute ischemia lower leg, unknown if femoral or popliteal, impending loss of limb. Diagnosis: acute ischemia (restriction in blood supply to any tissue, muscle group, or organ of the body causing a shortage of oxygen that is needed) with orders that included need immediate communication with family for decision on hospitalization versus hospice. Record review of Progress Note dated 09/11/23 by RN D reflected Resident # 1 came back from doctor's office with order for Eliquis (anti-coagulant used to treat and prevent blood clots and to prevent stroke) 5 mg twice of day. Interview on 09/15/23 at 11:34 am with Social Worker revealed she attempted to call Resident #1's family members on 09/12/23 and was able to reach Resident #1's family member. The Social Worker informed the family member about the physician's recommendation. Interview on 09/18/23 at 1:44 pm with RN A revealed she had not completed the change of condition form for Resident #1 on 09/09/23. She was going to clock out of her shift, and she forgot to complete the change of condition for Resident #1. RN A said after she was notified by the CAN G on 09/09/23 she went to assess the discoloration on Resident #1 and did not document any information on the assessment. RN A said she thought she had called Resident #1's Nurse Practitioner but did not get a response from the Nurse Practitioner. RN A said she did not document she had called the resident's Nurse Practitioner on any notes. RN A said she had documented on progress notes on 09/09/23 at 6:11 am that a CNA had informed her that Resident #1 had a discoloration on her left inner thigh. Interview on 09/19/2 9:39 am with Resident #1's nurse practitioner revealed she had not received any calls relating to Resident #1's change of condition on 09/09/23 or any other call during that weekend. Nurse Practitioner said the facility should have called her to report the discoloration so she could address immediately what seemed to be circulation issues on resident's left leg and provide interventions such as doppler tests or pain medications depending on the information she would have received. Interview on 09/19/23 at 2:34 pm with Resident #1's physician revealed if the staff at the facility had reported the discoloration when it was identified on 09/09/23 the progression of the occlusion of oxygen would have been addressed as soon it was identified. Resident #1's physician said after he was notified on 09/10/23 at about 9:00 pm, his office gave orders for doppler test and x-rays to address the discoloration. The tests were not able to be completed until Monday 09/11/23 and then he was able to have the resident sent to his office for evaluation. The physician said he reviewed the x-rays with negative findings of fracture and the doppler tests that indicated resident had DVT to left lower extremity. The physician said he ordered Eliquis to help prevent blood clots and waiting for Resident #1's family to be notified whether they would decide on sending Resident #1 who was [AGE] years old for amputation or to place resident in hospice while at the facility. The family member was not contacted until Tuesday 09/12/23 and the resident was sent to the hospital. The physician said there was not reversible procedure that could have been done for the resident's diagnosis of acute ischemia. Interview on 09/18/23 at 2:20 pm with LVN B revealed when an abnormal condition was identified on any resident, nurses were required to assess the concern, complete a change of condition form, call the physician, notify family members, the DON and complete progress notes and link to the 24-hour report to communicate to all staff the change of condition. Interview on 09/18/23 at 2:42 pm with the DON revealed RN A did not complete the COC form, document on the general notes (24-hour report), notify the resident's physician, notify the family members and the DON as required. The DON said when RN A identified the dark discoloration on Resident #1 on 09/09/23 at about 6:00 am, RN A should have completed the Change of Condition form, documented on the general notes (24-hour report) and called the resident's physician and also informed the DON about the discoloration on Resident #1's inner thigh. The DON said this failure placed Resident #1 of not receiving immediate care to the diagnosis of acute ischemia as per Resident #1's physician. Interview on 09/19/23 at 5:32 pm with the Administrator revealed that RN A had been terminated. Record review of the hospital records for Resident #1 reflected Resident #1 was admitted to the hospital on [DATE]. Resident presented to the emergency room for evaluation of left ischemic limb x 3 days and has gotten worse. Patient was started with Eliquis at the nursing home yesterday with improvement. Patient left leg is red and purplish, very poor circulation in the left limb. Patient was clear with significant perioperative morbidity and mortality during surgery and eventually surgery recommended amputation below the knee on the left side. Family members and patient decided on their free will to pursue conservative management and palliative care. Patient will be discharged back to nursing home. An Immediate Jeopardy was identified on 09/19/23. The Immediate Jeopardy template was provided to the facility Administrator on 09/19/23 at 6:10 pm. While the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m., the facility remained out of compliance pending approval of Plan of Correction. F726 Nursing Services Plan of Removal September 19, 2023 This plan of removal is written and submitted on behalf of in response to the citation and findings related to F726 for failure to ensure a nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident as determined by resident assessments and individual plans of care. This deficient practice was identified during complaint visit survey conducted on 09/15/2023. F726 - Nursing Services Immediate Action 1. Medical Director notified of IJ on 9-19-23. 2. Residents #1, is no longer in the facility. 3. IDT consisting of DON, MDS, Infection Preventionist, Director of Rehab, RN clinical resource to Audit all residents with skin condition, current care plan, Braden scores to identify high risk residents that may develop skin issues and verify notification to MD this will be completed on 9-19-2023. An audit of all current skin assessments will be completed to ensure issues identified have been communicated to MD and orders are in place. 4. In-service/Education begun for Licensed Nurses by DON on reporting all identified changes in condition to the Director of Nursing immediately. In-service will be completed 9/20/23. Inservice/ Education initiated with all staff on assessment and immediate intervention upon identification of any changes of condition. This will be completed on 9-19-23. Any employee not in facility will receive inservice via phone, any employee who has not received the inservice will not be allowed to work until in service has been received. In-service will be general and resident specific. 5. All clinical staff will complete competency on proper and timely assessment initiated 09/20/2023.This training and competencies will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for any PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and knowledge check. 6. All residents will have a head-to-toe assessment completed on 9/19/23, any resident identified with change of condition will have MD notified immediately and orders put in place 7. QA meeting regarding items in the IJ template completed 09/19/2023. Attendees included the Medical Director, Clinical Resource, Administrator, DON, ADON, Clinical Resources, Market Leader, and Clinical Market Leader, and included the plan of removal items and interventions. 8. The DON, ADON, QA Nurse, or Clinical Resource will verify staff competency by reviewing skin assessments and interventions, with knowledge checks with a random 5 nurses per week x 2 weeks then, a random 5 nurses every 2 weeks x 2 months then a random 5 nurses per month on going. 9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the POR included the following. Observations with the Wound Treatment Nurse/LVN on 09/16/23 revealed 6 residents identified with COC on the Skin. No further concerns were noted on these residents upon observation. Staff on interviewed from the shift of 6:00 am to 2:00 pm included six CNAs, two LVNs, one RN, one speech therapist, one ADON, and two med aides. Staff interviewed from the shift of 2:00 pm to 10:00 pm included eight CNAs, and two LVNS. Staff interviewed from the shift of 10:00 pm to 6:00 am included four CNA and three of three LVNS. All staff interviewed revealed they had been in-serviced on COC, Resident Rights, Quality of Care/Treatment, Nursing Services. Reporting, documenting, notifying and verifying the COC made. Staff interviews were conducted on 09/21/23 from 8:33 am to 3:39 pm. Reviewed In-service records dated 09/15/23, 09/16/23, 09/17/23, 09/18/23, 09/19/23 and 09/20/23 on topics: Nursing Services, Changes of Condition, Quality of Care, Resident Rights, with Validation of Topics reviewed for each staff in-serviced. The in-services reflected that all staff was trained, including housekeeping, maintenance, dietary, pending staff out on leave and new staff that would start this weekend. Reviewed Head to Toe 100% skin audits were conducted on 09/16/23 and 09/27/32. Eleven residents were identified with a Change of Condition in the areas of thick, yellow toenails, 2 of them with fungus on their toenails. A COC was completed for those 11 residents. Doctors and RP were notified, progress notes, COC forms which included SBAR (s), physician orders for treatment (also podiatrist referrals),care plans were updated, and 24-hour reports were completed. Record review of 100 % of residents Skin Audit completed on 09/19/23 after the IJ was called and no residents were found to have a new COC. Reviewed Progress Notes Summary and entered in the 24-hour report available to staff. In-services received by staff from interviews: In-services included COC, Resident Rights, Nursing Services, Quality of Care/Treatment. COC topic included, reporting incidents to charge nurses, documenting in POC for CNAs and verifying by doing follow-ups on reported incidents. LVNs/RNs training included completing COC, notify MD,RP, DON, completing Progress Notes, linking report to the 24-hour report and carrying out orders from MD if needed. The Administrator was informed the Immediate Jeopardy was removed on 09/22/23 at 11:57 a.m. 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for 1 (Resident #70) out of 7 residents reviewed for significant medication errors in that: 1. LVN H administered Potassium Chloride liquid 20 meq (milliequivalents)/15 mL (milliliters) via g-tube (gastric tube) without diluting with 4-6 ounces of water prior to administration 26 times from 03/01/23-04/25/23 2. LVN H failed to administer 5mL (milliliters) of Chlorhexidine Gluconate 0.12% solution via g-tube as ordered by physician for Resident #70 and without confirming the order with the physician prior to administering the medication 55 times from 03/03/23-04/25/23. 3. Chlorhexidine Gluconate route was administered via G-tube from 11/09/22 until 04/26/23, by facility nursing staff including the DON and the ADON without verifying the route and obtaining a physician consultation. An Immediate Jeopardy (IJ) situation was identified on 05/11/23. The IJ template was provided to the facility on [DATE] at 05:25 p.m. While the IJ was removed on 05/15/23, the facility remained out of compliance at a scope identified as isolated and a severity level of potential for minimal harm that was not immediate jeopardy due to the facility's need to complete in-service training on all staff and evaluate the effectiveness of the corrective systems. These deficient practices placed residents who receive medications administered by the facility at risk for serious injuries up to and including cardiac arrest, increased drug reactions, and decreased quality of life. The findings included: Record review of Resident #70's admission record dated 04/26/23 documented a [AGE] year-old female with an admission date of 06/17/21. Diagnoses include dysphagia (difficulty in swallowing food or liquid), cerebral infarction (a brain lesion in which a cluster of brain cells die when they do not get enough blood), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis of one side of the body following a stroke and affecting the left non-dominant side), dysarthria (difficulty in speech due to weakness of speech muscles), speech and language deficits, gastrostomy status (having a creation of an artificial external opening into the stomach for nutritional support or gastric decompression), apraxia (motor disorder caused by damage to the brain which causes difficulty with motor planning to perform tasks or movements), weakness, cognitive communication deficit (difficulties with communication), dementia (group of symptoms that affect memory, thinking, and may interfere with activities of daily life). Record review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility was unable to obtain a brief mental interview for status (BIMS) score for the resident. It also revealed Resident #70 required extensive assistance with one-person physical assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS also revealed Resident #70 had a feeding tube, received 26-50% of total calories through parenteral or tube feeding and 501 cubic centimeter (cc)/day or more of fluid intake per day by tube IV or tube feeding. Record review of Resident #70's Lab Results Report dated 03/20/23 revealed a potassium level of 4.4 mmol (millimoles)/L (liter). Reference range 3.6-5.0. Record review of Resident #70's order summary report dated 05/10/23 revealed 20 Fr (French) G-tube inserted on 11/08/22 with a discontinued date of 11/09/22. 1. Record review of Resident #70's active physician orders dated 04/26/23 documented an order for Potassium Chloride Liquid 20 meq/15 mL (10 %) with a start date of 02/03/23. Orders were as follows: Give 30 mL via g-tube one time a day for hypokalemia (low potassium). Give 30 mL to equal 40 meq; dilute with four (4) to six (6) ounces (oz.) of water. Record review of Resident #70's March and April 2023 medication administration record (MAR), revealed Potassium Chloride liquid 20 milliequivalents (meq)/15 milliliters (mL) (10%) 30 mL =40 meq was scheduled to be given at 09:00 a.m. Further record review of Resident #70's MAR revealed LVN H administered Potassium Chloride 36 times between 02/01/23 through 04/25/23. Record review of Resident # 70's MAR between February through April 2023 revealed Potassium Chloride was scheduled at 0900 a.m. Record review of Resident #70's Potassium Chloride medication bottle revealed a label with medication name and dose as follows: Potassium Chloride Oral Solution, USP 10% 20 meq (milliequivalent)/15 mL (milliliters) Dilute prior to administration. Medication bottle also contained medication label with orders as follows: Give 30 ml (milliliters) per tube 1 time daily. Label had yellow alert sticker with following alert: Do not use a salt substitute without checking with your doctor or pharmacist, (in bold) take with food and must dilute before using. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN H administered Potassium Chloride liquid 20 meq/15 mL to Resident #70 via g-tub without diluting it in 4-6 ounces of water prior to administration. An observation of Resident #70 on 04/26/23 at 08:25 a.m. revealed resident in bed with bed in lowest position, bed rails down, call light within resident reach. Resident #70 awake, alert, and unable to answer surveyor questions or make needs known. Resident in no distress at that time. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked the orders prior to administration of the Potassium Chloride. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated Potassium Chloride should not have been given without being diluted. LVN H stated she would have to verify Potassium Chloride was not pre-diluted with the DON. LVN H stated the bottle containing medication Potassium Chloride did have a yellow label that stated, must dilute before using and a manufacturer's label that stated, dilute prior to administration. Later that morning, at 10:50 a.m., LVN H revealed she had informed both the DON and the resident's physician of the medication errors. She stated both the DON and Resident #70's physician verified to her that Potassium Chloride had to be diluted. She stated Potassium Chloride's potential negative effect on the resident could include gastrointestinal irritation and a laxative effect. LVN H stated she did not initiate a change in condition, document in the computer or monitor for 72 hours but she did assess Resident #70 to make sure she was ok. An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Potassium Chloride to Resident #70 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 10:00 a.m. with DON revealed LVN H should not have given Potassium Chloride to Resident #70 without diluting the medication first. He stated, I am not going to lie, going on to state he would have to look up the negative effects or consequences because he did not know what the side effects were to Potassium Chloride. Later that morning at 11:30 a.m. the DON stated he had spoken to their own pharmacist who had confirmed to him that the nurse should have diluted Potassium Chloride prior to administering the medication to the resident. The DON provided a document from his research stating that he had found side effects of Potassium Chloride and most of the negative outcomes were GI symptoms including stomach irritation and laxative effects. Review of documentation provided by DON (no source or date) quoted in part, Potassium Chloride liquid can cause electrolyte disturbances and congested states including central and peripheral edema . Increased dilution of the solution and taking with meals may reduce gastrointestinal irritation. The most common adverse reactions to oral potassium salts are nausea, vomiting, flatulence, abdominal pain/discomfort, and diarrhea. Potassium Chloride Liquid must be completely dissolved in at least one-half glass of cold water or juice to reduce its possible stomach-irritating or laxative effect. An interview on 05/10/23 at 10:40 a.m. with LVN H revealed she had worked at the facility since 2022 and was assigned to work in Hall 1 since November 2022. LVN H stated she had cared for Resident #70 since November 2022 when Resident #70 had her G-tube placed. Prior to medication observation on 04/26/23, LVN H stated she never diluted Potassium Chloride when administering it to Resident #70. LVN H stated she did look at the orders and did look at the labels on the bottle, which included labels that indicated Potassium Chloride must be diluted. LVN H stated she corrected her medication administration after 04/26/23 and diluted it with 30 mL (milliliters) or four to five mL of water. LVN H stated she informed Resident #70's physician and DON of the medication error but failed to document in the resident's progress notes. LVN H stated the physician's response to her was that Potassium Chloride had to be diluted and that adverse effects to look for would include loose stools. 2. Record review of Resident #70's active physician orders dated 04/26/23 documented an order for Chlorhexidine Gluconate 0.12% solution with a start date of 11/09/22. Orders were as follows: Give 5 mL via g-tube after meals for gingivitis (gum disease that can cause irritation, redness and swelling of the gums/base of your teeth); rinse gums with toothbrush. Record review of Resident #70 medication administration record (MAR) revealed Chlorhexidine Gluconate 0.12% was scheduled for 09:00 a.m., 01:00 p.m., and 06:00 p.m. or after meals. Further record review of Resident #70's MAR revealed LVN H administered Chlorhexidine Gluconate 82 times between 02/01/23 through 04/25/23. Record review of Resident #70 MAR revealed Chlorhexidine Gluconate 0.12% was administered by 9 different nurses between 02/01/23 through 04/25/23 including LVN M LVN N, LVN O, LVN P, WCN W, RN Q, the ADON and the DON. Record review of Resident #70 Chlorhexidine Gluconate medication bottle revealed label as follows: Chlorhex Glu Sol 0.12 % Rinse with 5ml (milliliters) po (by mouth) after meals. Yellow alert label read as follows: keep out of reach of children, swish in mouth. Then spit. Do Not swallow. During an observation of the medication pass on 04/26/23 at 08:20 a.m., LVN H administered 5 mL of Chlorhexidine Gluconate 0.12% solution to Resident #70 via g-tube without verifying the order with the physician prior to administering the medication. An interview on 04/26/23 at 09:50 a.m. with LVN H revealed she had not checked or verified the orders prior to administration of the Chlorhexidine Gluconate 0.12%. LVN H stated she would have to inform the DON and the physician of this error. LVN H stated she would call the physician to verify the order for Chlorhexidine Gluconate because it read via g-tube, and it also read rinse mouth and gums. LVN H stated she would also clarify this order with the resident's physician because this medication was to be given oral and the consistency would have to be altered due to the resident's inability to swallow. LVN H stated Chlorhexidine Gluconate's potential negative effect on the resident could include gastric ulcers. An interview on 04/26/23 at 09:55 a.m. with RN I revealed LVN H should not have given Chlorhexidine Gluconate 0.12% to Resident #70 without diluting the medication first. She stated she did not know the negative effects or consequences. She stated she would have to look up the side effects of this medication. An interview on 04/26/23 at 09:55 a.m. with the DON, stated LVN, G should not have given Chlorhexidine Gluconate without verifying the order with the physician prior to administering the medication. The DON also stated he did not know what the negative outcomes of this medication was. He stated he would have to look up the negative effects or consequences because he did not know what the side effects to Chlorhexidine Gluconate were. An interview on 05/10/23 at 10:40 with LVN H revealed she did look at the orders prior to administering Chlorhexidine Gluconate on 04/26/23 and continued to administer it via g-tube without notifying or questioning the physician or pharmacist because it was not a new order. LVN H stated the order said, rinse gums in all caps and was using that part of the order to administer the medication. LVN H stated Chlorhexidine Gluconate was administered oral with a toothbrush and the resident was to spit it out. LVN H stated that prior to the medication observation she had administered it correctly via the oral route, however on the day of medication observation the surveyor made her nervous. LVN H stated on 04/26/23 she did notify physician and DON of the medication error with Chlorhexidine Gluconate after she had administered the medication but did not document the error in the resident's progress notes. LVN H stated she did not know what the purpose of the Chlorhexidine Gluconate was for and was not familiar with the side effects. LVN H stated she had not brought up the discrepancy in the medication administration record to the DON, the pharmacist, or the physician prior to the medication error on 04/26/23 and that she had cared for Resident #70 since November when her g-tube was placed. An interview on 05/10/23 at 11:10 a.m. with LVN M revealed he had been a nurse for 27 years, working at the facility since 2009 and assigned to Hall 1for about 4 years. LVN M stated he was familiar with Resident #70 and had administered both Potassium Chloride and Chlorhexidine Gluconate to her. LVN M stated Potassium Chloride was diluted in 4-6 ounces of water. LVN M stated the bottle for Potassium Chloride had yellow labels marked on the bottle that stated, must dilute. He stated Potassium Chloride was a supplement used for hypokalemia with potential side effects such as irritation of the stomach, nausea, and vomiting. LVN M stated Chlorhexidine Gluconate was administered orally with a toothbrush. He stated Chlorhexidine Gluconate was used for gingivitis and potential side effects were irritation of the stomach, nausea, and vomiting. LVN M stated he had not questioned the order for Chlorhexidine Gluconate to the DON, the physician, or the pharmacist because the order stated, rinse gums in all capitalized letters. LVN M stated he would report medication errors to the DON, the physician, the resident's family, initiate a change of condition, document in the resident's progress notes and monitor the resident for 72 hours. An interview on 05/10/23 at 11:30 a.m. with the DON revealed he was not aware Potassium Chloride was being administered undiluted to Resident #70 by LVN H. The DON stated LVN H was in-serviced on 04/26/23 and that a medication error report was completed on Potassium Chloride on the same day. The DON stated he also had no idea there was a discrepancy on the Chlorhexidine Gluconate order and could not say why it was not caught by other nurses administering it. The DON stated he could not say whether the nurses were looking at the order. The DON stated he was able to view the date and by whom the order for Chlorhexidine Gluconate was entered and discovered it was an order entry error. The DON stated Resident #70's orders changed from oral to g-tube, a route change, on 11/09/23 by the ADON who made an order entry error when changing the order. The DON stated the facility ensures staff are adequately trained to identify when medications are changed by performing the following: yearly check offs, trainings, and reviews performed by the pharmacy with recommended deficient practices. The DON stated the facility's record keeping system (point click care) flags changes in medications if it was an allergy, enteric coated, or if the medication was not allowed to be crushed; however, he stated Chlorhexidine is an anomaly, meaning that is a route not normally seen on that medication and that would not likely be flagged by the system. The DON stated he, the MDS nurse, and the ADON run a report in the morning on new orders, to make sure all orders are being put in correctly and discuss those new orders during morning meetings. The DON stated the report is not printed, it is only viewed on a big screen television in the conference room where everyone can view it and discuss those new orders, prior to executing them and initiating new care plans. The DON stated that when Chlorhexidine Gluconate was changed in the system, the person who changed the order should have, but did not verify the orders with the physician prior to the change. The DON also stated the nurses who administered this medication should have verified it prior to administration including the route. He stated that nurses communicate the orders during 24-hour report, therefore if there was a change to the order, the nurses would have been updated of that order during that time. The DON stated the facility distinguishes new orders from changed orders on their system because a new start date will reflect for each medication. He also stated charge nurses round every shift to ensure the new routes are observed by the staff, but that the facility does not keep a log for their rounds. In an interview on 05/10/23 at 12:00 p.m. with MD R revealed he was unaware of the medication error by LVN H of Potassium Chloride being administered to Resident #70 undiluted. MD R stated he assessed Resident #70 on 05/02/23 and at that time her potassium levels were 3.7. MD R stated he did not think this would affect the resident in the long run. MD R said he was informed of the medication error by LVN H of Chlorhexidine Gluconate being administered via g-tube on 04/26/23. MD R stated, the medication had been discontinued and although rare, may cause gastrointestinal irritation. MD R stated he had a scheduled follow up with Resident #70 in two (2) weeks. In an interview on 05/10/23 at 12:25 p.m. with LVN N revealed she had been a nurse for approximately five (5) years and employed at the facility since 07/23/18. LVN N stated she held a PRN position at the facility and worked in Hall 1 as needed. LVN N stated she worked nights and evenings and worked there the previous Sunday taking care of Resident #70. LVN N stated she had administered medications to Resident #70, including Chlorhexidine Gluconate. LVN N stated she administered Chlorhexidine Gluconate by mouth and was used to treat gingivitis. LVN N stated Resident #70 used to be able to take medications by mouth prior to being transitioned to g-tube, but she never administered this medication via g-tube. LVN N stated she did not know the side effects of Chlorhexidine Gluconate if ingested. She stated side effects including dry mouth and tongue staining. LVN N stated if a medication error occurred she would initiate a change in condition, monitor resident, check vital signs and mental status. In an interview on 05/10/23 at 12:35 p.m. with LVN O revealed he had been a nurse for approximately twelve (12) years and employed at the facility since 05/18/21. LVN O stated he had worked in Hall 1 for about 2 years and cared for Resident #70. LVN O stated he had administered medications to Resident #70 including Chlorhexidine Gluconate. LVN O stated he had administered Chlorhexidine Gluconate by mouth as an oral rinse and had resident spit out. He stated, it was never given via g-tube, although, the order entailed giving via g-tube, it specified oral. LVN O further stated, knowing it was mouth wash, I stuck to oral route and explained it was for gingivitis. LVN O stated he did not know the side effects of Chlorhexidine Gluconate if ingested but listed browning of teeth as a side effect. LVN O stated medication errors are documented and reported to the DON. He stated nurses are to follow the instruction of the DON, file an incident report, inform the physician and the resident representative, monitor the resident for side effects after ingestion of the medication. LVN O further went on to state he was unaware of the exact process to follow for medication error. In an interview on 05/11/23 at 10: 50 a.m. with RPH S revealed he reviewed all medications for residents at the facility monthly. RPH S stated he did recommendations to the facility or the physician via the facility staff through a written letter to clarify any discrepancy on any order(s). RPH S was unable to provide any other information on Resident #70 or the orders at the time of the call. No other attempts to return surveyor's calls were made. In an interview on 05/11/23 at 02:00 p.m. with MD R revealed he was not aware there was a discrepancy for the order Chlorhexidine Gluconate for Resident # 70 beginning 11/08/22. MD R stated he was notified of the medication error in April 2023. MD R stated, it would be a good idea to have a plan or project for the nurses at the facility to be more aware. MD R stated there should be a plan, to avoid these problems in the future. MD R stated, brainstorming a plan to prevent this from happening again because he, was concerned. MD R stated that any medication that could be given through the mouth could be given through the PEG (percutaneous endoscopic gastrostomy) tube and was not sure what medications could cause that type of negative consequences. MD R stated there were concerns and the facility needed to have a corrected plan of some sort in place to avoid for this to happen again. In an interview on 05/11/23 at 02:30 p.m. with LVN P revealed she had been a nurse for approximately four (4) years and employed with the facility since 12/15/20. LVN P stated she helped cover the floor on occasion and had administered medications including Potassium Chloride and Chlorhexidine Gluconate to Resident #70. LVN P stated nurses are always in a hurry and they use their common sense and we think everyone is going to be like that and apparently it is not like that. LVN P stated if she sees a discrepancy in a medication, she investigated the correct route and what the medication is for. LVN P stated she looked at progress notes and asked the DON or the ADON for clarification of the information. LVN P stated medication errors are caught on admission or when physicians send new orders. LVN P stated nurses should notify the DON or ADON or medication errors and documented right away. She stated that nurses are supposed to follow the protocol. Interview on 05/11/23 at 02:45 p.m. with RN Q revealed she had been a nurse for approximately 30 years and been employed at the facility since 04/17/02. RN Q stated she helped cover Hall 1 and administered medications to Resident #70. RN Q stated she administered Chlorhexidine Gluconate with a toothbrush orally. RN Q stated she did not question the order for Chlorhexidine Gluconate because she was just covering and it slipped her mind. RNQ stated she knows it is a mouth administered medication. She stated she did not remember informing the ADON or the DON of the discrepancy. RN Q stated she is supposed to inform the ADON or the DON and the physician is supposed to be informed too. RN Q stated she is supposed to call the pharmacist and clarify the discrepancy with the physician. RN Q stated Chlorhexidine Gluconate is used to cleanse the mouth for oral candidiasis and if she does not know what the medication is for, she googles, calls the pharmacy or the doctor. RN Q stated, nurses have to read the EMAR (electronic medication administration record) and use their nursing judgment. RN Q stated negative consequences depend on the dosage; however, the resident must be observed and the error must be reported to the doctor at once. RN Q further stated nurses should, tell the DON of the error, monitor the resident, inform the resident representative. RN Q stated medication errors can be a negative consequence, every resident can have a different reaction to medications. Interview on 05/11/23 at 03:00 p.m. with ADON revealed she changed all the orders from oral to g-tube in November 2023. The ADON stated she informed the Nurse Practitioner who was rounding for MD R when Resident #70 had the G-tube inserted and needed her medications to be changed from oral to G-tube that Resident #70 needed her medications orders changed. ADON received a verbal ok from the Nurse Practitioner to change the orders from oral to G-tube. The ADON stated she proceeded to do a batch update conversion on their computer system that changed all medication orders from oral route to g-tube route. The ADON stated the physician was notified and he signed off on all orders after all updates are made. The ADON stated none of the nurses who administered Chlorhexidine Gluconate notified her there was a discrepancy in the order. The ADON stated staff do look at the orders but not one by one individually. The ADON stated nurses who questioned the ordered could have changed it without having to notify the physician. The ADON stated nurses did not have to call the physician and notify him because he would have replied, why are you calling me, just change it, common sense. The ADON stated she did not realize the discrepancy when administering the medication to Resident #70. The ADON stated she, cannot compare, judge or say and depends on the situation if it would have been a different medication with more serious consequences. The ADON stated, if nurses do not know what a medication is they have a PDR (physician's desk reference), can call the pharmacy or google the medication in question. In an interview on 05/11/23 at 03:15 p.m. with the DON revealed Chlorhexidine Gluconate was changed from oral to g-tube since November 2022. The DON stated there were approximately nine to eleven nurses including himself and the ADON who administered this medication to Resident #70 with an incorrect order between February 2023 through April 2023 when the medication error was observed. The DON stated nurses should have notified the physician. The DON stated the medication error should have been documented in a progress note. The DON also stated a progress note was needed to document the correction of route clarified by the nurse. The DON stated that none of the nurses who administered this medication questioned the order or notified him of the discrepancy. The DON stated he is unsure why the nurses did not question the order or notify him of this discrepancy. The DON stated he did not notice the order when he did his own medication pass for Resident #70. The DON stated when he saw the order he saw mouth wash and I know what I need to do. The DON stated he should have changed the order immediately upon identifying the discrepancy. He stated he should have questioned the staff to verify the route they had been giving the medication. The DON could not state how often the medication got restocked/refilled. He stated, this was an oversight, we all missed it. The DON further went on to state I see the clerical mistake, except nurses were giving it the right route. The DON stated, it would be speculation on his part if he stated it could have been a more serious medication and he would not be able to tell if there would be any negative consequences from that. In an interview on 05/11/23 at 03:25 p.m. with the Administrator revealed this discrepancy could have affected Resident #70 as well as other residents at the facility. The Administrator stated nurses must review the medications. The Administrator stated negative consequences depend on the medication that is being given. Record review of document provided by the DON, signed, and dated by LVN H on 06/21/22, titled, Skills competency checklist-Enteral Med Pass, quoted in part, Nurse verifies medication & strength with order as prescribed .medication errors are reported to supervisor. Record review of facility policy and procedures titled Medication Administration (no date), revealed Medication Administration-Oral: It is the policy of this facility to accurately prepare. Administer and document oral medications: Procedures: Preparing Liquid Medications: 3. Read medication card. 4. Read the label on the bottle as it is removed from the shelf and check label with medication card. 5. Read the label again prior to pouring the drug. 7. Read label before returning bottle to the shelf. 8. Verify with medication card as drug is placed on medication tray. Essential points: 8. If there is any question regarding dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage. Review of a facility policy titled Medication Administration via Feeding Tube dated 1/ 2022, quoted in part: A physician's order is required for the administration for the administration of any medication via feeding tube. Liquid dosage forms should be ordered if available . To ensure that medications administered via feeding tube are administered safely and accurately .Guidelines: 2 .The order must specify the medication, dose route (tube), frequency, and volume of water to be administered with the medication. The amount of water used to flush, mix, and administer the medication must be considered when calculating the total free water prescribed by the physician .Procedure: 1 .Confirm physician's order. Review of facility policy titled Pharmacy Services dated 08/2007 with a revision date 12/2019; 01/2022, quoted in part, It is the policy of this facility that medication errors and adverse drug reactions must be reported to the resident's attending physician .1. Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. Review of facility policy titled Nursing Services, Physician Orders, dated 05/2021 with a reviewed date 08/2021; 08/2022, quoted in part, It is the policy of this facility that verbal/written/electronic orders for changes in medications including routes will be written upon receipt from Physician/Designee .orders for medications must include .right route of administration if other than oral. Record review of [NAME] Advisor, https://advisor.lww.com/lna/document.do?bid=6&did=1232821&searchTerm=potassium%20chloride&hits=potassium,chloride, quoted in part, Potassium supplements .Administration .Give with meals and a full glass of water or other liquid to minimize GI (gastrointestinal irritation) . Adverse reactions .GI: nausea, vomiting, abdominal pain, diarrhea, flatulence .Nursing considerations . Patients at increased risk for GI lesions when taking oral potassium include those with scleroderma, diabetes, mitral valve replacement, cardiomegaly, or esophageal strictures, and older adults or patients who are immobile. Record review of https://www.drugs.com/mtm/chlorhexidine-gluconate-oral-rinse.html, Chlorhexidine Gluconate quoted in part, may cause serious allergic reaction that may be life-threatening . do not swallow the mouthwash .an overdose of chlorhexidine would occur only if the medicine were swallowed .overdose symptoms may include nausea, stomach pain, or the appearance of being drunk .can cause a rare but serious allergic reaction that may be life-threatening. Get emergency medical help if you have any of these signs of an allergic reaction: hives, severe skin rash, wheezing, difficulty breathing, cold sweats, feeling l[TRUNCATED]