**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure staff ordered and administered Resident #1's antibiotic medication when he returned from the hospital on [DATE] after being diagnosed with sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs) from a prostate infection. Resident #1 was sent back to the hospital by EMS on 03/22/25 due to no improvement in his condition. Resident #1 was readmitted to the hospital and diagnosed with Severe Sepsis. An IJ was identified on 05/02/25. The IJ template was provided to the facility on [DATE] at 6:15 p.m. While the IJ was removed on 05/03/25, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of further decline, infection, dehydration, and hospitalization. Findings include: Review of Resident #1's admission Record, dated 05/02/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #1 had diagnoses including mild cognitive impairment, generalized muscle weakness, hemorrhage (loss of blood from blood vessels) of anus and rectum, type 2 diabetes mellitus without complications, and acute respiratory failure with hypoxia (a serious condition where the lungs are unable to deliver enough oxygen to the blood). Review of Resident #1's admission and Modified MDS, dated [DATE], reflected he had a BIMS score of 10, which indicated he had moderate cognitive impairment. Resident #1's MDS assessments did not indicate that he had any infections and taking any high risk antibiotics during the last seven days or since admission/entry. Resident #1 required partial/moderate assistance with toileting. Resident #1 was always incontinent with urinary and bowel movements. Review of Resident #1's Care Plan, initiated 01/22/25, reflected he required 2-person assistance with all care and ADLs. Resident #1 had an ADL self-care performance deficit and required CNAs to assist him with using the toilet. Resident #1 also had bladder incontinence and required CNAs to provide incontinent care at least every two hours and report to the charge nurse any foul smelling urine or if the urine was any color other than yellow. Review of Resident #1's Progress Notes reflected: -A transfer notification note by LVN A on 03/17/25 at 9:41 a.m., [Resident #1] was transferred to the hospital on [DATE] 9:41 a.m. related to AMS. -A nursing progress note by LVN A on 03/18/25 at 10:33 a.m., Spoke with [Nurse] at hospital and the admitting dx is AMS for resident. Review of the facility's copy of Resident #1's Hospital Visit and Discharge Summary and Orders, printed on 03/18/25 at 12:39 p.m., reflected he was admitted to the hospital on [DATE] at 11:04 a.m. with a primary diagnosis and chief complaint of altered mental status. Resident #1 also had diagnoses including chronic prostate cancer (a type of cancer that develops in the prostate gland, a walnut-sized organ in the male reproductive system located below the bladder, which can persist and affect a person's health for many years) and chronic prostatitis (a long-lasting inflammation of the prostate gland, typically lasting three months or more). Resident #1's hospital evaluation reflected he met the systemic inflammatory response syndrome criteria (a set of objective findings that indicate a systemic inflammatory response to an insult, whether it's an infection or a non-infectious event) with intermittent tachycardia (a heart rate that is faster than normal) and tachypnea (a rapid shallow breathing in which the respiratory rate exceeds the normal range for a person's age) with a mildly elevated white blood cell count at 11.8 during his labs on 03/17/25 at 11:26 a.m. Resident #1's Assessment and Plan reflected he had a differential diagnosis of urosepsis (when a urinary tract infection leads to sepsis) during his AMS assessment, sepsis of chronic prostatitis (inflammation or infection in the prostate) in which his prostate was markedly enlarged and tender on examination and was required to take Ciprofloxacin IV twice a day for four weeks through 04/18/25 that was converting to by mouth on hospital discharge. Resident #1's medications changed and he was required to start taking one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Resident #1 was required to take antibiotics exactly as prescribed, not to skip doses and not stop taking antibiotics even if he felt better. Resident #1's vitals were stabilized, he was awake, alert and oriented, his next dose of one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily was due on 03/18/25, and he was discharged back to the facility on [DATE]. Review of Resident #1's readmission Nurse's Note, effective 03/18/25 at 6:04 p.m. and signed by RN B on 03/18/25, reflected: readmitted from the hospital or ER visit: Yes. Arrived by: EMS. Does the resident have IV access: No. Bowel Control: Incontinent. Date of last BM: 03/18/25. Urine Control: Incontinent. Additional Information: Incontinent=Briefs. Toileting: 1-person assistance. Review of Resident #1's continued Progress Notes reflected: -A nursing note by RN B on 03/18/25 at 6:04 p.m., readmission Note: readmitted /returned from the hospital .Arrived by: EMS .Accompanied by FAM .Incontinent. Date of last BM: 03/18/25. Urine Control: Incontinent. Urinary observations: No negative findings. Additional Urinary information: incontinent=briefs .ADL Assistance needed: .Toileting - 1 person assist .Behaviors: No known behaviors. -A nursing note by RN B on 03/18/25 at 6:14 p.m., RN C on 03/19/25 at 1:06 a.m., RN B on 03/19/25 at 6:33 p.m., RN C on 03/20/25 at 12:20 a.m., RN B on 03/20/25 at 4:21 p.m., LVN D on 03/21/25 at 1:49 a.m., LVN E on 03/21/25 at 3:22 p.m., LVN D on 03/22/25 at 1:30 a.m., LVN A on 03/22/25 at 11:22 a.m., and LVN F on 03/22/25 at 3:03 p.m., reflected, Skilled Nurse Note: Interventions/Treatments Received Post admission -. Staff did not document any interventions/treatments that Resident #1 was to receive on readmission. Review of Resident #1's Order Summary Report, January - May 2025, reflected there were no orders listed regarding his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's Medication Administration Record for March 2025 reflected there were no administrations listed regarding his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's Discharge MDS, dated [DATE], reflected there was no BIMS score indicated. Resident #1 was not triggered for any infections and taking any high risk antibiotics during the last seven days or since admission/entry. Resident #1 required partial/moderate assistance with toileting. Resident #1 was always incontinent with urinary and bowel movements. Resident #1 had an unplanned discharge to a short-term hospital. Review of Resident #1's e-Transfer form, effective on 03/22/25 at 8:29 p.m. and signed by LVN F on 03/22/25, reflected, [Resident #1] was hospitalized earlier in the week for sepsis. FAM felt he was not improving and needed fluids and requested that he be sent out by EMS. Date and Time of Transfer: 03/22/25 at 4:40 p.m. Incontinence: .Date of last BM: 03/22/25. Review of Resident #1's continued Progress Notes reflected: -A transfer notification note by LVN F on 03/22/25 at 8:29 p.m., [Resident #1] was transferred to a hospital on [DATE] at 4:40 p.m. related to resident was hospitalized earlier in the week for sepsis. [Resident #1's] FAM felt he was not improving and needed fluids and requested that he be sent out by EMS Review of the facility's admission and Discharge Report, from 03/01/25 through 05/02/25, reflected Resident #1 was transferred to an acute care hospital on [DATE]. Review of Resident #1's Hospital Records, printed on 05/05/25 at 4:34 p.m., reflected he was admitted to the hospital from [DATE] through 03/25/25. Resident #1's medication list prior to admission, reviewed by a hospital MD on 03/22/25 at 9:55 p.m., reflected his Ciprofloxacin HCI 500 MG tablet order was authorized, ordered and started on 03/18/25 and was discontinued on 03/25/25. Emergency department provider notes, dated 03/22/25 at 5:58 p.m., reflected Resident #1 presented with a chief complaint of weakness and an evaluation of sepsis with an onset on 03/17/25 and EMS reported he was recently discharged on 03/17/25, hospitalized due to sepsis and prostate infection, and the facility was supposed to give and did not give his one 500 MG tablet of Ciprofloxacin HCI by mouth two times daily (one tablet in the morning and one tablet at bedtime) for the inflammation of his prostate gland. Review of Resident #1's systems reflected his genitourinary (the organs involved in both reproduction and urination) was positive for hesitancy (delay in initiating urination). Sepsis Care Summary reflected severe sepsis was identified and present on 03/22/25 at 7:00 p.m. on the day of Resident #1's hospital evaluation. Emergency Department Course reflected on 03/22/25 at 7:31 p.m., C-reactive protein (protein produced by the liver in response to inflammation) is very high at 317.1, lactic acid is elevated at 2.5 .complete blood cell count is elevated, white blood cell count 12.3 not unexpected given that [Resident #1] had not been receiving his antibiotics for his prostatitis .admission IV antibiotics ordered. Resident #1's labs reflected his white blood cell count was 11.8 on 03/17/25 at 11:26 a.m., 9.4 on 03/18/25 at 5:38 a.m., and 12.3 on 03/22/25 at 6:18 p.m. Resident #1 stayed at the hospital for two days based on medical necessity for sepsis and discharged on 03/25/25. Emergency Department note, dated 03/22/25 at 5:16 p.m., reflected, [Resident #1] was discharged from [hospital] on Monday (03/17/25) after being diagnosed with sepsis from a prostate infection. [Resident #1] was supposed to be on antibiotics, but [facility] did not order them. 20G IV left forearm with normal saline bolus. FAM stated [Resident #1] had declined since being discharged back to [facility]. Another Emergency Department note, dated 03/22/25 at 7:55 p.m., reflected, discharged from [hospital] last Monday (03/17/25), sent to [facility]. Per emergency medical services, [Resident #1] has not received prescribed antibiotic since discharge .[Resident #1] reports lethargy (a state of abnormal drowsiness or lack of mental alertness and energy) and feeling weak. 20g to left forearm, received 800 mL normal saline en route. Resident #1's Medical History and Physical reflected he was admitted to the hospital for systemic inflammatory response syndrome/sepsis. Resident #1's History of Present Illness reflected, [Resident #1] had a past medical history significant for metastatic prostate cancer to bone .presents with worsening mental status, lethargy, fatigue, confusion .was recently discharged here 03/18/25 after a similar presentation with what felt to be a component of chronic prostatitis, poly pharmacy (the regular use of 5 or more medications at the same time). Unfortunately, he has not received any antibiotic. Resident #1's Hospital Course reflected, [Resident #1] presented from facility for worsening mental status, lethargy, fatigue, confusion .He was admitted for Sepsis and Metabolic Encephalopathy (a change in how the brain works due to an underlying condition) due to Chronic Prostatitis in the setting of suspected medication noncompliance and progression of his metastatic prostate cancer. Unfortunately, FAM stated he had not received any of his prescribed antibiotics at facility. Per previous documentation, [Resident #1] was correctly prescribed his Ciprofloxacin regimen x 6 weeks and sent to the proper facility pharmacy. Receipt was confirmed by pharmacy on this hospitalization. Facility was contacted and stated the had the proper documentation and admitted to providing the correct antibiotic regimen. On admission, he was found to be septic. Urinalysis indicated of infection. He was started on empiric antibiotics (the use of antibiotics before the specific bacteria causing an infection is identified and its susceptibility to different antibiotics is known) and IVF . He had some improvement in his mental status and lab work. Family ultimately wanted to honor [Resident #1's] wishes and decided to pursue a comfort pathway due to his progressive metastatic prostate cancer. [Resident #1] remained medically stable and discharged on home hospice. Disposition reflected Resident #1 went home with hospice. During an interview on 05/02/25 at 12:43 p.m., MA G stated MAs and nurses were responsible for administering medications to residents. MA G stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. MA G stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders and said, It is very important to put the orders in the MAR because the medications were ordered from the hospital. The orders were to treat the resident for a reason. To untreat could worsen their conditions. MA G stated she knew the importance of residents receiving their antibiotics and said, Residents could have worsening infections if they did not receive their antibiotics. MA G stated she could not recall if Resident #1 was given antibiotics for infections during his readmission to the facility . During an interview on 05/02/25 at 1:11 p.m., CNA H stated MAs and nurses were responsible for administering medications to residents. CNA H stated the charge nurses or DON were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CNA H stated there were no residents who reported they did not receive their medications. During an interview on 05/02/25 at 1:22 p.m., CN stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CN said, Usually, the nurses would obtain the hospital discharge orders the same day the resident returned from the hospital or in the following 24 hours. CN stated she did not know what happened with Resident #1's hospital discharge orders on 03/18/25, who reviewed and was supposed to order Resident #1's hospital discharge medication orders during his readmission on [DATE], and where the breakdowns were that resulted in him not getting the medication from 03/18/25 through 03/22/25. During an interview on 05/02/25 at 1:27 p.m., CNA I stated MAs and nurses were responsible for administering medications to residents. CNA I stated the charge nurses or DON were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. CNA I stated there were no residents who reported they did not receive their medications. During an interview on 05/02/25 at 1:38 p.m., FAM stated Resident #1 had an inactive prostate cancer before his admission to the facility. FAM stated Resident #1 resided at the facility for two and a half months. FAM stated Resident #1 went to the hospital on [DATE] for AMS. FAM stated Resident #1 was diagnosed with sepsis and a prostate infection. FAM stated the hospital staff wanted Resident #1 to take Ciprofloxacin for his prostate infection. FAM stated Resident #1 returned to the facility from the hospital on [DATE]. FAM stated EMS provided the facility staff with the hospital discharge orders on 03/18/25. FAM stated Resident #1 did not notify her that he did not receive his Ciprofloxacin order during his readmission to the facility. FAM stated she believed Resident #1's Ciprofloxacin order for his prostate infection should have been started and administered to him from 03/18/25 through 03/22/25. FAM stated Resident #1 not receiving his Ciprofloxacin order for his prostate infection was negligent. FAM stated the facility staff did not notify her that Resident #1 was not receiving his Ciprofloxacin order from 03/18/25 through 03/22/25. FAM stated she requested the facility staff to send Resident #1 to the hospital on [DATE]. FAM stated she believed she should not have had to send Resident #1 to the hospital on [DATE]. FAM stated she believed Resident #1's lack of antibiotics could have pushed him closer towards his death because he was already declining. During an interview on 05/02/25 at 2:24 p.m., RN B stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. RN B stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, You got to see the changes in residents' orders. What was changed, ordered, discontinued, appointments, and numerous other things. RN B stated she knew the importance of residents receiving their antibiotics and said, So whatever infection residents have could be cured. RN B stated she knew the importance of reviewing residents' hospital discharge orders, updating their orders, antibiotics orders, and said, Residents could face a delay of antibiotics if they did not receive their antibiotics orders. RN B stated she could not recall if she reviewed Resident #1's hospital discharge orders during his readmission to the facility on [DATE] and she would have to see his hospital discharge paperwork to remember. RN B stated she knew Resident #1's discharge orders should have been updated before he came back to the facility from the hospital on [DATE]. RN B stated the ADON or DON oversaw to ensure charge nurses reviewed residents' hospital discharge orders and updated residents' orders in their EHR upon residents' readmission to the facility. RN B stated charge nurses were also responsible for notifying the physician of any medication changes. RN B stated she could not recall if she notified the physician about Resident #1's hospital discharge orders if she did review his discharge orders. During an interview on 05/02/25 at 2:58 p.m., LVN F stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. LVN F stated charge nurses were also required to notify the physician and discuss with the ADON and/or DON whenever there were new medications to be started on the hospital discharge orders. LVN F stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, First and foremost, the medication changes. If something needs to be started, it needs to be ordered to get it started. Resident could decline very fast, especially when they have sepsis. LVN F stated she did not readmit Resident #1 to the facility on [DATE]. LVN F stated she caught that Resident #1's antibiotic discharge order from the hospital was not ordered. LVN F stated she could not recall when she observed Resident #1's antibiotic discharge order was not ordered. LVN F stated she notified the former DON and current MD on an unknown date about Resident #1's antibiotic discharge order from the hospital not being ordered. LVN F stated she discussed with FAM about her not administering any antibiotics to Resident #1 that were prescribed from the hospital on an unknown date. LVN F stated FAM wanted to send Resident #1 to the hospital ER on [DATE] due to him missing several days of antibiotics and he still had sepsis. LVN F stated she agreed with FAM and sent Resident #1 to the hospital on [DATE]. During an interview on 05/02/25 at 3:07 p.m., the DON stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' new orders as soon as residents readmit to the facility. The DON stated there was no ADON. The DON stated she was responsible for overseeing and reviewing residents' discharge orders to ensure residents' orders were entered in their EHR within 48 hours of readmission. The DON stated she began her employment with the facility on 03/17/25 and did not have access to residents' EHR until the end of March 2025. The DON stated she did not believe there was an interim staff member who was overseeing residents' admission/readmission process during the time she did not have EHR access. The DON stated she was unsure if she went back and reviewed residents who were admitted /readmitted to the facility from 03/17/25 through 03/31/25 after obtaining EHR access. The DON stated she did not in-service staff on the admission/readmission process and medication order process from 03/17/25 through 05/02/25. The DON stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, So residents get medications that were prescribed to them. The DON stated charge nurses were also responsible for notifying the MD whenever residents had new medication orders from the hospital. The DON stated she knew the importance of antibiotics and said, Antibiotics were to get rid of infections. The DON stated she knew the importance of residents receiving their antibiotic medication and said, Residents could get sicker, end up in the hospital and get sepsis. The DON stated she was not notified about Resident #1's medication changes when he returned from the hospital on [DATE]. The DON stated she did not know why Resident #1 went back to the hospital on [DATE]. During an interview on 05/02/25 at 3:30 p.m., the MD stated nurses were responsible for obtaining and reviewing residents' hospital discharge orders and notifying her whenever there were changes in residents' medications upon their readmission to the facility from the hospital. The MD stated she knew the importance of antibiotics and said, Antibiotics were used to mainly treat and prevent infections. The MD stated she knew the importance of residents receiving their antibiotics and said, They could have burning urination, urgency, and it could exacerbate infection if they did not receive their antibiotics. The MD stated Resident #1 had an inactive prostate cancer when he was admitted to the facility. The MD said, [Resident #1] went from being alright to not doing well at the facility. The MD stated unknown facility staff notified her on unknown date that there was a mix-up with some of Resident #1's medications that did not get ordered after his readmission to the facility on [DATE]. The MD stated she believed the unknown facility staff told her that one of the pages to Resident #1's hospital discharge orders, which illustrated his medication changes, was missing. The surveyor showed to the MD Resident #1's hospital discharge orders provided to the facility from EMS on 03/18/25. The MD stated the unknown facility staff notified her on 03/22/25 that they found the missing page and that Resident #1 was supposed to be started on a few medications when he returned from the hospital. The MD stated she believed one of Resident #1's medications that was supposed to be started on 03/18/25 was an antibiotic. The MD stated the unknown facility staff notified her on an unknown date that Resident #1's Ciprofloxacin medication was not started on 03/18/25 and could not recall the reason she was provided as to why the medication was not started. The MD stated FAM could not decide what treatment she wanted Resident #1 to have and decided to send him to the hospital on [DATE]. The MD stated the unknown facility staff notified her on an unknown date that that Resident #1 was placed on hospice services and sent home from the hospital on an unknown date. During an interview on 05/05/25 at 10:02 a.m., FAM stated a Hospitalist called the unknown facility staff on an unknown date and was told by the facility staff that Resident #1 received his antibiotic medication. During an interview on 05/06/25 at 11:33 a.m., LVN E stated charge nurses were responsible for obtaining and reviewing residents' hospital discharge orders and updating residents' orders when residents readmit to the facility. LVN E stated she would review the residents' hospital discharge orders, put in the orders into the residents' order summary report, which would directly go to the facility's pharmacy, and notify the MD within 24 hours of any medication changes. LVN E stated the DON oversaw to ensure charge nurses reviewed residents' hospital discharge orders and updated residents' orders in their EHR upon residents' readmission to the facility daily. LVN E stated she knew the importance of reviewing residents' hospital discharge orders, updating readmitted residents' orders, and said, We have to maintain resident's continuation of care from the hospital. Very important. LVN E stated she was in-serviced on admission/readmission process a few months ago by the former DON. LVN E stated she learned the hospital orders must be reviewed, updated in residents' EHR, and completed upon residents' readmission to the facility from the hospital. LVN E stated she did not readmit Resident #1 to the facility on [DATE]. LVN E stated she knew the importance of antibiotic medication, residents receiving their antibiotic medication, and said, To get rid of infection. Residents could get worse if they did not receive their antibiotic medication. LVN E stated she could not recall administering Resident #1's Ciprofloxacin medication to his because she did not believe she was assigned to his hallway. LVN E stated she was not notified that Resident #1 did not receive his Ciprofloxacin medication before the surveyor visited the facility on 05/02/25. Review of the facility's in-services, from 03/01/25 through 05/02/25 , reflected no in-services related to admission/readmission process and medication orders process. Review of the facility's Medication Orders policy, dated 2003, reflected, Procedure: 2. Documentation of the medication order A. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheets (if it is a verbal order) and the Medication Administration Record (MAR). B. The following steps are initiated to complete documentation: -Clarify the order -Enter the orders on the medication order and receipt record -Call (or fax) the medication order to the provider pharmacy -Transcribe newly prescribed medications on the MAR or treatment record. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing A DISCONTINUED on the MAR. Enter the new order on the MAR as a separate entry with arrows drawn to the start date. 3. Specific Procedures for the four types of medication orders A. NEW HANDWRITTEN ORDERS signed by the prescriber. The charge nurse on duty at the time the order is received, notes the order and enters it on the physician order sheet if not written there by the prescriber. If necessary, the order is clarified before the prescriber leaves the nursing station whenever possible. C. WRITTEN TRANSFER ORDERS (SENT WITH A RESIDENT BY A HOSPITAL OR OTHER HEALTH CARE FACILITY). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature. Example: A Order verified by phone with Dr. [NAME]/M. [NAME], R.N. Review of the facility's Admission/readmission policy, dated 2003, reflected, readmission to a facility occurs after a hospitalization or therapeutic leave. readmission involves a review of the initial admission data with reinforcement where needed and an update of information regarding health status. Procedure: 2. Review the medical diagnoses and physician orders. admission orders should include as applicable: .orders for medications (prn orders will state specific use), orders for treatments, code status, and other orders as specified by the physician. 3. Inquire about any immediate needs and facilitate handling of those needs. This failure resulted in the identification of an IJ on 05/02/25. The ADM was notified and provided with the IJ template on 05/02/25 at 6:15 p.m. The following Plan of Removal was submitted by the facility and accepted on 05/03/25 at 12:52 p.m.: On 05/02/2025 an abbreviated survey was initiated at the facility. On 05/02/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure Resident #1 received his antibiotic medication from 03/18/25 through 03/22/25. Plan of Removal 1. Resident #1 no longer resides in the facility as of 5/2/25. 2. Action: A 100% audit of all orders from residents who were admitted or readmitted in the last 30 days was completed to ensure all orders including antibiotic orders were transcribed in PCC and started as ordered. All residents who were admitted and readmitted in the last 30 days were assessed for a change in condition. No additional findings were identified. Start Date: 05/02/2025 Completion Date: 05/02/2025 Responsible: This audit was completed by DON and Regional Compliance Nurse 3. Inservice Action (Leadership): The Administrator and DON were in-serviced 1:1 on following topics. o Abuse and Neglect: Failure to transcribe and administered an ordered medication including antibiotics could cause a change in condition and be considered neglect. o Medication Reconciliation Policy: transcribing orders for admission and readmissions o Following Physician Orders Policy o Notification of Change in Condition Policy Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained. Start Date: 05/02/2025 Completion Date: 05/02/2025 Responsible: This in-service was completed by Area Director of Operations and Regional Compliance Nurse 4. Inservice Action (All Direct Care Staff): All direct care staff (CNAs, Med Aides, Licensed Nurses) were in-serviced on the following topics. All staff who are not present for in-servicing will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (1) of ten (10) residents reviewed for behavioral health services. (Resident #1) The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. On 09/30/24 the MD ordered psychological services to evaluate and treat Resident #1, no mental health interventions were received, and she was discharged to a BHH seven days later. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/17/25 at 1:18 PM. While the IJ was removed on 01/18/2025 at 2:54 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents who had documented signs and symptoms of mental health disturbance. Findings Included: Review of Resident #1's face sheet dated 01/02/25 reflected an [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, mild with mood disturbance, sepsis, UTI, (bacterial infection that occurs in the urinary tract and encounter for surgical aftercare following surgery on the genitourinary (urinary and genital organs) system. Review of Resident #1 discharge document, dated 10/07/24 reflected, resident discharged to [BHH] facility for eval and treatment. Primary diagnosis, UTI Sepsis , course of treatment skilled services pt, ot, st Review of Resident #1's care plan focus initiated 09/15/24 reflected the resident has a history of trauma that may have a negative impact. The trauma is related to history of event of removal of fecal impaction. Resident alleges that a [NAME] comes into her room at night and takes pictures of her buttocks. Goal dated 10/04/24 maintain resident's safety and integrity during post trauma episode using appropriate interventions. Interventions: Date initiated 09/15/24 identify situation/events/images that trigger recollection of traumatic event and limit the resident's exposure to these as much as possible. Date 10/04/24 arrange to licensed mental health provider as ordered by physician Review of Resident #1's BIMS assessment dated [DATE] reflected a BIMS score of 9, moderate cognitive impairment. Review of Resident #1's Discharge MDS dated [DATE] reflected discharge assessment, return not anticipated, type of discharge - planned, discharge status short term general hospital (acute hospital), MDS score of 7 indicating severe cognitive impairment, evidence of an acute change in mental status of resident's baseline, disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), behavior - delusions, utilized a manual wheelchair, urinary and bowel incontinence - always incontinent. Chronological Review of Resident #1's EMR revealed: Review of standard medication order signed by the MD dated 08/16/24 reflected medication Escitalopram by mouth 1 tablet one time a day for depression related to depression, unspecified. Review of Treatment Administration Order signed by the MD dated 08/16/24 reflected behavior monitoring including hallucinations/paranoid delusion. 09/30/24 12:22 pm called RP to discuss resident concern; no answer and no voicemail activated; will try again this date. 09/20/24 4:43 pm called RP to discuss resident concern; no response; sent email to RP requesting communication. Review of Resident #1 standing order dated 09/30/24 signed by the facility medical director for psychological services to evaluate and treat one time only related to dementia in other diseases, mild with mood disturbance for 1 day. 10/01/24 9:19 am This nurse called RP for verbal consent to have [psychological services] see resident for incident on 9-30-24. no answer received. will inform DON 10/01/24 1:11 pm 2nd attempt made to contact RP, no answer and unable to leave a voice mail, Will inform social worker 10/03/24 10:17 am Behavior Note: This PTA had Resident in therapy gym for her daily therapy session along with COTA. During session resident kept bringing up that the front of our build [sic] is covered with crate [NAME] trees and she is highly allergic to and cannot go near. She then stated that she needs to jump out the therapy gym window when she goes home so she doesn't go near these trees. We discussed with resident that that is not safe, and we cannot be jumping out of windows. Resident kept focusing on this fact that she needs to jump out the window when she leaves and started laughing about it thinking that it is a funny situation. We tried to redirect resident to pay attention to her treatment and to not talk about the window any more to focus on getting better and stronger in therapy. Resident continued talking about jumping out window and laughing throughout the entire session. 10/03/24 10:40 am SS called and residents [name] to inform of care conference meeting on October 9th at 10:30 am. [RP] voice message was not accepting message. SS sent an email with care conference invite. 10/04/24 6:23 am Behavior Note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room. Resident assured that the nurse was not in the building and that this nurse would ensure that she would be safe today. Resident reluctantly gave fork to nurse. CNA was informed to be aware of resident's behavior. DON to be informed. 10/04/24 8:24 am Behavior Note Resident continues perseveration re: the [NAME], stating that the person was taken away by the FBI to a criminally insane asylum and the head nurse there let her out. As per Medical Director, will refer to [BHH] 10/07/24 Nursing Progress Note resident left facility at 11:52 am with facility transport. Resident continues with delusions of a [NAME] and feeling unsafe. Interview on 01/03/25 with LVN at 12:13 pm revealed Resident #1 was having hallucinations and was paranoid. Because of these mental health issues she should have been seen by the facility psychological services and the social worker or the DON should have arranged this . Interview on 01/07/24 with the DON at 1:32 pm revealed that when a resident was having mental health issues, they were referred to [the name of the facility psychological service group the facility employees] for services to be evaluated by a mental health professional. Interview on 01/17/25 with the ADON of the psychological service group the facility employees to treat residents at 4:06 pm revealed the group had no referral from the facility for mental health services for Resident #1. Interview on 01/17/25 with the facility DON at 5:56 pm revealed she was not employed at the facility when Resident #1 was a resident, and she does not know why the facility did not reach out to the psychological services as ordered by the facility MD. She revealed that delayed assistance for ordered mental health services could be life or death. A review of the 10/04/24 at 6:23 behavior note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room sounded like Resident #1 really needed some help. Review of facility Behavior Management Policy dated 04/19/05 reflected behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. Goals: 1. The resident will modify behavior for optimal functioning and well-being. 2. The resident will facilitate behavior changes with expression of anger and negative behaviors/responses managed in a constructive fashion. 3. The resident will comply with behavior modification program with behavioral expectations achieved. 4. The resident will experience a decrease in anxiety as evidenced by a calmer and less combative attitude. Dementia and Behavioral Health Policy - undated Monitoring: When monitoring antipsychotics, it is important to not only evaluate ongoing effectiveness and potential adverse consequences, as discussed below, but also to evaluate the use of any other psychopharmacological medications (e.g. mood stabilizers, benzodiazepines) being given to the resident. The ADM was notified on 01/17/25 at 1:18 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/18/25 at 10:52 am. Entrance Date: 1/16/2025 Problem: F742 On 01/17/2025 an abbreviated survey was initiated at the facility. On 01/17/2025 the surveyor provided an Immediate Threat (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. Action: 5. Resident #1 currently does not reside in the facility as of 1/17/25. 6. The DON/ADON audited all psychology and psychiatry orders for active residents over the last 6 months. Two residents were identified, and both are actively receiving psychiatric services. This was completed on 1/17/25. The facility has 11 total residents on psych services and 2 of those were referred to psych services within the last 6 months. 7. The Administrator and DON will be responsible for initiating all psychological and psychiatry referrals to the provider. This will start 1/17/25. 8. The Administrator DON, and ADON were in serviced 1:1 by the Regional Compliance Nurse on the following topics below on 1/17/25. E. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. F. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. G. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. 9. The Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator. 10. An ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. In-services The Administrator and DON initiated the following in-services for Licensed Nurses. Training began 01/17/2025 and will be completed 01/17/2025. Licensed Nurses not present and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. 11. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. 12. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. 13. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. The Administrator and DON initiated the following in-services for all staff. Training began 01/17/2025 and will be completed 01/17/2025. All staff not present, and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Surveyor Monitoring: The administrator and/or DON will review all orders daily x 5 days a week for any orders in reference to psychological and psychiatry services to ensure that all referrals have been initiated. This will begin 1/17/25 and end on 2/14/25. Interview with the DON confirmed that a facility audit was conducted of all psychology and psychiatry orders for active residents over the last 6 months. Reviewed the orders for the two residents who were identified and confirmed they both are actively receiving psychiatric services by reviewing most recent psychiatric records. Interview with the Administrator and DON confirmed they will be responsible for initiating all psychological and psychiatry referrals to the facility contracted provider. Interview with the ADM and DON (ADON unable to interview the ADON because of family medical emergency) that they were in serviced by the Regional Compliance Nurse on the following topics below on: Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. Reviewed documentation that the Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator and an ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six nurses all from various shifts all stated they were in-serviced prior to their assigned shift on: . 1. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. 2. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. 3. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six CNAs, two medication aides, and 1 dietary across various shifts all stated they were in-serviced prior to their assigned shift on: A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. The ADM was notified on 01/18/2025 at 2:54 PM, that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.