**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician regarding a significant change in the resident's medical status, for 1 of 6 residents (Resident #1) whose records were reviewed for change in condition, in that: The facility failed to notify the physician that Resident #1 had not received her prescribed anticoagulant (Lovenox) from 11/14/2022 to 11/16/2022, resulting in the resident missing four doses of medication related to DVT (blood clot) diagnosis after it was not available at the facility and Resident #1 expressed pain during the time she was without the medication. An Immediate Jeopardy (IJ) was identified on 11/18/2022 at 6:22 p.m. While the IJ was lowered on 11/23/22, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure placed all residents who were prescribed high risk medications at risk of experiencing pain, physical distress, and death. Findings include: Record review of a Face Sheet dated 11/17/2022 for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis include: acute kidney failure, sepsis (infection), acute kidney failure, muscle weakness, urinary tract infection, type 2 diabetes mellitus, essential hypertension (high blood pressure), hyperlipidemia (high blood cholesterol), anemia, alcohol cirrhosis of the liver, and end stage renal disease. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 12 of 15 which indicated a cognition level that was moderately impaired. Record review of Resident #1's physician's progress note dated 11/11/2022 indicated the resident had history of DVT/PE and was receiving Coumadin. Record Review of Resident #1's ultrasound report dated 11/14/2022 indicated the resident was positive for DVT of her right lower extremity. Record Review of Resident #1's physician's orders dated 11/14/22 revealed an order for Lovenox Solution, Prefilled Syringe (Enoxaparin Sodium) Inject 118 mg subcutaneously every 12 hours for DVT. Record review of Resident#1's care plan with initial date 09/29/22 and revision on 11/17/2022 revealed a focus that Resident #1 was on anticoagulant therapy r/t DVT prophylaxis (Lovenox 118 mg), with goals that the resident will be free from discomfort or adverse reactions related to anticoagulant use, and interventions in place to .administer med as ordered, labs as ordered, report abnormal lab results to MD, and to observe/document/report to MD PRN s/sx of anticoagulant complications. Record review of Resident #1's MAR dated November 2022 indicated that the medication was not recorded as administered for 11/14/22, 11/15/22, or the morning of 11/16/2022 for a total of four doses. Resident #1 received the initial dose of medication on 11/16/2022 at 5 p.m. Record review of Resident #1's progress note entered by LVN A dated 11/15/22 at 1 p.m., read in part, . Pharmacy called to check on the status of Lovenox delivery to the facility, the lady stated it will be on the next run. Oncoming nurse notified of pharmacy response . There was no documentation that Physician A residents MD or /NP A had been notified. Record review of Resident #1's progress note entered by LVN A dated 11/16/22 at 12:40 p.m., read in part, . Nurse came on duty noticed resident medication Lovenox [sic] that was being followed up on yesterday has not yet arrived. Called was place to pharmacy, pharmacy notified nurse that resident needs charge approval for medication [sic]. I asked who did you sent it to, the pharmacy lady said was sent to an email address and I asked her to send to DON, gave email address. DON was notified, about the charge approval, in which she approved the medication. DON said to inform the [Physician A/NP A] . There was no documentation that the Physician A or NP A were contacted by LVN A. Record review of Resident #1's progress note entered by LVN B dated 11/16/22 at 3:27 p.m., read in part, . Pharmacy has been called to send the Lovenox for resident STAT and it is hopped to be sent this evening. [sic] There was no information documentation that the Physician A or /NP A were contacted by LVN A. Record review of the pharmacy packing slip dated 11/16/2022 from pharmacy indicated that Resident #1's Enoxaparin injections were delivered to the facility on [DATE] at 5 p.m. Record review of Resident #1's care plan with initial date 09/29/22 and revisions on 11/17/2022 revealed a focus that Resident #1 was on Anticoagulant therapy r/t DVT prophylaxis (Lovenox 118 mg) with goals and interventions in place. Interview on 11/16/2022 at 2:30 p.m. with Resident #1. She stated that she had a blood clot in the right leg. She stated the physician told her that she would get a shot to treat the clot but, she had not received it, and she was told that the medication had not been delivered. In an interview and Observation on 11/16/2022 at 2:45 p.m. with the DON, she reviewed the MAR dated November 2022 for Resident #1. She said that the Lovenox prescribed to Resident #1 was coded as 9 on the MAR the dates of 11/14/2022-11/16/2022, which meant that the medication was not available. In an interview on 11/16/2022 at 3 p.m. with the Administrator, DON, and Regional Clinical Director(RCD), the RCD said NP A had put the order in on 11/14/22 at 12:17 p.m. for Resident #1's Lovenox 118 mg every 12 hours by injection to the stomach for her DVT. The RCD said that LVN C confirmed the order on 11/14/22 at 1:38 p.m. The RCD said on 11/14/2022 the nurse (LVN B) on the 2 p.m.-10 p.m. should have followed up with the pharmacy when the medication was not delivered, so the medication could have been started on 11/15/2022 at 8 a.m. The RCD continued and said that as of 11/15/2022 at 7:05 a.m. the morning medication was pending delivery from the pharmacy. The RCD said that there was no documentation that nursing staff contacted the resident's physician. The RCD said that the pharmacy was not able to document in the facility's medical records. The RCD said that residents prescribed anticoagulants were usually discussed in the morning meeting, but there had not been a meeting since the SA had entered the building on 11/15/2022. The DON said that she was notified on 11/16/2022 at 2 p.m. by LVN A that the resident's medication was not delivered by the pharmacy. The DON said that LVN A communicated to her after contacting the pharmacy on 11/16/2022 that there was a charge approval preventing the medication from being delivered to the facility. The DON said that she approved the charge on 11/16/2022 shortly after speaking with LVN A. The DON denied having knowledge of the medication not being available on 11/14/2022 or 11/15/2022. The DON said she would need to follow up to confirm if the resident's physician was notified. The DON said the risk of the resident not receiving Lovenox was the DVT could travel, resulting in harm to the resident, and the worst-case scenario could be death to the resident. The Administrator remain silent during the interview. In an interview on 11/16/2022 at 4:05 p.m.with LVN B, he said he worked the hall of Resident #1 from 11/14/2022 to 11/16/2022 from 2 p.m.-10 p.m. He said NP A for Resident #1 prescribed Lovenox for her DVT on 11/14/2022 during the 6 a.m. - 2 p.m. shift. He said the resident had not received the medication because the pharmacy had not delivered the medication to the facility. He said that the pharmacy needed approval for payment which delayed the delivery. He said that on 11/15/2022, LVN A called the pharmacy during the 6 a.m.-2 p.m. shift, and she was told that the medication would be delivered the same day during his shift. He said the medication did not arrive, so he sent a fax to the pharmacy to reorder the medication. He said he did not call the pharmacy or the physician on 11/15/2022. He said on 11/16/2022 at the start of his shift, LVN A called the pharmacy in his presence. He said the pharmacy needed a charge approval was sent to the former DON, and LVN A provided the pharmacy with the contact information for the current DON. He said he called the pharmacy 11/16/2022 at 3 p.m. to confirm that the charge approval had been received from the DON, and the pharmacy agreed to deliver the medication STAT. He said that Resident #1's physician should have been notified immediately on 11/14/2022 that the medication was not available at the facility, and he thought that LVN A notified NP A on 11/14/22 or 11/15/22. He said that he talked to the NP A on 11/16/2022 while she was doing rounds at the facility, and he told her that the medication was delayed but was scheduled to arrive that day during his shift. He said that Resident #1's Lovenox should have started on 11/14/2022. He said that the medication was used to dissolve clots, and the risk to the resident was death. In an interview on 11/16/2022 at 4:22 p.m. with LVN A. She said that she worked double shifts from 6 a.m.-10 p.m. on 11/14/2022 on 11/16/2022. She said that she only worked the hall for Resident #1 from 6 a.m. -2 p.m. She said that Resident #1 expressed pain in the right leg on 11/13/2022, and the physician was notified and ordered an ultrasound. She said that the results of the ultrasound were provided on 11/14/202, and it was positive for a DVT. She said she contacted the physician on 11/14/2022 during the morning but the physician did not respond to the page. She said she notified LVN C, the unit manager. She said LVN C spoke with the NP A, confirmed the order for Lovenox on 11/14/2022, but she was not sure of the time it was entered into the EMR system. She said the medication should have been delivered on 11/14/2022 during the 2 p.m. - 10 p.m. shift, but the medication was not delivered. She said that LVN B contacted the pharmacy when it was not delivered on 11/14/2022. She said she followed up with the pharmacy on 11/15/2022 when she arrived for her shift at 6 a.m. after she saw the medication was not delivered on 11/14/2022. She said that she did not contact the unit manager (LVN C), the DON, the Administrator, or the physician that the medication was never delivered on 11/14/2022 or 11/15/2022. She said that when she contacted the pharmacy on 11/16/2022 she was told that the medication was not delivered due to a charge hold, and the authorization had been emailed to staff that was no longer working at the facility. She said that she provided the pharmacy with the contact information for the current DON, and the issue was resolved. She said that LVN B requested that the medication be delivered STAT. She said that unit manager, LVN D, notified the physician of the delay in the medication being delivered to the facility. She said that Lovenox was prescribed to prevent or dissolve a clot. She said that the risk to the Resident was that if the clot traveled, it could cause a stroke, if the clot traveled to the lung it could cause respiratory failure and lead to death. In an interview on 11/16/2022 at 4:53 p.m. with the RCD, he said the pharmacy was contacted by LVN A on 11/15/2022 during her shift when Resident #1's medication was not delivered and was told that it would be delivered on the next shift. He said that LVN B resent the order to the pharmacy when the medication was not delivered on his shift. He said that LVN A followed up with the pharmacy on 11/16/2022 and she was told a guarantee of who would pay for the medication was needed. He said that LVN A told the pharmacy to send the authorization to the DON. He said that LVN A then informed the DON at 2 p.m., and the DON completed the authorization. He said that the DON told LVN A to notify the Physician, but LVN A did not get a response from the Physician when paged. He said that the unit manager, LVN D, was able to contact the physician to inform her of the delay in receiving the medication. He said that the physician communicated that the NP A had laid eyes on Resident #1 on 11/16/22, and she was stable, so the Physician did not want the resident sent out to the hospital. He said the that medication was ordered STAT and the medication would be given upon arrival. He said that the Administer should have notified the pharmacy that there had been a change in the DON last week. He said that both LVN A and LVN B would be written up as they did not notify the Unit Managers, DON, Administrator, or the Physician when the mediation was not delivered. He said that the Physician should have been notified immediately that the Lovenox was not available, as the risk to the resident could have been pulmonary embolism that could result in death. In a follow up interview on 11/17/2022 at 11:32 a.m. with LVN A, she said that on 11/16/2022 she notified the DON that the pharmacy needed a charge approval for Resident #1's Lovenox. She said that the DON check her email, she received the charge approval, and she signed it. She said that she was told to call the doctor, let them know Resident #1 had not gotten the medication, and check on the resident. She said that Resident #1 was okay because her vitals were within normal range, but the resident said that other than the pain on her leg she was fine. She said that they had Lovenox in the E-kit but the strength was 30 mg and 40 mg, and the strength for Resident#1 was 118 mg. She stated she did not notify the doctor about the medication not being delivered. She stated that she did not complete a pain assessment. She stated the blood clot could have dislodge, traveled, and it could have caused a stroke. In an interview on 11/17/2022 at 12:47 p.m. with unit manager, LVN D, . she said that she was never made aware that Resident #1 did not have prescribed Lovenox delivered to the facility by either LVN A or LVN B. She said that she was first made aware by the DON on 11/16/2022 after the DON was informed by LVN A. She said that she notified the Physician A on 11/16/2022 around 4 p.m. that the medication had not been delivered but expected to arrive that same day. She said that Physician A said to give the resident the medication once it arrived. She said that the LVN A and LVN B should have notified the physician immediately, let the physician decide if the resident should be sent to the hospital or to change the medication to something that was available in the E-Kit. She said the that medication was used to treat clots, and if left untreated could put the resident at risk of harm to include death. Interview on 11/17/22 at 2:31 p.m. with the Physician A . She said that she was contacted by the DON on 11/16/22, but unsure of the time, to inform her that the Resident #1 had not received the Lovenox. She said that the facility should have contacted her ASAP that the medication was not available. She said that the risk to the resident was pulmonary embolism. She requested that contact be made with the NP A for additional questions. Interview on 11/17 2022 at 2:50 p.m. with NP A, she said that Resident #1 was having pain in the right leg so she ordered an ultrasound that confirmed DVT to the right lower extremity on 11/14/2022. She stated that the facility contacted the answering services for the Physician on 11/14/2022 in the morning. She said that she spoke with LVN C to confirm Resident #1's weight before she ordered Lovenox. She said that she conducted rounds at the facility on Monday's, Wednesday's, and Friday's. She said that she arrived at the facility on Wednesday, 11/16/2022, between 1:30 p.m.- 2 p.m. for rounds. She said that when she was assessing Resident#1 for side effects of the Lovenox and Resident #1 told her that she had not received the medication. She said that she went to the nurse's station and spoke with LVN B between 2:30 p.m.- 3 p.m., he told her that the medication had been delayed, had arrived that day, and the resident had received the medication. She said that she went back to the resident's room and assessed her. She said that the DON contacted the Physician on 11/16/2022 to inform her that the medication was never delivered to the facility due to a preauthorization issue. She said that when she was in communication with Physician A who wanted the resident to go to the hospital, but they agreed that it was not needed because the medication had been delivered, and resident had received the medication. She said that the Physician A indicated that the DON did not want the resident to be sent out to the hospital. She said that the facility should have notified the Physician A or her immediately on 11/14/2022 when they became aware that the medication was not available, and the facility would have been directed to send the resident to the hospital. She said that the risk to the resident was pulmonary embolism, that could have cost the Resident #1 her life. She said that the facility did have Lovenox in the E-Kit. She said that if she would have been notified, she would not have authorized as lesser dosage from the E-kit and she would have recommended that Resident #1 be sent to the hospital. In an interview on 11/17/22 at 3:00 p.m. with Resident #1, she said she received her first dose of Lovenox on 11/16/2022 after 6:00 p.m. and one dose the morning of 11/17/2022. She said that she told a nurse that she had not received her blood thinner. She said that she told the same nurse that her right lower leg was throbbing, shooting, and jolting. She said that she was told they were still waiting for the pharmacy to deliver the medication. In an interview on 11/17/2022 at 4:50 p.m. with LVN B, he said that he gave the first dose of Lovenox to Resident #1 on 11/16/2022 in the evening after the medication was delivered. He said that he told NP A that the medication had not come in and it was called as STAT on 11/16/2022 between 2 p.m.-2:30 p.m. He stated that NP A said to give the medication as soon as they got it. In an interview on 11/18/22 at 2:09 p.m. with the Administrator, she said that she was notified that Resident #1's Lovenox was unavailable on 11/16/22 around 2 p.m., when LVN A told the DON. She said that she was not sure of the time, but she thought it was around 2 p.m. She said the DON told LVN A to contact the physician and document her efforts, but LVN A did neither. She stated that she was not sure of the date and time Physician A was notified. She said that the expectation was for a physician to be notified immediately when medications were unavailable. She said the negative outcome of Resident #1 not receiving her medication could be harm or death. She stated that she notified the pharmacy last week that there was a new DON, so they would have had the updated contact information for the charge approval for payment. Record review of Change in a Resident's Condition or Status Policy revised April 2007 read in part, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on call physician when there has been: e. A need to alter the resident's medical treatment significantly; . On 11/18/2022 at 6:22 p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR submitted by the Administrator was accepted on 11/20/2022 at 9:32 a.m. The facilities Plan of Removal read: 1. 11/18/2022- Resident #1 was assessed by the clinical services director RN and was in no apparent distress. This was documented in the resident's clinical record. Resident #1 was sent to the hospital on [DATE] for nausea and remained there at this time. 2. Nurses in-serviced on 11/18/2022 by the DON and designee on monitoring of residents with DVT for any adverse signs or symptoms. These assessments are to be q-shift and documented on the medication administration record. 3. The Attending Physician was notified at 4:47 p.m. on 11/16/2022 that the Lovenox injection had not been administered as ordered and she advised the Unit Manager that since NP A had been at facility earlier today and reported the patient was stable and there was no need to send to the ER. 4. The Attending Physician then stated to Unit Manager to administer the Lovenox when it arrives from the pharmacy. 5. The medication, Lovenox was delivered by the Pharmacy on 11/16/2022 at 5:00 p.m. and was administered immediately as ordered by the attending physician. The attending physician also asked that the next dose be given at 5:00 a.m. tomorrow (11/17/2022). 6. 11/18/22- The nurse manager in-serviced nursing staff currently responsible for Resident #1 on ensuring anticoagulant medications are given as ordered by the physician. The in-service also included reasons to notify the physician. This included when there was a change of condition or med availability issue. Nurses will not be allowed to work until they are in-serviced on administering anticoagulant medications as ordered by the physician. 7. 11/18/22- The DON confirmed via med cart and chart review that Resident #1's Lovenox was in in house and that she had not missed a dose of the medication since the medication was initially dosed on 11/16/2022 at 1730. 8. 11/18/2022- All resident's orders were reviewed by the Clinical Services Director to identify other residents receiving anticoagulant medications. No other discrepancies were noted. The Clinical Services Director, Unit Manager and Infection Prevention Nurse Manager verified that these residents were receiving their prescribed anticoagulant medications as ordered. 9. All residents who have experienced a change of condition will be reviewed. 10. On 11/18/2022 the Corporate Clinical Services Director and Administrator in-serviced the DON and Nurse Managers on notifying the attending physician as soon as a change of condition is identified or when a medication is not available for a resident. The DON and Nurse Managers verbalized teach back of education provided to them. 11. The Clinical Services Director reviewed the facility policy on 11/18/22 regarding notification of physician and no revisions were deemed necessary. 12. An in-service was completed on 11/18/2022 by the DON and Administrator with the licensed nursing, including contract staff, and medication aides on notifying the attending physician timely when a change of condition occurs or when a medication is not available for a resident. Licensed nurses, including contract nurses and medication aides will not be allowed to return to work until they receive this in-service. 13. The 24-hour report will be reviewed daily beginning on 11/19/22 by the DON or designee to audit nurse documentation in progress notes notifying the attending physician of patient resident change of conditions or medications not being available. Discrepancies noted during reviews will be immediately be corrected by contacting attending physician of change of condition or medications not being available and completing documentation in the patient's resident's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. 14. Review will be documented on an audit report form. 15. The Administrator will review the audit reports on a weekly basis to ensure the nurse managers are following the plan of correction. Review will be documented on an audit report form beginning 11/19/22. 16. On 11/18/22 an impromptu QAPI meeting was held, and the Plan of Removal was reviewed and accepted by the Medical Director. 17. On 11/19/22 the RVP communicated with the pharmacy representative via email on ensuring that they email the facility DON and Administrator when there are issues related to medication delivery and prior authorizations. This included sending the pharmacy the accurate email addresses for those individuals. Following acceptance of the facility's POR, the facility was monitored from 11/21/2022 to 11/23/2022, and the surveyor confirmed the facility implemented their POR sufficiently to lower the IJ. Record review of progress notes dated 11/18/2022 and entered by the RCD revealed that Resident #1 was assessed. Record review of progress notes dated 11/20/2022 and entered by the DON revealed that Resident #1 was sent to the hospital on [DATE] for UTI and A-fib. Record Review of, the In-Service Training Report, dated 11/18/2022 revealed that all Unit Managers and Charge Nurses were educated by the DON and Administrator on the topics of: Change in Condition. Record Review of, the In-Service Training Report, dated 11/18/2022 revealed that all nursing staff were educated by the IP and Administrator on the topics of: When to notify [Physician] or /[NP A]. Record Review of, the In-Service Training Report, dated 11/18/2022 revealed that all nursing managers were educated by the RCD on the topics of: Notification Changes. Record Review of, the In-Service Training Report, dated 11/18/2022 revealed that all nursing staff were educated by the Administrator and DON on the topics of: Notification Changes/Medication Orders. Record review of the QAPI completed on 11/18/2022 with the MD, Administrator, Regional Administrator, RVP, IP, and DON that revealed that topics identified in the POR were discussed with the MD. In an interview on 11/21/22 at 11:30 a.m., Resident #1 while at the hospital, Resident #1 the resident said that she was sent to the hospital due to her heart beating funny. While at the hospital, efforts to confirm with hospital staff if the resident was hospitalized due to DVT were unsuccessful; however, hospital staff confirmed that the resident was not receiving Lovenox since being admitted . In an interview on 11/21/2022 at 4:42 p.m.with the MD. She said that she was notified by the facility of the IJ, she participated in the QAPI, and during the meeting the POR was discussed. She said that she was concerned that the resident's physician was not notified immediately after the medication was not delivered by the pharmacy. She stated that without the medication that was prescribed there was a chance that the DVT could have detached and become a pulmonary embolism that could have been life threatening. Interviews were conducted 11/21/22 on the 2 p.m.-10 p.m. shift with the Administrator, DON, LVN D, LVN E, LVN F, MA A, LVN G, LVN H, MA B, and LVN I to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, expectations, and all were able to explain the policies/protocols concerning notification change, change in condition, and medication orders. Interviews were conducted 11/22/22 on the 6 a.m. -2 p.m. shift with RN A, LVN J, LVN K, LVN L, and MA C; and the 2pm-6pm and 2 p.m.-10 p.m. shift with the MDS Coordinator and PPS Coordinator to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, expectations, and all were able to explain the policies/protocols concerning notification change, change in condition, and medication orders. An interview on 11/22/2022 at 11:20 a.m. with DON, she said that she was not aware that Resident #1 did not have Lovenox to treat DVT in the facility until 11/16/2022, but she was unsure of the time. She said that she was in her office with the Administrator, when LVN A entered and said a charge approval was needed for the residents Lovenox. She said that she immediately checked her email, and replied to the pharmacy that the charge was approved. She said that was the only email that she had received from the pharmacy. She stated she instructed LVN A, to contact the resident's physician and document but she did not. She said that she did not ask the nurse how many doses of Lovenox were missed. She said that the only conversation she had with Unit Manager LVN C was the physician had ordered for the resident's oncologist to be contacted for management of the DVT, and she was reporting that she had contacted oncology and they gave an order for the Lovenox medications. She stated that the NP A put the order in for the Lovenox and LVN C confirmed the order. She said neither that LVN A or LVN B reported to their Unit Managers, Administrator, Physician, NP A, or her that the resident was not receiving the Lovenox. She said that the medication arrived on the 11/16/22 at 5 p.m. She said that the NP A came to the facility on [DATE] but she was not aware that the NP A entered the facility. She said that LVN B was terminated. She said that LVN A resigned before she could be terminated. She said that the risk of Resident #1 could have caused a pulmonary embolism that could have resulted in death. In an interview on 11/22/22 at 2:34 p.m. with Unit Manager LVN C, she said that she was never made aware by LVN A or LVN B that Resident#1 had not received her Lovenox as ordered by NP A. She said that the NP A ordered Lovenox after the DVT was confirmed on 11/14/2022. She stated that the NP A needed the resident's weight prior to the order, and that was the only communication that she had with the NP A. She stated that she was not at work on 11/15/2022 or 11/16/2022, and she was only made aware of the issue after the DON contacted her. She said that the staff should have notified the physician immediately and communicated the information to a Unit Manager and DON. She said that the risk of Resident #1 not receiving her medication as ordered could have caused a pulmonary embolism that could have resulted in death. She said that she was in-serviced along with all nursing staff, and she was able to explain the policies/protocols concerning notification change, change in condition, and medication orders. Interviews were conducted on 11/23/22 on the 6 a.m.- 2 p.m. shift with MA C to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, expectations, and all were able to explain the policies/protocols concerning notification change, change in condition, and medication orders. On 11/23/2022 at 12:04 p.m. the immediacy was lowered, however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an immediate jeopardy. The facility was continuing to monitor their POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 2 of 11 residents (Resident #1 and Resident #2) whose records were reviewed for significant medication errors, in that: -The facility failed to administer prescribed Lovenox, 118 milligrams to Resident # 1 for a total of four doses on 11/14/22-11/16/22. -LVN L changed the dosage on Resident#2's prescribed Metoprolol Tartrate without clarifying the change in the dosage with the prescribing physician. -LVN J and MA C administered Metoprolol Tartrate to Resident#2 that had been prescribed to another resident at the facility. An Immediate Jeopardy (IJ) was identified on 11/18/2022 at 6:22 p.m. While the IJ was lowered on 11/23/22, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who were prescribed high risk medications at risk of experiencing pain, physical distress, and death. Findings include: Resident #1: Record review of a Face Sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included acute kidney failure, sepsis, acute kidney failure, muscle weakness, urinary tract infection, type 2 diabetes mellitus, essential hypertension (high blood pressure), hyperlipidemia (high blood pressure), anemia, alcohol cirrhosis of the liver, and end stage renal disease. Record review of Resident#1's MDS dated [DATE] revealed a BIMS score of 12 which indicated a cognition level that was moderately impaired. Record review of Resident 1's physician progress note dated 11/11/2022 indicated that resident had history of DVT/PE on Coumadin. Record Review of Resident#1's ultrasound report dated 11/14/2022 indicated that resident was positive for DVT of right lower extremity. Record Review of physician orders dated 11/14/22 for Lovenox Solution, Prefilled Syringe (Enoxaparin Sodium) Inject 118 mg subcutaneously every 12 hours for DVT Record review of Resident #1's MAR dated November 2022 indicated that the medication was not recorded as administered for 11/14/22, 11/15/22, or the morning of 11/16/2022. Resident#1 received the initial dose of the medication 11/16/2022 at 5pm. Record review of packing slip dated 11/16/2022 from pharmacy indicated that Resident#1's Enoxaparin injections was delivered to the facility on [DATE] at 5pm. Record review of Resident#1's care plan with initial date 09/29/22 and revisions on 11/17/2022 revealed a focus that Resident#1 was on Anticoagulant therapy r/t DVT prophylaxis (Lovenox 118 mg) with goals and interventions in place. Resident #2: Record review of a Face Sheet for Resident #2 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included encephalopathy(diffuse disease of the brain that alters brain function), anemia, type 2 diabetes mellitus, hypertension(high blood pressure), cardiomegaly(enlarged heart), urinary tract infection, altered mental status, and hyperglycemia( high blood glucose). Record review indicated that Resident#2 did not have a completed 14 day admission MDS. Record review of Resident#2's baseline care plan dated 11/03/2022 revealed a focus for hypertension with goals and interventions in place. Record review of physician order summary revealed that Resident #2 was prescribed Metoprolol Tartrate Tablet 75 MG by Physician B on 11/02/2022 to be given 0.6666 tablet by mouth two times a day for HTN. The ordered was discontinued on 11/14/2022. Record review of physician order summary revealed that Resident #2 was prescribed Metoprolol Tartrate Tablet 50 MG Physician B on 11/14/2022 to be given 1 tablet by mouth two times a day for HTN. The ordered was discontinued on 11/18/2022. Record review of physician order summary revealed that Resident #2 was prescribed Metoprolol Tartrate Tablet 25 MG NP B on 11/18/2022 to be given 1 tablet by mouth two times a day for hypertension. Record review of Resident #2's MAR dated November 2022 read in part, .Metoprolol Tartrate Tablet 75 MG Give 0.6666 tablet by mouth two times a day for HTN, was given twice on 11/3/2022, 11/5/2022, 11/6/2022, 11/8/2022, 11/9/2022, and 11/10/2022. The medication was given once on 11/7/2022 and 11/12/2022. The medication was marked as unavailable twice on 11/4/2022 and 11/12/2022, and once on 11/07/2022, 11/11/2022, 11/13/2022, and 11/14/2022. Record review of progress notes dated 11/18/2022 entered by the DON, read in part . Discussed Metoprolol with NP B, vitals reviewed. NP B gave verbal order to decrease Metoprolol to 25 mg 1 tab twice a day. Resident #2 and resident's daughter made aware of medication change. Charge nurse made aware, instructed nurse to monitor resident's condition, B/P, pulse due to medication change and notify physician if medication dosage change is not effective . Interview on 11/16/2022 at 2:30 p.m. with Resident #1, she stated that she had a blood clot in the right leg. She stated that the physician told her that she would get a shot to treat the clot, she had not received it, and she was told that the medication had not been delivered. In an interview and observation on 11/16/2022 at 2:45 p.m. with the DON, she reviewed the MAR for Resident#1. She stated that the Lovenox prescribed to Resident#1 was coded as 9 on the MAR the dates of 11/14/2022-11/16/2022, which meant that the medication was not available. In an interview on 11/16/2022 at 3pm with Administrator, DON, and Regional Clinical Director(RCD). The RCD stated that the NP A put the order in on 11/14/22 at 12:17 p.m. for Resident#1's Lovenox 118 mg every 12 hours by injection to the stomach for DVT. The Regional Clinical Director stated that LVN C confirmed the order on 11/14/22 at 1:38 pm. The RCD stated that stated that on 11/14/2022 the nurse (LVN B) on the 2pm-10pm should have followed up with the pharmacy when the medication was not delivered, so that the medication could have started on 11/15/2022 at 8am. The RCD stated that as of 11/15/2022 at 7:05 am medication was pending delivery from pharmacy. The RCD stated that there was no documentation that nursing staff contacted the resident's physician. The [NAME] Clinical Director stated that the pharmacy is not able to document in the facility's medical records. The RCD stated that residents prescribed anticoagulants are usually discussed in the morning meeting, but there had not been a meeting since SA was in the building. The DON stated that she was notified on 11/16/2022 at 2pm by LVN A that the resident's medication was not delivered by the pharmacy. The DON stated that LVN A communicated to her after contacting the pharmacy on 11/16/2022 that there was a charge approval preventing the medication from being delivered to the facility. The DON stated that she approved the charge on 11/16/2022 shortly after speaking with LVN A. The DON denied having knowledge of the medication not being available on 11/14/2022 or 11/15/2022. The DON stated that she would need to follow up to confirm if the resident's physician was notified. The DON stated that risk of resident not receiving Lovenox, is that the DVT could travel, result in harm to the resident, and the worst-case scenario could be death to the resident. The Administrator remained silent during the interview. In an interview on 11/16/2022 at 4:05 PM with LVN B, he stated that he worked on the hall of Resident#1 from 11/14/2022 - 11/16/2022 from 2pm-10pm. He stated that the NP A for Resident#1 prescribed Lovenox for DVT on 11/14/2022 during the 6 am-2pm shift. He stated that resident had not received the medication because the pharmacy had not delivered the medication to the facility. He stated that the pharmacy needed approval for payment which delayed the delivery. He stated that on 11/15/2022, LVN A called the pharmacy during the 6 am-2pm shift, and she was told that the medication would be delivered the same day during his shift. He stated that the medication did not arrive, so he sent a fax to the pharmacy to re order the medication. He stated that he did not call the pharmacy or the physician on 11/15/2022. He stated that on 11/16/2022 at the start of his shift, LVN A called pharmacy in his presence. He stated that the pharmacy said they sent an charge approval to the former DON, and LVN A provided the pharmacy with the contact information for the current DON. He stated that he called the pharmacy 11/16/2022 at 3pm to confirm that the charge approval had been received from the DON, and the pharmacy agreed to deliver the medication STAT. He stated that Resident#1's physician should have been notified immediately on 11/14/2022 that the medication was not available at the facility, and he thought that LVN A notified NP A on 11/14/22 or 11/15/22. He stated that he talked to the NP A on 11/16/2022 while she was doing rounds at the facility, and he told her that the medication was delayed but scheduled to arrive that day during his shift. He stated that Resident#1's Lovenox should have started on 11/14/2022. He stated that the medication is used to dissolve clots, and the risk to resident is death. In an interview on 11/16/2022 at 4:22 pm with LVN A. She stated that she worked double shifts from 6 am-10pm on 11/14/2022-11/16/2022. She stated that she only worked the hall for Resident#1 from 6am-2pm. She stated that Resident#1 expressed pain in the right leg on 11/13/2022, and the physician was notified and ordered a ultrasound. She stated that the results of the ultrasound were provided on 11/14/202, and it was positive for DVT. She stated that she contacted the physician on 11/14/2022 during the morning but the physician did not respond to the page. She stated that she notified LVN C the unit manager. She stated that LVN C spoke with the NP A, confirmed the order for Lovenox on 11/14/2022, but she was not sure of the time it was entered in the system. She stated the medication should have been delivered on 11/14/2022 during the 2pm-10pm shift, but the medication was not delivered. She stated that LVN B contacted the pharmacy when it was not delivered on 11/14/2022. She stated that she followed up with the pharmacy on 11/15/2022 when she arrived for her shift at 6 am after she saw the medication was not delivered on 11/14/2022. She stated that she did not contact the unit manager (LVN C) DON, Administrator, or the physician that the medication was never delivered on 11/14/2022 or 11/15/2022. She stated that when she contacted the pharmacy on 11/16/2022 she was told that the medication was not delivered due to a charge hold, and the authorization had been emailed to staff that was no longer working at the facility. She stated that she provided the pharmacy with the contact information for the current DON, and the issue was resolved. She stated that LVN B requested that the medication be delivered STAT. She stated that the unit manager( LVN D) notified the physician of the delay in the medication being delivered to the facility. She stated that Lovenox is prescribed to prevent or dissolve a clot. She stated that the risk to the Resident is that if the clot travels it could cause a stroke, if the clot travels to the lung it could cause respiratory failure and lead to death. In an interview on 11/16/2022 at 4:53pm with the RCD. He stated that the pharmacy was contacted by LVN A on 11/15/2022 during her shift when the medication was not delivered and was told that it would be delivered on the next shift. He stated that LVN B resent the order to the pharmacy when the medication was not delivered on his shift. He stated that LVN A followed up with the pharmacy on 11/16/2022 and she was told a guarantee of who would pay for the medication was needed. He stated that LVN A told the pharmacy to send the authorization to the DON. He stated that LVN A then informed the DON at 2pm, and the DON completed the authorization. He stated that the DON told LVN A to notify the Physician, but LVN A did not get a response from the Physician when paged. He stated that the unit manager, LVN D, was able to contact the physician to inform of the delay in receiving the medication. He stated that the physician communicated that the NP A had had laid eyes on Resident#1 on 11/16/22, and she was stable, so the Physician did not want resident sent out to the hospital. He stated that medication was ordered STAT and the medication will be given upon arrival. He stated that the Administer should have notified the pharmacy that there had been a change in the DON last week. He stated that both LVN A and LVN B will be written up as they did not notify the Unit Managers, DON, Administrator, or Physician when the mediation was not delivered. He stated that the Physician should have been notified immediately, as the risk to the resident could have been pulmonary embolism that could result in death. In an interview on 11/17/2022 at 10:28 am with MA C. She stated that she had worked the 200, 300, and 600 hall. She stated that nurses put the medication in on admission, complete the initial dose, and take medications from the E-Kit. She stated that MAs administer PO medications, but the nurses give PRN medications. She stated that a nurse pulls the medication from the E kit. She said the nurse would pull the medication and give it to her because it was not initial dose and on the back of the medication it does have the name of the medication and the dose. She said she had about nine residents on two halls that are on blood pressure medication. She stated that medication are reordered 5 days before the medication runs out. She stated that she would notify the nurse that the resident's medication is out and the reorder is not available. She stated that the nurse will call the pharmacy and then they would pull it from the E-Kit. She stated that she had not run out of blood pressure medication or given PRN blood pressure medication for any of her resident on the halls that she has worked. She stated that she gave the medication as ordered. She stated that, she does not know anything about Resident #2's blood pressure medication. In an observation on 11/17/2022 from 10:49 am-11:20 am of the medication cart for the 200 hall revealed there was 1 (Resident#2) of 9 residents on blood pressure medication that did not receive medication. Resident#2's was admitted to the facility on [DATE], and the resident did not receive the medication for 11 days. Metoprolol 50 mg 1 tab po bid was ordered on 11/14/2022. In a follow up interview on 11/17/2022 at 11:32 am with LVN A. She stated that on 11/16/2022 she notified the DON that the pharmacy needed a charge approval for Resident#1's Lovenox. She stated that the DON checked her email, she received the charge approval, and she signed it. She stated that she was told to call the doctor, let them know Resident#1 had not gotten the medication, and check on the resident. She stated that Resident#1 was ok because her vital were within normal range, but the resident stated that other than the pain on her leg she was fine. She stated that they have Lovenox in the E kit but the strength was 30 mg and 40 mg, and the strength for Resident#1 was 118 mg. She stated she did not notify the doctor about the medication not being delivered. She stated that she did not complete a pain assessment. She stated the blood clot could have dislodged, traveled, and could have caused a stroke. In an interview on 11/17/2022 at 12:09 p.m with LVN L. She stated that when Resident #2 was admitted to 500 hall, on 11/14/2022, MA C, came to her and said when she clicked on Metoprolol it had dose of .6666. She stated that she looked at the discharged order from the hospital, looked the same, and she did not know what that meant. She stated that she called the pharmacy to see what it meant, and they figured to be 50 mg. She stated that she discontinued the order, and entered a new order for 50 mg. She stated that she did not call the doctor when she figured it out with pharmacy. She said she should have clarified with the doctor. In an interview on 11/17/2022 at 12:46 p.m. with unit manager, LVN D. She stated that she is the unit manager for 200, 300, and 600 Hall. She stated that she became aware of the issues with Resident #2's Metoprolol on 11/16/2022. She stated that the DON contacted the staff and the pharmacy to find out how it was filled due to the .6666. She stated LVN L stated that the order was messed up, she called the pharmacy, and they changed it to 50 mg. She stated that to reduce a resident medication, you have to get an order from the doctor, put the order in, contact the pharmacy to send a new dose, and the old dose will be taken. She stated that even if the pharmacy said it should be 50 mg the doctor should be notified before changing the order. She said that if a resident blood pressure medication was reduced it wound not manage the resident blood pressure, the blood pressure would be high, and may have a negative outcome. She stated that she was never made aware that Resident#1 did not have prescribed Lovenox delivered to the facility by either LVN A or LVN B. She stated that she was first made aware by the DON on 11/16/2022 after she was informed by LVN A. She stated that she notified the Physician on 11/16/2022 around 4pm that the medication had not been delivered but expected to arrive that same day. She stated that the Physician stated to give the resident the medication once it arrived. She stated that the LVN A and LVN B should have notified the Physician immediately, let the physician decided if the resident should be sent to the hospital or to change the medication to something that was available in the E-Kit. She stated that medication is used to treat clots, and if left untreated could put the resident at risk of harm to include death. In an interview on 11/17/2022 at 1:35 p.m. with the DON. She stated that she became aware of the issues with Resident #2's Metoprolol on 11/16/2022. She stated that the order was for 0.6666. She stated that LVN B said that he verified the order with the pharmacy and when the resident was moved LVN L certified it with a provider if she remembered correctly. She stated that LVN L put the order in the system and the pharmacy sent out the 50 mg. She stated that change to the medication should have been clarified with the physician. She said the changed medication would not be effective for the blood medication. She said she was waiting for the pharmacy to send the initial blister packet for the Metroprolol. She said if a resident did not receive the blood pressure medication it could cause the residents blood pressure to be high and the resident may stroke out. Interview on 11/17/22 at 2:31pm with the Physician A. She stated that she was contacted by the DON on 11/16/22 but unsure of the time she was informed the resident had not received the Lovenox. She stated that the facility should have contacted her ASAP that the medication was not available. She stated that the risk to the resident was pulmonary embolism. She requested that contact be made with the NP A for additional questions. Interview on 11/17/2022 at 2:50pm with NP A., she stated that Resident#1 was having pain in the right leg so she ordered an ultrasound that confirmed DVT to the right lower extremity on 11/14/2022. She stated that the facility contacted the answering services for the Physician on 11/14/2022 in the morning. She stated that she spoke with LVN C to confirm Resident#1's weight before she ordered Lovenox. She stated that she conducts rounds at the facility on Monday, Wednesday, and Fridays. She stated that she arrived at the facility on 11/16/2022 between 1:30m-2pm for rounds. She stated that when she was assessing Resident#1 for side effects of the Lovenox is when Resident#1 told her that she had not received the medication. She stated that she went to the nurse's station, she spoke with LVN B between 2:30pm-3pm, he told her that the medication had been delayed, had arrived that day, and the resident had received the medication. She stated that she went back to the resident's room and assessed her. She stated that the DON contacted the Physician A on 11/16/2022 to inform that the medication was never delivered to the facility due to a preauthorization issue. She stated that when she was in communication with the Physician who wanted the resident to go to the hospital, they agreed that it was not needed because the medication had been delivered, and resident had received the medication. She stated that the Physician indicated that the DON did not want the resident to be sent out to the hospital. She stated that the facility should have notified the Physician A or her immediately on 11/14/2022 when they became aware that the medication was not available, and the facility would have been directed to send the resident to the hospital. She stated that the risk to the resident was pulmonary embolism, that could have cost the resident her life. She stated that the facility does have Lovenox in the E-Kit. She stated that if she would have been notified, she would not have authorized a lesser dosage from the E-kit, and would have recommended that Resident #1 be sent to the hospital. In an Interview on 11/17/2022 at 2:50 p.m. with Resident #2, he was revealed to be a poor historian, but he said received his blood pressure medication. Resident #2's daughter was at the bed side, she stated resident got his blood pressure medication, and she did not remember if the staff told her he was not getting his Metoprolol or if the dose was changed. In an interview on 11/17/22 at 3:00 p.m. Resident#1 stated that she received first does of Lovenox on 11/16/2022 after 6:00 p.m. and one dose the morning of 11/17/2022. She stated that she told a nurse that she had not received her blood thinner. She stated that she told the same nurse that her right lower leg was throbbing, shooting, and jolting. She stated that she was told they are still waiting for the pharmacy to deliver the medication. In an interview on 11/17/2022 at 3:08 p.m. with Pharmacist A, he stated that the order for Lovenox for Resident #1 was received on 11/14/22 at 1:38pm. He stated that they receive thousands of orders each day, and they are filled in the order they are received. He stated that the pharmacy entered the order for Lovenox on 11/14/2022 at 6:23pm and it required a cost approval. He stated that the cut off to fill orders is at 6:30pm. He stated that an email was sent out on 11/15/2022 at 11:04am and 11/16/2022 10:53 am for the cost approval. He stated that the cost approval was received from the facility on 11/16/2022 at 2:04pm. He stated that he could not see who the pharmacy emailed but the charge approval was received from the DON. He stated that a request was made for the Lovenox STAT, and the order was delivered at 5:24pm on 11/16/22. He stated that the ordered for Resident #2's Metoprolol was received on 11/02/2022 at 8:10pm for 75 mg to give 2/3(0.6666) of tablet twice per day. He stated that the order was never dispensed because there was a question on the strength and dose. He stated that on 11/03/2022 at 10:49 am someone at the pharmacy spoke with LVN A. He stated that LVN stated that she would contact Resident #2's doctor and get back with them so the order was put on hold. He stated that on 11/14/2022 at 2:29pm they received an order for 50 mg tablet twice per day for Metoprolol for Resident #2, and it was delivered on 11/14/2022 at 5:42pm. He stated that there was no documentation of conversation between a nurse and pharmacy to give 50 mg to Resident#2. He stated that the facility does have access to the medication, Metoprolol, from the E-Kit but there is no authorization that it was dispensed for that Resident #2. He stated that the pharmacy would receive a notification on all medication that dispensed from the E-Kit if it is done properly, and if it is done incorrectly the machine will not open. In an interview on 11/17/2022 at 4:50 p.m. with LVN B, he stated that he said he gave the first dose of Lovenox to Resident #1 on 11/16/2022 in the evening after the medication was delivered. He stated that he told NP A that the medication had not come in and it was called as STAT on 11/16/2022 between 2 p.m-2:30pm. He stated that NP A said to give the medication as soon as they got it. He stated he called the hospital in regards to Resident #2's Metoprolol to find out what 0.666 meant. He stated that the hospital nurse said that was what the doctor wrote. He stated that he called the on-call doctor, he was told to send it in the way it was written, and the pharmacy will figure it out. He stated that he did not document it, and did not know if the medication was sent or not. He stated that if the resident did not get his blood pressure medication the resident could stroke. In an interview on 11/18/22 at 2:09pm with the Administrator. She stated that she was notified that Resident #1's Lovenox was unavailable on 11/16/22 around 2pm when LVN A told the DON. She stated that the DON told LVN A to contact the Physician and document her efforts, but LVN A did neither. She stated that she was not sure of the date and time the Physician was notified. She stated that the expectation is for a physician to be notified immediately when medications are unavailable. She stated negative outcome of Resident #1 not receiving her medication could be harm or death. She stated that she notified the pharmacy last week that there was a new DON, so they would have had the updated contact information for the charge approval for payment. Record review of Administering Medication Policy revised December 2012 read in part, .Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident, or medications has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concern. 23. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State Law and facility policy, and approved by the director of Nursing Services . Record Review of Medication and Treatment Orders Policy revised July 2016 read in part, .Orders or medication and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in the state . On 11/18/2022 at 6:22 p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The POR submitted by the Administrator was accepted on 11/20/2022 at 9:32 AM. The following actions were taken regarding Residents Free of Significant Med Errors: 1. 11/18/22- Resident # 1 was assessed by clinical services director and was in no apparent distress. This was documented in the resident clinical record. 2. Resident #1 was sent to the hospital on [DATE] and remains there at this time. 3. 11/18/22- Nurse manager has in-serviced nursing staff currently responsible for Resident #1 on ensuring anticoagulant medications are given as ordered by a physician. 4. 11/18/22-Clinical services director in-serviced the unit managers on ensuring the attending physician is notified when a change of condition occurs or when a medication is not available for a resident. 5. 11/18/22-Facility DON confirmed via med cart and chart review that Resident #1's Lovenox is in house and that she had not missed a dose of the medication since the medication was initial dosed at 1730. 6. 11/18/22- All resident's orders were reviewed by clinical services director to identify other residents receiving anticoagulant medications. Clinical services director, unit manager and infection prevention nurse manager verified that these residents were receiving their prescribed anticoagulant medications as ordered. No discrepancies were noted in the audit. 7. 11/18/22--Clinical services director reviewed facility policy on changes in condition and no revisions were deemed necessary. 8. 11/19/22-Medication administration competency checks initiated by facility DON for licensed nurses and medication aides. 9. 11/18/22-DON and/or designees will do medication administration record audits Monday through Friday to ensure that residents on anticoagulants and other high risk medications receive them as ordered. The Weekend Supervisor will complete medication administration record audits on Saturdays/Sundays to ensure that residents on anticoagulants receive their medications as ordered. 10. 11/19/22-Facility administrator conducted in-service with DON, unit managers and weekend supervisor on auditing medication administration records for missed anticoagulants and other high risk medications. 11. 11/18/22- DON and/or designees will review the physician's orders Monday through Friday to ensure that medications are received from pharmacy as ordered. The Weekend Supervisor will review physician's orders Saturday and Sunday to ensure that medications are received from pharmacy as ordered. 12. On 11/18/22 an in-service was conducted by the DON with the licensed nurses and medication aides on ensuring that anticoagulant 13. medications are administered as ordered by a physician. If the medication is not available in the e-kit the charge nurse is to notify nursing management as well as the physician for further direction within 2 hours. Licensed nurses and medication aides will not be allowed to work until they receive the in-service. When a medication aide identifies that a medication is unavailable, they are to mark the medication as unavailable on the medication administration record and notify the corresponding charge nurse within 2 hours. 14. The facility policy regarding changes in a resident's condition and ordering medications was included in this in-service. 15. On 11/19/22 the DON and designee conducted an in-service with the nurses and medication aides on ensuring that high risk medications are administered as ordered by the physician. 16. From 11/19/22 moving forward the facility nurse management team will ensure that newly hired nurses and medication aides are in-serviced on medication administration and that competencies are completed upon hire. 17. On 11/19/22 the unit managers and DON were in-serviced by the facility administrator on verifying newly hired nurses and medication aides are in serviced on medication administration. This also includes verifying that they have a corresponding medication administration competency. 18. On 11/18/22 the administrator and DON were in-serviced by the facility administrator on reviewing the medication administration records and completing audits as well as ensuring physician notification is completed if medications are not available. 19. 11/18/22 An impromptu QAPI meeting was held and the Plan of Removal was reviewed and acc[TRUNCATED]