**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three of three residents (Residents #23, #34, #41, #61, #65, #66 and #179) reviewed for supervision. The resident environment did not remain free of accident hazards in addition to the supervision failure because the courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 1. The facility failed to ensure Resident #23, and Resident #34 were adequately supervised to prevent them from leaving the secured unit unsupervised. Residents #23 and #34 had moderate/severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/29/24 at or around 3:30 PM, Residents #23 and #34 gained access to a courtyard that was currently under construction, leaving the secure unit unsupervised. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 2. The facility failed to ensure Resident #179 was adequately supervised to prevent him from leaving the secured unit unsupervised. Resident #179 had severe cognitive impairment, wandering behavior, and lacked safety awareness. On 01/14/24 at or around 3:30 PM and on 01/15/24 at or around 10:25 PM, Resident #179 gained access to a courtyard under construction, leaving the secure unit unsupervised. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping there were no fencing or warning signs around the affected construction areas. The courtyard also contained a laundry facility that was unlocked, with the door observed to be frequently open and lacking a self-closing mechanism. The laundry facility contained numerous laundry chemicals that could cause serious injury if placed on exposed skin, eyes or ingested. 3. The facility failed to ensure that doors on the secure unit with magnetic locking mechanisms were functioning properly allowing secure unit residents unsupervised access to a courtyard that was under construction for several weeks. An IJ was identified on 01/30/24. The IJ template was provided to the facility on [DATE] at 2:07 PM. While the IJ was removed on 02/01/24 at 4:00 PM, the facility remained out of compliance at a scope of a pattern with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems, and lack of safety precautions for an adjoining courtyard under a current state of construction. 4.The facility failed to properly maintain wheelchairs for Residents #41, #61, #65, and #66. These failures could place residents at risk for injury and/or death from eloping, falls, exposure to sharp debris, and possible exposure to harmful chemicals. Findings included: 1. Record review of Resident #23's quarterly MDS assessment, dated 11/13/23, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Insomnia, Muscle Weakness, Unsteadiness on Feet, Difficulty Walking, and Other Lack of Coordination. The cognitive section C1000 of the MDS indicated Resident #23 had moderate cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, no psychosis, and wandering behavior. She had an unsteady gait and required a walker for mobility. Record review of Resident #23's care plan dated 01/25/24, reflected a problem identified as risk for elopement .requires secured unit related to: Wandering Risk, Alzheimer's Disease initiated on 10/10/23 which reflected, [Resident #23] will remain safe during placement at Living Center on secured unit through review date target date 04/29/24. Interventions on the care plan, dated 10/10/23 reflected Assess for risk of elopement per living center policy and Redirect [Resident #23] from doors. Record review of Resident #23's Wandering Assessment, dated 10/10/23, completed by an unknown nurse, reflected Resident #23 was admitted for High Risk for Wandering, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering, Wander/elopement alarm not indicated. Record review of Resident #23's Quarterly Wandering assessment dated [DATE], completed by Licensed Wound Nurse, reflected Resident #23 was disorientated, Forgetful/short attention span, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, Early dementia, known wanderer/history of wandering, Wander/elopement alarm is indicated. Record review of Resident #34's quarterly MDS assessment, dated 01/10/24, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's Disease, Dementia, Neurocognitive Disorder with Lewy Bodies (protein growths in brain), Muscle Wasting, Hallucinations, Unsteadiness on Feet, and Other Lack of Coordination. The cognitive section of the MDS indicated Resident #34 had severe cognitive impairment. She had symptoms which included continuous disorganized thinking, incoherent rambling, unclear flow of ideas, and unpredictable switching from subject to subject, psychosis, and wandering behavior. Record review of Resident #34's care plan dated 01/22/24, reflected a problem identified as risk for elopement .related to: attempts to leave living center .wandering initiated on 06/22/23 which reflected, [Resident #34] will remain safe during placement at Living Center on secured unit through review date target date 12/20/23. Interventions on the care plan, dated 10/10/23 reflected Assess for risk of elopement per living center policy and Redirect [Resident #34] from doors. Record review of Resident #34's Wandering Assessment, dated 11/03/23, completed by ADON bb, reflected Resident #34 was admitted for High Risk for Wandering, could walk independently, was disorientated, does not understand surroundings, independent with aid (cane/walker), Alzheimer's disease, known wanderer/history of wandering. Record review of Resident #34's Quarterly Wandering assessment dated [DATE], completed by LVN cc, reflected Resident #34 was disorientated, Forgetful/short attention span, combative, expresses fear and anxiety, does not understand surroundings, ambulates with one assist/Independent (no assist), Alzheimer's disease, dementia with psychosis, known wanderer/history of wandering, Wander/elopement alarm is indicated. In an interview on 01/29/24 at 10:00 a.m. with the Administrator revealed the facility had plumbing problems that had been addressed sometime the end of December, the Administrator stated that the construction had begun then and the trenches had been dug. The Administrator stated that would have been 4-6 weeks prior to today (01/29/24), but with he ice and the rain they had been unable to continue to correct the plumbing problems. He stated that the facility maintenance staff had covered the ditches with the plywood to make the area safer. In an interview on 01/29/24 at 4:51 PM, LVN L revealed that earlier that day Residents #23 and #34 had left the secure unit through a door that leads to the courtyard under construction. She stated that she must have had not been on that end of the hallway when Residents #23 and #34 went through the door. She stated that CNA PP had spotted the two residents in the courtyard and brought Residents #23 and #34 back to the secure unit. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed she used to work on the secure unit and knows all the residents on the secure unit. She stated that sometimes the door on the secure unit (leading to the courtyard under construction) sticks and does not latch. She stated that she had just entered the courtyard from another building and saw Resident #34 holding the door open for Resident #23 so that Resident #23 could bring her walker through the door. She stated that the staff sometimes puts med carts or chairs in front of the door leading to the courtyard to deter residents on the secure unit getting outside of the unit. In an interview on 01/30/24 at 9:08 AM, with the Administrator revealed that he was aware that a couple of residents had managed to get out of the secure unit unobserved. He stated that it was his fault because he had not made sure that the door was secure as he entered the secure unit (from the courtyard entrance). He stated that he had notified all staff to be more mindful of the door not latching. He stated that the two residents (Resident #23 and #34) were found by another CNA right away. In an interview on 01/30/24 at 9:10 AM, the Maintenance Supervisor revealed that he had just found out about the door, he stated that it is not the door frame, but the door that is not hung right. In an observation on 01/29/24 at 10:45 a.m. the laundry room door was open and there was no one in the laundry. In and observation on 01/29/24 at 11:45 a.m. the laundry room door was open there was no one in the laundry. In an observation on 01/30/ 24 at 1:00 p.m. the laundry door was open and there was no one in the laundry. On 01/30/24 at 1:30 p.m. pictures were obtained of the courtyard of the ditches approximately 40 ft long and 3-4 feet deep, mounds of dirt broken pipes, debris that contained sharp edges of broken plastic pipe, broken fencing, barrels marked as hazard materials, and no protective fencing or signs indicating the hazards. In an observation and interview on 01/30/24 at 3:17 PM, it was observed that the laundry facility was located within the courtyard that was under construction courtyard that was currently under construction. The courtyard contained mud-filled trenches approximately 40 feet long and 3-4 feet deep, mounds of dirt and debris that contained rocks and sharp shards of plastic piping, there were no fencing or warning signs around the affected construction areas. The door to the laundry facility was propped open with no automated door closing device was observed to be attached to the door. Directly inside the door to the left were numerous containers of laundry chemicals including All-purpose cleaner and degreaser, Neutralizing Sour, Chemical Alkaline Booster, Laundry Detergent and Laundry De-Stainer. All containers were observed to have warnings that denoted serious harm or injury if digested or continuous contact with exposed skin/eyes. Housekeeper EE stated that the housekeeping staff liked to keep the door open to the laundry facility because it gets very warm inside. 2. Record review of Resident #179's quarterly MDS assessment, dated 01/17/24, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's Disease, Vascular Dementia, and sleep disorder. The cognitive section C1000 of the MDS indicated Resident #179 had severe cognitive impairment. He had symptoms which included continuous inattentiveness, continuous trouble falling asleep, continuous wandering and rejection of care behaviors. Record review of Resident #179's care plan dated 01/15/24, reflected a problem identified as [Resident #179] has realized that holding the memory unit locked door for 15 seconds will release the emergency egress function of door and door will open [Resident #179] has ambulated from memory unit into courtyard X 2 but has been redirected back to memory locked unit initiated on 01/16/24. Interventions on care plan, dated 01/16/24 reflected [Resident 179] to remain 1:1 until discharge. Care Plan dated 1/15/24, reflected a problem identified as risk for elopement and required a more secured unit to ambulate safely and freely related to: Attempts to leave living center, initiated on 01/16/24. Interventions on care plan dated 01/16/24 reflected, [Resident #179] Assess for risk of elopement per living center policy and Assess for secure unit. Record review of Resident #179's Elopement Risk Assessment, dated 01/12/24, completed by an unknown nurse, reflected Resident #179 was admitted with High Risk for Elopement, could walk independently, exhibited wandering behavior, was cognitively impaired and had poor decision-making skills, had verbalized a desire to go home and had eloped/wandered from his home without supervision prior to his admission to the facility. No quarterly Elopement assessment was available as the resident was at the facility for respite care x 5 days. Record review of Progress notes from 1/14/24 at 3:30 PM and written by LVN L revealed that Charge nurse was notified resident [Resident#179] was outside of exit door. Charge nurse noted resident on the sidewalk and immediately redirected resident back to unit. Resident was calm with some confusion noted. No injuries noted. Record review of Progress notes from 1/15/24 at 10:25 PM written by LVN K revealed that .this nurse hears the door rattle from res(ident)[Resident #179] pushing it once, then followed by quiet this nurse walks out of nurses station to see res [Resident #179] running on sidewalk toward 200 hall side building, this nurse try's to follow but has to put code in door as it is locked, this nurse runs outside and catches res as res is knocking on window of other building, this nurse turns res and takes res back inside locked unit where this nurse has to put code in again to get in, res is taken to nurses station and socks are changed and DON (Director of Nursing) is notified, this nurse blocks door while waiting on staff to come and look at door as res is put on 1 on 1 monitoring as well as Q(every)15 min checks. In an interview on 01/29/24 at 3:00 PM, with LVN L revealed that Resident #179 was a very busy resident, he would only sleep for 20 minutes at a time, and he constantly wandered and checked all the exit doors all day and all night. In an interview on 01/29/24 at 4:16 PM, CNA D revealed that the door next to the nurse's station (that leads to the courtyard under construction) sometimes does not latch and that it sometimes sticks open, so the staff must make sure that they check it every time they use the door . She stated that she had reported it to a nurse a couple of months back ago. An observation on 01/29/24 at 4:20 PM, revealed that the exit door from the secure unit to the courtyard under construction was intentionally left unlatched for 1 minute, no alarm sounded to indicate the door was open. In an interview on 1/30/24 at 4:50 AM, RN V revealed that she had heard of a few instances lately of residents getting out of the secure unit and that the door leading from the secure unit to the courtyard does not close very well. She stated that it would be very helpful to have some type of alarm that goes off on the doors on the secure unit. She stated that when the facility has fire drills that the staff in the secure unit would sometimes put barriers up in front of the doors on the secure unit because the fire alarm automatically unlatches the doors. In an interview on 01/30/24 at 5:00 AM, CNA M revealed that if a resident were to get out of the secure unit unsupervised, she would immediately bring the resident back to the secure unit and inform the Charge nurse or the Administrator. In an interview on 01/30/24 at 5:11 AM, LVN GGG revealed that the door next to the nurse's station on the secure unit (leading to the courtyard) sometimes sticks open and does not latch, she stated that she had reported it a while ago but could not remember when. In an interview on 01/30/24 at 7:40 AM, CNA PP revealed that the staff working on the secure unit would sometimes put med carts or chairs in front of the exit (leading to the courtyard) next to the nurse's station on the secure unit to deter residents from getting outside of eh unit. In an interview on 01/30/24 at 7:47 AM, LVN K revealed that she had been the nurse on the night that Resident #179 got out of the secure unit. She stated that there are no alarms on the door (leading to the courtyard) but that may be a good idea. She stated that the door (leading to the courtyard) would stick open and not latch from time to time. She stated that the door did latch after Resident #179 got out of the secure unit and that delayed her getting out to him, she stated that he had made it all the way to the 200 building. She stated that she brought the resident back to the secure unit and informed the DON that the door was not working well and that she did put some chairs in front of the door until other staff arrived to fix the door. In an interview on 01/30/24 at 8:58 AM, the Administrator revealed he was aware of the door (on the secure unit leading to the courtyard) not closing properly and that the facility had put a new automatic door closer on the door to fix the problem. He stated the staff and visitors had been advised to make sure to check the door after they enter/exit to make sure that the door had latched properly. In an observation and interview on 01/30/24 at 4:08 PM, Maintenance Assistant DD toured the under construction courtyard with the Investigator. He stated the trenches in the courtyard had been started by the Administrators son the same week as Christmas around the 19th or the 20th of December, he was not exactly sure. He stated the trenches had to be dug around 3-4 feet deep to get all of the pipe out of them and put in new pipe. He stated the trenches had been dug up and then there was a freeze aound Christmas so the ground had frozen and then it rained a lot after that, that was why the trenches were still there. He identified the trenches as being 3-4 feet deep with mud at the bottom. He identified the pIles of dirt anD debris next to the trenches as being 2-3 feet tall and containing large rocks, shards of broken pipe and other debris. In an interview and observation on 01/30/24 at 6:20 PM, the Maintenance Supervisor stated that he placed a new automatic door closer on the secure unit door (leading to the courtyard) a few weeks ago. He stated he thought that Resident #179 must have got out because he had pushed on the release on the door for more than 15 seconds to disengage the lock. Maintenance Supervisor then pushed on the exit bar to the door on the secure unit leading to the courtyard for a full minute, the magnetic door latch was observed to not disengage. He then stated that the door seemed not to be seated right in the door frame and that maybe that stopped the door from latching properly sometimes. In an observation on 01/31/24 at 8:30 a.m. revealed alarms had been placed on all the exit doors of the secured unit. In an interview on 01/31/24 at 9:10 a.m. with the Administrator revealed he had the Maintenance Supervisor purchase the alarms the evening before and place them on all the exit doors, so that an alarm would sound if the doors were opened. In an interview on 01/31/24 at 12:54 PM, the Administrator revealed that he and the DON had been trained by the Regional RN for elopement, wandering and safety concerns at the facility, and that all staff had been trained. He stated that he had designated the Housekeeping Supervisor and the Maintenance Supervisor to monitor the courtyard area. In an interview on 02/01/24 at 12:55 PM, the DON revealed that the staff were educated by in-services, hands on training and on-line training and that all training was currently up to date. She stated that she thought the IJ was caused by the courtyard being dug up for several weeks and not having the trenches blocked off and marked. Secure Unit residents may have injured themselves if they got out of the secure unit unsupervised. She stated that the facility now had alarms on the doors of the secure unit and the courtyard trenches were being filled in and the debris removed. She also stated that a self-closer mechanism was going to be installed on the laundry facility door to deter residents from having access to the chemicals stored there. In an interview on 02/01/24 at 3:00 PM, the Administrator and Maintenance Supervisor revealed that they made sure that the facility would do in-servicing and education and when and how to report and identify that there may be discrepancies. The Admininstrator stated that he supervised through daily clinical meetings with the nursing department, have daily stand-up meetings with all the department heads including Maintenance and do daily advocacy rounds. I think the IJ occurred through an increase of hazards in the courtyard due to repairs. There was a missed opportunity for staff and visitors to make sure that the entrance to the secure was closed. To prevent another recurrence, the facility verified that the locks worked, the facility added alarms to the doors, staff were re-educated, to make sure that the door was checked and that the door was closed. They also stated that the facility was making sure that there were no debris or trenches in the courtyard that could (present) a hazard to residents. 4. Review of Resident #41's quarterly MDS assessment, dated 11/25/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of schizoaffective disorder bipolar type (Mental illness), general weakness (weakness lower limbs), and abnormalities of gait and mobility (abilities to mobilizes safely ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #41's plan of care dated 11/25/23 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation on 01/29/24 at 9:30 a.m., revealed Resident #41 was sitting in her wheelchair, in the secured unit activity room and had no skin problems. The wheelchair's right armrest was cracked with foam exposed. Review of Resident #61's quarterly MDS assessment, dated 01/06/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Schizoaffective disorder (mental illness), muscle wasting (muscle deterioration), abnormalities of gait and mobility (unable to mobilize safely), and unsteadiness on feet (instability to walk ). Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #61's plan of care dated 01/06/24 with updates reflected goals and approaches to include wheelchair mobility. in the secure unit activity room Observation on 01/29/24 at 9:31 a.m., revealed Resident #61 was sitting in his wheelchair in the secured unit activity room and the wheelchair's left and right armrests were cracked with exposed foam. There were no skin tears on arms. Review of Resident #65's annual MDS assessment, dated 01/28/24, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Dementia (brain dysfunction) pulmonary embolism (clot in the lung), abnormalities of gait and mobility (unable to mobilize safety), difficulty in walking, and muscle weakness . Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #65's updated plan of care dated 01/28/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:32 a.m., revealed Resident #65 was in her wheelchair in the secured unit activity room, and the wheelchair's right armrests were cracked with the foam exposed. There were no skin tears on arms. Review of Resident #66's annual MDS assessment, dated 01/23/24, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Dementia (brain disorder confusion & forgetfulness), unsteadiness on feet, and lack of coordination and weakness. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #66's updated plan of care dated 01/23/24 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 9:35 a.m., revealed Resident #66 was in his wheelchair, wheeling in the hallway and with no skin problems. The wheelchair's right armrest was cracked with dried food in the cracks. Review of Resident #47's quarterly MDS assessment, dated 11/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of epilepsy (seizures), abnormality of gait and mobility, and instability of left knee. Further review of the MDS reflected the resident was cognitively severely impaired and unable to make decisions for themselves. Review of the Resident #47's updated plan of care dated 10/08/23 with updates reflected goals and approaches to include wheelchair mobility and skin not being in contact with hard surfaces since she has thin skin and a history of skin tears on her hands. Observation on 01/29/24 at 1:45 p.m., revealed Resident #47 was in her wheelchair and had no skin problems. The wheelchair's left and right armrests were cracked with the foam exposed. Resident #47 was unable to be interviewed. In an interview on 01/29/24 at 11:00 a.m., CNA D stated when a resident's wheelchair needed repair the staff were to tell the maintenance supervisor. CNA D stated she had not reported any wheelchairs that needed repair to the maintenance supervisor. In an interview on 01/29/24 at 11:05 a.m., LVN A stated when a resident's wheelchair needed repair the staff were to report it to the maintenance supervisor, LVN A stated she thought there was maintenance log at the nurses station in the other building but there was not one at this nurse's station. In an interview on 01/30/24 at 5:00 a.m., the with Maintenance Supervisor revealed the staff tells him if equipment needs to be fixed or if a room needs repair. He stated they are supposed to use the electronic reporting system, but they do not use it. He stated to his knowledge the staff had not been trained to use the electronic reporting system, he just fixes things when he knows about it. In an in interview on 01/30/24 at 9:15 a.m., the with Administrator and Maintenance Supervisor revealed neither of them were aware of any wheelchairs that required repair on the unit. The Administrator state the staff is supposed to use the electronic reporting system. The Administrator stated he did not know when or if the staff had been in-serviced on how to use the system, the staff just usually tells them, if the wheelchairs needed to be fixed. The Maintenance Supervisor agreed with the Administrator. A review of the electronic maintenance system with the Maintenance Supervisor on 01/30/24 reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired for the October-January 2024. In an interview on 02/01/24 at 1:32 PM, the Medical Director revealed that she had been informed of the IJ on 01/30/24. Record review of the facility's Policy Statement Grounds dated 05/2018 version 1.1 (H5MAPL0360) reflected 1. Maintenance shall be responsible for keeping grounds free of litter .3. Areas around buildings (i.e., sidewalks, patio, gardens, etc.) shall be maintained in a safe and orderly manner at all times. Record Review of the facility's Policy Wandering and Elopements, dated 03/2019 version 1.2 (H5MAPL0944) reflected The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement or other safety issues .to maintain the resident's safety .483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents . A review of the facility's policy and procedure Maintenance dated July 2018 reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff Equipment provided by the community will be: 1. Maintained in working order. A review for the facility's policy and procedure Assist devices and Equipment dated January 2020 reflected: Our facility maintains and supervises the use of assistive devices and equipment for residents device conation. 1. certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include but limited to: .c. mobility devices wheelchairs, walkers, and canes) . 6.c. Device condition-devices and equipment are maintained on schedule and according to manufacture's instructions. Defective or worn devices are discarded or repaired . This was determined to be an Immediate Jeopardy on 01/30/24 at 2:07 PM. The Administrator was notified. The Administrator was provided with the IJ template on 01/30/24 at 2:07 PM The following plan of removal submitted by the facility was accepted on 02/01/24 at 9:52 AM and indicated the following: Plan of Removal: Immediate Corrections Implemented for Removal of Immediate Jeopardy. On January 30, 2024 at approximately 3:30 pm the following immediately corrective actions were taken: Resident #179 discharged to home (1/17) Director of Nursing and ADONs and MDSC, completed updated wander risk assessment on resident #23 and Resident #34 on (1/30). IDT reviewed interventions initiated and care plan updated r/t elopement risk (1/30). Maintenance Director installed (1/30) temporary magnet-activated alarms/chimes on all exit doors on Secure Unit until permanent alarm system can be installed by professional contractor (Contractor site survey completed 1/30 to provide quote by end of week). Maintenance Director physically inspected all Secure Unit doors/locks and tested each to make sure they're working correctly (closing properly without impediment, locking and unlocking with keypad only) - completed 1/30. Administrator verified that already existing padlocks on courtyard gates, and mag-locks on halls adjoining Secure Unit, were securely locked and functioning properly to prevent elopement from facility via this route (1/31). Life Safety team alerted Admin that trench required orange construction fencing per OSHA regulations. Fence materials were immediately purchased and installed around trench area (1/31). IDENTIFICATION OF OTHER AFFECTED: All residents on Secure Unit have the potential to be affected. Director of Nursing /designee (ADON's and MDSC) completed Wander Assessment for all 20 residents on Secure Unit in Point Click Care on 1/30/2024, and all Secure Unit residents will be reassessed Quarterly by ADON (Ongoing for duration of Secure Unit stay) Director of nursing/designee validated all residents at high risk of elopement (17 of 20 residents on Secure Unit), (score of 11 or[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents , for one (Resident #1) of 9 residents reviewed for medication use using medications that are brought in by outside pharmacies or families, in that: 1. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. Medication error was discovered when FAM called to see if medication needed to be replenished and medication was started again on 07/24/23, which Resident #1 to not receive medication as ordered for 17 days. 2. The facility failed to have a system or policy in place with guidance for staff to check in and follow up on orders for medications brought to the facility from an outside pharmacy or family. An IJ was identified on 08/10/23. The IJ template was provided to the facility on [DATE] at 10:37 AM. While the IJ was removed on 08/11/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not IJ scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed resident at risk of deterioration in health, worsening of cancer, extended recoveries, hospitalizations. Findings included: Record review of Resident #1's admission record dated 08/09/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included, multiple myeloma not having achieved remission (a cancer of plasma cells, a type of white blood cell, that normally produces antibodies), dysphagia (difficulty in swallowing food or liquid), anxiety disorder (feeling nervous, restless or tense or having a sense of impending danger, panic or doom), cognitive communication deficit (difficulty with thinking or how someone uses language), diabetes (a group of diseases that result in too much sugar in the blood), and PTSD (post-traumatic stress disorder)(a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS of 13, which indicated he was cognitively intact and required supervision and set-up help only with all activities except bathing which revealed he was independent with and required no setup or physical help from staff. Record review of Resident #1's physician orders dated 08/09/23 revealed order for Revlimid Oral Capsule 25 MG (Lenalidomide) Give 1 capsule by mouth at bedtime for RECEIVED FROM OUTSIDE PHARMACY related to MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION (C90.00) until 08/14/2023 23:59 wear gloves with med administration/ do not given if broken--- NOTIFY ADON/DON WHEN 7 PILLS REMAIN-- SO ORDER CAN BE DONE******** Record review of Resident #1's Nursing Progress Note, dated 7/23/2023 21:56 (9:56 PM) revealed the following: Residents son asked this nurse how many capsules does resident have left Revlimid 25mg. This nurse noted bottle sealed and has not been opened. RP upset d/t resident has not been getting his Revlimid medication and next dosage of 21 days is soon to come up again. This nurse noted residents last dose of Revlimid was around 6/30/23. NP notified of missed medication video call this nurse via spruce new order to restart Revlimid 25mg as ordered and notify VA DR. ADON, RP, VA notified. Revlimid ID'd at 2000 (8:00 PM) with narn. vs: 117/75, 74, 18, 97.5, SPO2 96% RA. Record review of Resident #1's MAR for June 2023 revealed Revlimid Oral Capsule 25 MG was administered on June 1st and 2nd and then June 9th through 29th at 6:00 PM. Record review of Resident #1's MAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 24th at 6:00 PM. Record review of Resident #1's TAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 25th through 31st at 6:00 PM. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 1st through 8th at 6:00 PM. Revlimid Oral Capsule 25 MG (Lenalidomide) 1 capsule by mouth at bedtime. This medication is a chemotherapy and is used to treat multiple myeloma not having achieved remission, which is a cancer of plasma cells, a type of white blood cell, that normally produces antibodies per Google. Record review of Resident #1's care plan dated 07/25/2023 revealed resident takes cancer medication Revlimid. Cycles on medication for 21 days and off for 7 days- (Medication supplied by the VA Pharmacy/ resident's FAM brings medication to facility) Goals: Staff to assure medication is administered per orders through review period. Interventions: Monitor for adverse reactions- which include- hypersensitivity, angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes that is often a reaction to medication or an infection), toxic epidermal necrolysis (a life threatening skin disorder characterized by a blistering or peeling of the skin), Tumor Lysis Syndrome (a group of metabolic abnormalities that can occur as a complication from the treatment of cancer), hepatotoxicity (injury or impairment of the liver function caused by exposure to xenobiotics such as drugs, food additives, alcohol, chlorinated solvents, peroxidized fatty acids, fungal toxins, radioactive isotopes, environmental toxicants, and even some medicinal plants), thrombocytopenia (a low number of platelets in the blood), neutropenia, pruritis (itching), rash, fatigue, constipation, nausea. Staff to assure that medication is swallowed whole and not chewed. Staff to wear gloves with administration of this medication. Record review of facility policy titled Medications brought to the facility by the resident/family dated 2001 (revised April 2007) revealed Policy Statement: The facility shall ordinarily not permit residents and families to bring medication into the facility. Policy Interpretation and Implementation: 3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician, and Consultant Pharmacist, shall check to ensure that: b. The medications have been ordered by the resident's Attending Physician and documented on the physician's order sheet. During an interview on 08/09/2023 11:16 AM with MA E, she stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause major side effects. She stated a blood pressure medication could cause a blood pressure to rise or fall, aspirin could cause heart problems, and Depakote could cause agitation, and missing a medication could even cause death depending on the medication. She stated she was in-serviced regularly on abuse/neglect and medication administration. During an interview on 08/09/2023 11:44 AM with LVN A, he stated medications should be given to residents as ordered by the physician. He stated if a resident was not given medications correctly, it could potentially cause adverse reactions. He stated he was in-serviced regularly on abuse/neglect and medication administration. During an interview on 08/09/2023 11:55 AM with LVN B, she stated she was in-serviced regularly on abuse/neglect and medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause adverse side effects, delayed action of medication for whatever it was supposed to cure, or if it's for a preventative measure, whatever it was supposed to prevent could occur. She stated Resident # 1's medication came from the VA. She stated the son picked the medication up and dropped it off at the facility. She stated the medication did not come from their pharmacy, and they did not order it. She stated Resident #1 took the medication for 21 days and was off of the medication for 7 days and it continuously cycled that way. She stated she was not sure where the disconnect was, where the medication was brought in and the order was not put in the system to be administered, or if the nurse that the FAM gave it to just forgot or what, but the resident did not get his medication started back up this last time on time. She stated she did not know exactly how many days the medication had been missed. During an interview on 08/09/2023 12:13 PM with MA F, she stated she was in-serviced regularly on abuse/neglect and medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause a change in residents body or it could potentially cause harm. During an interview on 08/09/2023 at 1:16 PM with ADM and DON, they stated they were in-servicing staff regularly on medication administration. They stated medications should be given to residents as ordered by the physician. They stated if a resident was not given medications correctly, it would depend on the medication being given as to what reactions could occur. They stated if it was discovered that a medication was not given properly, the nurse should do an assessment on the resident and follow up with notifying the family and doctor. They stated Resident #1 received the chemotherapy medication from the FAM picking it up from the VA and bringing it to the facility. They stated the FAM called facility on 07/23/23 at 21:56 (9:56 PM) and spoke to a nurse and asked how many pills were left to see if he needed to re-order the medication, and that was how it was discovered Resident #1 was not currently receiving the medication. They stated that was when staff realized there was a full bottle of the medication on the medication cart. They stated Resident #1 took the medication for 21 days and off for 7 days, then it started back up and cycled routinely with that order. They stated when the FAM brought the most recent bottle of medication, resident had still not completed previous cycle of medication so nurse could not put the new cycle into the administration record. They stated they could not put the medication into the system to stop and restart the way the medication was ordered. They stated if a resident did not receive this type of medication, it could cause their blood count to be off. They stated they had in-serviced their staff on medication administration and receiving and accepting medications. They stated they had put the medication on a management board, and they discussed this medication every morning now to ensure that the dates were aligned, and the medication was available and being administered as ordered. They stated they had their clinical resource person to look into the system to see if there was any way to put it in the system with no resolution, and they had the pharmacy consultant to check for this as well. They stated if a resident did not receive this medication, it could cause his blood count to be off. They stated the VA informed them that they ran all of residents labs to check for any off blood counts and to make sure that everything looked ok or there was no changes from previous status. They stated resident went to the ONC at the VA every week and has done this throughout the time he was not receiving the medication and there were no adverse reactions. During an interview on 08/09/2023 1:47 PM with PA, she stated there was always a potential for harm or adverse reaction with any medication that is missed or not taken. She stated any medication being missed could certainly cause side effects. 08/09/2023 1:56 PM Call placed to ONC, doctor was not available to speak to surveyor. During an interview on 08/09/2023 at 1:58 PM with PHARM, he stated the only potential thing that could have occurred would have been the progression of cancer. During an interview on 08/09/2023 at 2:14 PM with Resident #1, he stated he just got back from the VA, and he goes to the VA every week because he has cancer. He stated liked it here and the staff all treated him well. He stated he was told about missing his cancer medication and his son talked to him about it also. He stated he has not had any problems or issues due to the medication being missed. He stated he did not realize he was missing any medication and he would not have known it if they didn't tell him. He stated he feels safe here in the facility and he has no complaints about nothing. He stated he uses a cane or walker for mobility, and he always gets to his appointments. During an interview on 08/09/2023 3:09 PM with LVN C, she stated they only received the chemotherapy medication orders from the new bottles of medication when the residents family brought it to them. She stated the only order they had for the medication is what the medication bottle says and from the original paperwork when resident first started the medication. 08/09/2023 Record reviewed of physician orders dated 04/07/23 and 07/26/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days then, 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). During an interview on 08/09/2023 5:30 PM with ADM, he stated there was only one resident in the facility which receives Chemotherapy. He stated there may have been others before and there were residents with a diagnosis of cancer, but none received chemotherapy now except the one in incident. 08/09/23 Record review of facility policy titled Administering Medications dated 2001 (Revised December 2012) revealed in policy statement: Medications should be given in a safe and timely manner, and as prescribed. Record review of staff in-service training report dated 07/25/2023 revealed nurses and medication aides were in-serviced on medication administration and medication orders. 08/09/23 4:31 PM Record review of facility policy titled Accepting Delivery of Medications which is not dated revealed Policy heading: 1. All staff follow a consistent procedure in accepting medications. Policy Interpretation and Implementation 4. A nurse signs the delivery ticket, indicating review and acceptance of the delivery, and keeps a copy of the delivery ticket. Both the nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket is archived in a designated location. An immediate Jeopardy (IJ) was identified on 08/10/2023 at 10:15 AM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Survey team monitored the plan of removal as follows: The Plan of Removal was accepted on 08/11/2023 at 1:50 PM and is as follows: DON assessed resident #1 on 8/9/2023 for new or worsening symptoms associated with his multiple myeloma or adverse side effects of the missed medication including increased pain or neurological symptoms. The attending physician and ONC were notified of medication error and no new orders were given with the exception of restarting medication immediately. The assessment did not reveal any obvious adverse effects related to the deficient practice. The Corporate Clinical Consultant provided education to the DON on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. DON/Designee completed education with all licensed nursing staff on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New staff, will be in-serviced during orientation period prior to working a shift. The DON/Designee completed an audit of all residents to establish which residents receive medications from outside pharmacies on 8/10/2023. 8 residents were identified through this audit. The DON/designee then conducted an audit of medication storage areas to validate that none of these residents' medications were missing and the administration record was reviewed for each resident to validate that there were no missed doses within the last 90 days on 8/10/2023. Care plans updated with directions of receiving from outside pharmacy, also initiated instructions RECEIVED FROM OUTSIDE PHARMACY No issues were identified related to missed doses or missing medication. DON/Designee completed education with all licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required licensed staff were educated on 8/10/2023 on entering orders correctly in Point Click Care for proper and error-free medication administration, and to include instructions 'RECEIVED FROM OUTSIDE PHARMACY as identification when medication is brought in from outside pharmacy, this education will be ongoing for all newly hired nurses. Sr [NAME] President of Clinical Services revised policy titled Medications Brought to the Facility by Resident/Family to having a signed receipt of accepting of the medication by licensed staff only, on 8/10/23. Director of Clinical Operations educated DON in regard to policy change. DON/Designee completed education with all licensed nursing staff informing this of this policy change. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New nursing staff and agency staff will be educated upon or upon initial shift at facility, ongoing. Education completed on 8/10/23. DON/designee completed a review of all residents to validate the availability of all medications on 8/9/2023. There were no concerns identified related to the availability of medications through this review. Director of Nursing/designee completed review of all residents to identify which medication are provided by outside pharmacy. 8 residents were identified. This review was completed on 8/9/2023. No concerns were identified related to missing medications or missed doses in the last 90 days for any of the 8 residents. The orders for the 8 residents identified were updated to reflect that meds are received from an outside Pharmacy to alert nursing staff that refills should not be requested from the house pharmacy on 8/9/2023. Corporate Clinical Consultant completed a review of the following policies on 8/10/2023: Pharmacy Services Overview, Administering Medications, Medications Brought into the Facility by Resident/Family, Accepting Delivery of Medications. Medications Brought into the Facility by Resident/Family policy was revised by Sr [NAME] President of Clinical Services to include signed acceptance receipt of medication, no other policy changes were made. Licensed nurses will communicate via 24 hour report and shift hand off of medications that were ordered and not received during shift. The Corporate Clinical Consultant completed education with the DON on 8/10/2023 on these policies and the procedure for receiving, ordering, and administering medications brought in by family or received from an outside pharmacy. The procedure is to include receipt of medication by a licensed nurse, notification of DON/designee, verification of order from the attending physician, verification of proper order entry in PCC to include notation that medication is received from and outside pharmacy, verification of proper labeling of medication container with medication and resident information, verification of quantity and type medication being delivered from outside pharmacy. The receiving nurse will be responsible for conducting the first check verification as medications are received and orders are entered and the DON/designee, will conduct the second check verification Monday-Friday in the morning clinical meeting to include needed medications for upcoming weekend, and any changes/needs from prior weekend. For after hours or weekends, the receiving nurse will contact on-call nurse manager and physician for any concerns related to supply of medications. The DON/designee completed education with licensed nurses on 8/10/2023 regarding the procedure to ensure that medications are received and administered according to ordered date, time, and frequency for residents whose medications are dispensed from an outside pharmacy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all licensed nursing staff were educated. Medications that are received from outside pharmacies will be entered with an additional note in the instruction section indicating that meds are 'RECEIVED FROM OUTSIDE PHARMACY with any additional information on the pharmacy name and/or who delivers the medication and how to obtain a refill. Communication will be shift to shift via 24 hour report, when medications are ordered or needed for licensed nurses to assure timely delivery. Education will be provided to all newly hired nurses prior to their first shift and all current staff have been educated as of 8/10/2023. DON/designee added orders with skipped days through end of calendar year, also added onto daily monitoring for review of ongoing order, on 8/10/2023. The DON/designee will conduct monitoring of new medication orders and medications stocked in medication carts/rooms/refrigerators to validate that medications received from outside pharmacies have orders entered appropriately in Point Click Care, that they are received and administered according to ordered date, time and frequency and that there is adequate stock remaining or that refill request has been initiated. Any concerns identified will be reported to the physician immediately upon identification with corrections made according to physician orders. Monitoring will occur, starting on 8/10/23, 3 times per week for 4 weeks then weekly for 2 months. Any trends identified will be reported to the QAPI Committee monthly and as needed until a lessor frequency until substantial compliance is achieved. QAPI meeting was held on 8/10/23 with the Medical Director, ADM, DON, and Nurse Management to review newly revised policy on medication brought in by family, and review and validate the plan of removal. The Administrator will be responsible for the implementation of ensuring the adequate process regarding Safe Medication Administration. The new processes/system was initiated, and all licensed nursing staff had completed education by 8/10/2023. This new process will be ongoing for new hires and agency staff prior to working a shift at the facility. All licensed nurses and medication aides were in-serviced. DON/designee used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated, completed on 8/10/23. Monitoring was conducted from 08/10/2023 through 08/11/2023. During an interview on 08/10/2023 at 12:47 PM with the ADM and DON, they stated the facility had a QAPI meeting the morning of 08/10/2023 with the medical director included addressing the medication error in incident but they had not had a meeting regarding medication errors in the past 3 months prior to surveyor entrance. During an interview on 08/10/2023 at 12:58 PM with LVN A, he stated he had recently been in-serviced by management regarding medication administration, receiving medications, how to put the medication in the system, and when medications come in from an outside pharmacy or family. He stated the in-service taught him if the medicine comes in from an outside pharmacy or the family delivered it, to specifically make a progress note to say that the medication came in. He stated he would write that additional note in the system and label the bottle or card that comes from the pharmacy. He stated he was informed on and had reviewed the policies for medication administration, receiving medications, and receiving medications from an outside pharmacy. He stated he had never been given medication from hospice from an outside pharmacy but that always had an order prior to medication being delivered and he had to sign a receipt of delivery. During an interview on 08/10/2023 at 1:15 PM with LVN D, she stated she had recently been in-serviced by management that morning regarding medication administration, pharmacy protocols, medication coming in from the pharmacy and outside pharmacy or families protocol, and basically everything that had to do with medications coming into the facility. She stated there was a sheet that they will be signing and documenting on when receiving a medication from an outside pharmacy or family member. She stated the in-service taught her to document and double check everything and leave it in the book to refer to. She stated she would sign in any medications received from an outside pharmacy or family member and document that she received it. She stated would also check to make sure there are orders for the medications and verify that the orders have been transcribed into the MAR's or TAR's. She stated she was informed on and had reviewed the policies for incoming medications, medication administration, and signing in medications and checking orders. She stated she had not been given medication that was brought in from an outside pharmacy or family member that she can recall. During an interview on 08/10/23 at 1:31 PM with MA F, she stated she had recently been in-serviced by management regarding medications that are coming in from outside of the facility pharmacy or family members. She stated the in-service taught her that any medication given to her will go directly to the nurse and that it should be noted on the MAR's if the medication came from their pharmacy, an outside pharmacy, or family. She stated she would re-direct whoever is bringing the medication to the nurse so the nurse could sign the medications in. She stated she was informed on and had reviewed the policies for medications coming from family or other pharmacies and to check and make sure everything was correct on their MAR's. She stated she had not been given medication that was brought in from an outside pharmacy or family before. During an interview on 08/10/2023 at 1:36 PM with MA E, she stated she had recently been in-serviced by management this morning regarding family bringing in medication and pharmacy bringing in medication. She stated the in-service taught her that if a family member brings in medication that she was to re-direct them to take the medication from the nurse and if the medication comes from an outside pharmacy there was to be a note put in the system to show the medication was received. She stated she would direct family to give any medication to the nurses if they try to bring it to her. She stated she was informed on and had reviewed the policies for receiving medication from families or outside pharmacies. She stated there were 3 in-services, but she could not remember all of the exact names of the policies. She stated she had not been given medication that was brought in from an outside pharmacy or family before. She stated she had family and pharmacies try to give her medications, but she had been taught from the beginning to not accept or sign for any medications and to re-direct them to the nurse. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 9th at 6:00 PM. Medication was administered correctly during this time. On 08/11/23 at 9:30am - Monitoring visit conducted in facility. 08/11/23 Reviewed facility in-servicing for staff that covered Medications Brought to the Facility by the Residents/Family, Receiving Medication from Outside Pharmacy and Pharmacy Services Overview dated 08/10/2023. Reviewed MAR's for the sampled residents: All reviewed residents have a note added with the medication order stating the order comes from an outside pharmacy. Interview on 08/11/23 at 10:30am - DON stated that nurses and MA's are being in-serviced on the Medications Brought to the Facility by the Residents/Family policy, the procedure for Receiving Medication from Outside Pharmacy and Pharmacy Services Overview. DON stated that the facility's nurses and MA's are receiving the services prior to working their shift. DON stated some staff are receiving the training verbally and some in person to ensure all staff were trained immediately. DON stated that she asked all staff if they understood the training, and all replied yes. DON stated the facility implemented a receipt of medication brought in by the resident/family. Nurse reviewing and family member bringing medication in had to be signed and dated. DON stated there is a sticker placed on the medication that states it is from another pharmacy and a note entered with the order from other pharmacy or provided by family. DON stated that there was an alert added the facility's clinical white board for Resident #1 chemotherapy medication to be re-added to PCC. DON stated that PCC will not allow medication to be added more than 3 months at a time. DON stated that the white board is reviewed daily by the facility's clinical team Administrator, ADONs, DON, Therapy, Social Worker. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 10th at 6:00 PM. Medication was administered as ordered. Reviewed change to Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. Reviewed care plans for Resident #'s 1-9, care plans were updated to reveal medications were brought in from outside sources such as family or other pharmacies. On 08/11/23 at 11:45am - MA E stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. MA E stated she understood the training and has no issues or concerns. On 08/11/23 at 12:15pm - MA F stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. MA F stated she understood the training and has no issues or concerns. On 08/11/23 at 12:30pm - LVN G stated she has been trained on Medications Brought to the Facility by the Residents/Family policy. The facility added Signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP, and receiving staff member is completed. LVN G stated she understood the training and has no issues or concer[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received his chemotherapy medication for 17 days (07/07/23 to 07/23/23) after medication was delivered to the facility (between 06/29/23 and 07/07/23) for 1 of 9 residents reviewed for medication administration. Resident #1 should have restarted medication on 07/07/23. Medication error was discovered when FAM called to see if medication needed to be replenished and medication was started again on 07/24/23, which Resident #1 to not receive medication as ordered for 17 days. An IJ was identified on 08/09/23 at 3:30 PM. The IJ template was provided to the facility on [DATE] at 5:36 PM. While the IJ was removed on 08/11/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not IJ scoped at a pattern, due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk of complications from deterioration in health, worsening of cancer, extended recoveries, and hospitalizations. Findings included: Record review of Resident #1's admission record dated 08/09/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included, multiple myeloma not having achieved remission (a cancer of plasma cells, a type of white blood cell, that normally produces antibodies), dysphagia (difficulty in swallowing food or liquid), anxiety disorder (feeling nervous, restless or tense or having a sense of impending danger, panic or doom), cognitive communication deficit (difficulty with thinking or how someone uses language), diabetes (a group of diseases that result in too much sugar in the blood), and PTSD (post-traumatic stress disorder)(a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being). Record review of Resident #1's quarterly MDS assessment, dated 06/06/23, revealed a BIMS of 13, which indicated he was cognitively intact and required supervision and set-up help only with all activities except bathing which revealed he was independent with and required no setup or physical help from staff. Record review of Resident #1's physician orders dated 04/07/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days, then 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). Record review of Resident #1's Nursing Progress Note, dated 7/23/2023 at 21:56 (9:56 PM) revealed the following: Resident's family member asked this nurse how many capsules does resident have left Revlimid 25mg. This nurse noted bottle sealed and has not been opened. RP upset d/t resident has not been getting his Revlimid medication and next dosage of 21 days is soon to come up again. This nurse noted resident's last dose of Revlimid was around 6/30/23. NP notified of missed medication video call this nurse via spruce (communication platform) new order to restart Revlimid 25mg as ordered and notify VA DR. ADON, RP, VA notified. Revlimid ID'd at 2000 (8:00 PM) with narn. Record review of Resident #1's physician orders dated 07/26/23 and signed by ONC, received by LVN C which revealed Lenalidomide 25 mg po daily x 21 days, then 1 week off (next cycle to start once completed prior 21 day supply and 1 week off). Record review of Resident #1's physician orders dated 08/09/23 revealed order for Revlimid Oral Capsule 25 MG (Lenalidomide) Give 1 capsule by mouth at bedtime for RECEIVED FROM OUTSIDE PHARMACY related to MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION until 08/14/2023 at 23:59 (11:59 PM) wear gloves with medication administration/ do not give if broken--- NOTIFY ADON/DON WHEN 7 PILLS REMAIN-- SO ORDER CAN BE DONE******** Record review of Resident #1's MAR for June 2023 revealed Revlimid Oral Capsule 25 MG was administered on June 1st and 2nd and then June 9th through 29th at 6:00 PM. Medication was administered correctly for the month of June. Record review of Resident #1's MAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 24th at 6:00 PM. Medication should have restarted on 07/07/23 through 07/27/23. Medication was missed on the days from 07/07/23 to 07/23/23 when medication error was discovered. Medication was restarted on 07/24/23 after physician was notified of error and the order was given to restart medication immediately. Record review of Resident #1's TAR for July 2023 revealed Revlimid Oral Capsule 25 MG was administered on July 25th through 31st at 6:00 PM. Medication was continued correctly. Record review of Resident #1's TAR for August 2023 revealed Revlimid Oral Capsule 25 MG was administered on August 1st through 8th at 6:00 PM. Medication was administered during this time. Revlimid Oral Capsule 25 MG (Lenalidomide) 1 capsule by mouth at bedtime. This medication is a chemotherapy and is used to treat multiple myeloma not having achieved remission, which is a cancer of plasma cells, a type of white blood cell, that normally produces antibodies per Google. Record review of Resident #1's care plan dated 07/25/2023 revealed resident takes cancer medication Revlimid. Cycles on medication for 21 days and off for 7 days- (Medication supplied by the VA Pharmacy/ resident's FAM brings medication to facility) Goals: Staff to assure medication is administered per orders through review period. Interventions: Monitor for adverse reactions- which include- hypersensitivity, angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes), [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucous membranes that is often a reaction to medication or an infection), toxic epidermal necrolysis (a life threatening skin disorder characterized by a blistering or peeling of the skin), Tumor Lysis Syndrome (a group of metabolic abnormalities that can occur as a complication from the treatment of cancer), hepatotoxicity (injury or impairment of the liver function caused by exposure to xenobiotics such as drugs, food additives, alcohol, chlorinated solvents, peroxidized fatty acids, fungal toxins, radioactive isotopes, environmental toxicants, and even some medicinal plants), thrombocytopenia (a low number of platelets in the blood), neutropenia, pruritis (itching), rash, fatigue, constipation, nausea. Staff to assure that medication is swallowed whole and not chewed. Staff to wear gloves with administration of this medication. During an interview on 08/09/2023 at 11:16 AM with MA E, she stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause major side effects. She stated a blood pressure medication could cause a blood pressure to rise or fall, aspirin could cause heart problems, and Depakote could cause agitation, and missing a medication could even cause death depending on the medication. She stated she was in-serviced 07/25/23 on medication administration. During an interview on 08/09/2023 at 11:44 AM with LVN A, he stated medications should be given to residents as ordered by the physician. He stated if a resident was not given medications correctly, it could potentially cause adverse reactions. He stated he was in-serviced 07/25/23 on medication administration. During an interview on 08/09/2023 at 11:55 AM with LVN B, she stated she was in-serviced 07/25/23 on medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause adverse side effects, delayed action of medication for whatever it was supposed to cure, or if it was for a preventative measure, whatever it was supposed to prevent could occur. She stated Resident # 1's medication came from the VA. She stated the FAM picked the medication up and dropped it off at the facility. She stated the medication did not come from their pharmacy, and they did not order it. She stated Resident #1 took the medication for 21 days and was off of the medication for 7 days and it continuously cycled that way. She stated she was not sure where the disconnect was or if the nurse that the FAM gave it to just forgot or what, but the resident did not get his medication started back up this last time on time. She stated she did not know exactly how many days the medication had been missed. During an interview on 08/09/2023 at 12:13 PM with MA F, she stated she was in-serviced 07/25/23 on medication administration. She stated medications should be given to residents as ordered by the physician. She stated if a resident was not given medications correctly, it could potentially cause a change in resident's body or it could potentially cause harm. During an interview on 08/09/2023 at 1:16 PM with ADM and DON, they stated they had in-serviced staff 07/25/23 on medication administration. They stated medications should be given to residents as ordered by the physician. They stated if a resident was not given medications correctly, it would depend on the medication being given as to what reactions could occur. They stated if it was discovered that a medication was not given properly, the nurse should do an assessment on the resident and follow up with notifying the family and doctor. They stated Resident #1 received the chemotherapy medication from the FAM picking it up from the VA and bringing it to the facility. They stated the FAM called facility on 07/23/23 at 21:56 (9:56 PM) and spoke to a nurse and asked how many pills were left to see if he needed to re-order the medication, and that was how it was discovered Resident #1 was not currently receiving the medication. They stated that was when staff realized there was a full bottle of the medication on the medication cart. They stated Resident #1 took the medication for 21 days and off for 7 days, then it started back up and cycled routinely with that order. They stated when the FAM brought the most recent bottle of medication, resident had still not completed previous cycle of medication so nurse could not put the new cycle into the administration record. They stated they could not put the medication into the system to stop and restart the way the medication was ordered. They stated if a resident did not receive this type of medication, it could cause their blood count to be off. They stated they had in-serviced their staff on medication administration and receiving and accepting medications. They stated they had put the medication on a management board, and they discussed this medication every morning now to ensure that the dates were aligned, and the medication was available and being administered as ordered. They stated they had their clinical resource person to look into the system to see if there was any way to put it in the system with no resolution, and they had the pharmacy consultant to check for this as well. They stated if a resident did not receive this medication, it could cause his blood count to be off. They stated the VA informed them that they ran all of residents labs to check for any off blood counts and to make sure that everything looked ok or there was no changes from previous status. They stated resident went to the ONC at the VA every week and has done this throughout the time he was not receiving the medication and there were no adverse reactions. 08/09/2023 at 1:44 PM Attempted to reach the FAM, no answer, left message for return call. During an interview on 08/09/2023 at 1:47 PM with the PA, she stated there was always a potential for harm or adverse reaction with any medication that is missed or not taken. She stated any medication being missed could certainly cause side effects. 08/09/2023 at 1:56 PM Call placed to the ONC, doctor was not available to speak to surveyor. During an interview on 08/09/2023 at 1:58 PM with the PHARM, she stated the only potential thing that could have occurred would have been the progression of cancer. During an interview on 08/09/2023 at 2:14 PM with Resident #1, he stated he just got back from the VA, and he goes to the VA every week because he has cancer. He stated he liked it here and the staff all treated him well. He stated he was told about missing his cancer medication and his FAM talked to him about it also. He stated he has not had any problems or issues due to the medication being missed. He stated he did not realize he was missing any medication and he would not have known it if they did not tell him. He stated he feels safe here in the facility and he has no complaints about anything. He stated he uses a cane or walker for mobility, and he always gets to his appointments. During an interview on 08/09/2023 at 3:09 PM with LVN C, she stated they only received the chemotherapy medication orders from the new bottles of medication when Resident #'s family brought it to them. She stated the only order they had for the medication is what the medication bottle says and from the original paperwork when the resident first started the medication. An immediate Jeopardy (IJ) was identified on 08/09/2023 at 3:30 PM, due to the above failures. The Administrator was notified of the IJ and the IJ template was provided. The Administrator verbalized understanding of the IJ and a Plan of Removal was requested. The Survey team monitored the plan of removal as follows: The Plan of Removal was accepted on 08/11/2023 at 1:50 PM and is as follows: DON assessed resident #1 on 8/9/2023 for new or worsening symptoms associated with his multiple myeloma or adverse side effects of the missed medication including increased pain or neurological symptoms. The attending physician and ONC were notified of medication error and no new orders were given with the exception of restarting medication immediately. The assessment did not reveal any obvious adverse effects related to the deficient practice. The Corporate Clinical Consultant provided education to the DON on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. DON/Designee completed education with all licensed nursing staff on 8/10/2023 regarding the administration of medication in a safe manner according to physician orders and per policy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New staff, will be in-serviced during orientation period prior to working a shift. The DON/Designee completed an audit of all residents to establish which residents receive medications from outside pharmacies on 8/10/2023. 8 residents were identified through this audit. The DON/designee then conducted an audit of medication storage areas to validate that none of these residents' medications were missing and the administration record was reviewed for each resident to validate that there were no missed doses within the last 90 days on 8/10/2023. Care plans updated with directions of receiving from outside pharmacy, also initiated instructions RECEIVED FROM OUTSIDE PHARMACY No issues were identified related to missed doses or missing medication. DON/Designee completed education with all licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required licensed staff were educated on 8/10/2023 on entering orders correctly in Point Click Care for proper and error-free medication administration, and to include instructions 'RECEIVED FROM OUTSIDE PHARMACY as identification when medication is brought in from outside pharmacy, this education will be ongoing for all newly hired nurses. Sr [NAME] President of Clinical Services revised policy titled Medications Brought to the Facility by Resident/Family to having a signed receipt of accepting of the medication by licensed staff only, on 8/10/23. Director of Clinical Operations educated DON in regard to policy change. DON/Designee completed education with all licensed nursing staff informing this of this policy change. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New nursing staff and agency staff will be educated upon or upon initial shift at facility, ongoing. Education completed on 8/10/23. DON/designee completed a review of all residents to validate the availability of all medications on 8/9/2023. There were no concerns identified related to the availability of medications through this review. Director of Nursing/designee completed review of all residents to identify which medication are provided by outside pharmacy. 8 residents were identified. This review was completed on 8/9/2023. No concerns were identified related to missing medications or missed doses in the last 90 days for any of the 8 residents. The orders for the 8 residents identified were updated to reflect that meds are received from an outside Pharmacy to alert nursing staff that refills should not be requested from the house pharmacy on 8/9/2023. Corporate Clinical Consultant completed a review of the following policies on 8/10/2023: Pharmacy Services Overview, Administering Medications, Medications Brought into the Facility by Resident/Family, Accepting Delivery of Medications. Medications Brought into the Facility by Resident/Family policy was revised by Sr [NAME] President of Clinical Services to include signed acceptance receipt of medication, no other policy changes were made. Licensed nurses will communicate via 24 hour report and shift hand off of medications that were ordered and not received during shift. The Corporate Clinical Consultant completed education with the DON on 8/10/2023 on these policies and the procedure for receiving, ordering, and administering medications brought in by family or received from an outside pharmacy. The procedure is to include receipt of medication by a licensed nurse, notification of DON/designee, verification of order from the attending physician, verification of proper order entry in PCC to include notation that medication is received from and outside pharmacy, verification of proper labeling of medication container with medication and resident information, verification of quantity and type medication being delivered from outside pharmacy. The receiving nurse will be responsible for conducting the first check verification as medications are received and orders are entered and the DON/designee, will conduct the second check verification Monday-Friday in the morning clinical meeting to include needed medications for upcoming weekend, and any changes/needs from prior weekend. For after hours or weekends, the receiving nurse will contact on-call nurse manager and physician for any concerns related to supply of medications. The DON/designee completed education with licensed nurses on 8/10/2023 regarding the procedure to ensure that medications are received and administered according to ordered date, time, and frequency for residents whose medications are dispensed from an outside pharmacy. All licensed nurses and medication aides were in-serviced. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all licensed nursing staff were educated. Medications that are received from outside pharmacies will be entered with an additional note in the instruction section indicating that meds are 'RECEIVED FROM OUTSIDE PHARMACY with any additional information on the pharmacy name and/or who delivers the medication and how to obtain a refill. Communication will be shift to shift via 24 hour report, when medications are ordered or needed for licensed nurses to assure timely delivery. Education will be provided to all newly hired nurses prior to their first shift and all current staff have been educated as of 8/10/2023. DON/designee added orders with skipped days through end of calendar year, also added onto daily monitoring for review of ongoing order, on 8/10/2023. The DON/designee will conduct monitoring of new medication orders and medications stocked in medication carts/rooms/refrigerators to validate that medications received from outside pharmacies have orders entered appropriately in Point Click Care, that they are received and administered according to ordered date, time and frequency and that there is adequate stock remaining or that refill request has been initiated. Any concerns identified will be reported to the physician immediately upon identification with corrections made according to physician orders. Monitoring will occur, starting on 8/10/23, 3 times per week for 4 weeks then weekly for 2 months. Any trends identified will be reported to the QAPI Committee monthly and as needed until a lessor frequency until substantial compliance is achieved. QAPI meeting was held on 8/10/23 with the Medical Director, ADM, DON, and Nurse Management to review newly revised policy on medication brought in by family, and review and validate the plan of removal. The Administrator will be responsible for the implementation of ensuring the adequate process regarding Safe Medication Administration. The new processes/system was initiated, and all licensed nursing staff had completed education by 8/10/2023. This new process will be ongoing for new hires and agency staff prior to working a shift at the facility. All licensed nurses and medication aides were in-serviced. DON/designee used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated, completed on 8/10/23. During an interview on 08/09/2023 at 5:30 PM with the ADM, he stated there was only one resident in the facility who receives Chemotherapy. He stated there may have been others before and there were residents with a diagnosis of cancer, but none received chemotherapy now except Resident #1. On 08/09/23 at 5:36 PM Notified ADM of past non-compliance immediate jeopardy and provided ADM with immediate jeopardy template. During an interview on 08/10/2023 12:47 PM with ADM and DON, they stated the facility had a QAPI meeting the morning of 08/10/2023 with the medical director that addressed the medication error in incident but they had not had a meeting regarding medication errors in the past 3 months prior to surveyor entrance. Record review of staff in-service training report dated 07/25/2023 revealed nurses and medication aides were in-serviced on medication administration and medication orders. Record review of facility policy titled Administering Medications dated 2001 (Revised December 2012) revealed in policy statement: Medications should be given in a safe and timely manner, and as prescribed. Record review of facility policy titled Medications brought to the facility by the resident/family dated 2001 (revised April 2007) revealed Policy Statement: The facility shall ordinarily permit residents and families to bring medication into the facility. Policy Interpretation and Implementation: 3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician, and Consultant Pharmacist, shall check to ensure that: b. The medications have been ordered by the resident's Attending Physician and documented on the physician's order sheet. Record review of facility policy titled Pharmacy Services Overview dated 2001 (revised April 2019) revealed Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medication and biologicals and the services of a licensed pharmacy consultant pharmacist. Policy Interpretation and Implementation: 4. Residents have sufficient supply of their prescribed medication and receive medications (routine, emergency or as needed) in a timely manner. 7. Medications are received, labeled, stored, administered and disposed of according to applicable state and federal laws and consistent with standards of practice. 9. The consultant pharmacist , in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including, (but not limited to): a. Acquisition and availability of medications: (4) Facility staff roles and responsibilities during the receipt and storage of medications; b. Medication packaging and dispensing systems; c. Administration of medication; d. Disposition of medications; e. Authorization, training, and competency of personnel; and f. Documentation of processes, as applicable. 08/11/23 10:30am DON stated that on 07/25/23, that there was an alert added to the facility's clinical white board for Resident #1's chemotherapy medication to be re-added to the facility electronic recording system. DON stated that the white board was reviewed daily by the facility's clinical team Administrator, ADON's, DON, Therapy, Social Worker). On 08/11/2023 at 1:50 PM at exit, the facility was notified that the IJ was lowered. However, the facility remained out of compliance at a severity level no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility requiring time to train all staff and monitor their plan of removal.