**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect, in that: The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not receiving their ordered medications, the loss of the medication's therapeutic benefits, and changes in physical and psychological conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypothyroidism (a condition resulting from decreased production of thyroid hormones) and a history of thyroid cancer resulting in a thyroidectomy (complete or partial removal of the thyroid gland). Review of Resident #1's quarterly MDS assessment, dated 06/22/24, reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 03/26/24, reflected she had hypothyroidism with an intervention of administering thyroid replacement medication which would help restore the level of thyroid hormone produced by the thyroid gland. Review of Resident #1's physician order, dated 02/09/24, reflected Levothyroxine Sodium Oral Tablet - 150 MCG - one time a day for hypothyroidism. Review of Resident #1's progress notes, dated 06/28/24 and documented by LVN A, reflected the following: [Resident #1] had c/o nausea with small emesis . [Resident #1] was given Zofran and Tylenol for the headache . Review of Resident #1's progress notes, dated 07/09/24 and documented by LVN A , reflected the following: [Resident #1] notified this nurse and aide that she feels like her mental health is going down. She is requesting to see or speak to someone about it. She stated she just wants to give up . Note left in the social worker's office for eval . Review of Resident #1's psychiatric diagnostic assessment, dated 07/10/24, reflected the following: Reason for referral: depression, withdrawal, appetite disturbance, weight loss, refusal/low motivation to participate in rehab therapy . Review of Resident #1's physician order, dated 06/30/24, reflected Remeron Oral Tablet - 15 MG - give 1 tablet by mouth one time a day for depression. Review of Resident #1's physician order, dated 07/10/24, reflected Sertraline HCl Oral Tablet - 50 MG - give 1 tablet by mouth one time a day for depressive symptoms. Review of Resident #1's lab results, dated 07/15/24, reflected a high level of TSH32 - 28.62 (normal range is .450 - 5.330). Review of Resident #1's progress notes, dated 07/15/24 and documented by the NP, reflected the following: [Resident #1] needs to be getting her levothyroxine, spoke with ADON concerning this. Re-check TSH in 4 weeks. During a telephone interview on 07/24/24 with Resident #1's RP, she stated toward the end of June (2024), the noticed Resident #1 had a change in condition. She stated she felt weak, terrible, achy, depressed, and like she wanted to die. She stated it affected her enough that she took herself off therapy (psychological) services. She stated although she was now receiving her thyroid medication , she was still not herself as it would take months to get her levels back to normal. During an interview on 07/24/24 at 12:15 PM, Resident #1's PA stated he saw the residents one time a week and the NP saw the residents the other four days but she was on vacation. He stated he was not aware of the situation where Resident #1 went an experienced extended period of time without her thyroid medication. He stated a negative outcome of not being administered thyroid medication when you had been on it for a long period of time and were dependent on it like someone like Resident #1 could be a thyroid crisis, depression, mood problems, and there could be no thyroid hormones in the body which could cause fatigue. He stated he believed her mood could have been affected. He stated after being without the medication for an extended period of time, it could take up to six months to readjust the TSH levels. He stated checking off in the MAR that the Levothyroxine was given when it actually was not would be a huge medication error. During an interview on 07/24/24 at 1:52 PM, Resident #1 stated she had not been aware she was not receiving her thyroid medication but had noticed how much complications it had caused. She stated about three weeks prior to when they realized she had not been receiving the medication (at the beginning of July 2024, she had become really exhausted, was dizzy, had a loss of appetite, and did not even have the energy to go to therapy. She stated she still felt affected by it as she continued to be fatigued and out of it. She stated it has caused her to be scared to trust the nurses to make sure she was receiving her ordered medications. During an interview on 07/24/24 at 2:32 PM, the ADON stated the NP brought to her attention at the beginning of July (2024) that Resident #1's thyroid level was extremely elevated which indicated she had not been receiving her thyroid medications. She stated Resident #1 had been complaining of feeling down, so she looked at everything. She stated when she looked in the medication cart, she found a blister pack with only four missing pills and she could not find the previous blister back from the month prior (June 2024). She stated it was hard to say how many doses she missed but believed it could have been 5-8 doses. She stated not receiving thyroid medication for an extended period of time could lead to someone not feeling good, tired, and weak. She stated the nurse she believed that was not administering the medication (LVN B ) no longer worked there. She stated she did conduct a full cart audit on that medication cart but none of the other carts. During an interview on 07/24/24 at 4:32 PM, the DON stated on 07/12/24 the NP notified her that there were only two pills missing from Resident #1's thyroid medication blister pack. She stated the ADON looked into it and they had been delivered on 06/28/24. She stated she believed Resident #1 only could have gone 7-12 days without the medication, but it was not guaranteed. She stated a negative outcome of not receiving the medication for an extended period of time could be feeling tired or depression issues but did not believe that was the case for Resident #1 since it could have only been five days that she had gone without. During a telephone interview on 07/29/24 at 11:58 AM, Resident #1's NP stated Resident #1 had been admitted to the facility over five months ago and she was stable until her depression spiked within the last month. She stated Resident #1 was a good historian and told her at the beginning of July (2024) that for the past few weeks she had been feeling more depressed and felt it getting worse and worse. She stated it was to the point where she did not want to get out of bed. She stated once she ordered lab work and her TSH came back extremely high, it was evident that she had not been receiving her thyroid medication, especially with the symptoms she had been experiencing. She stated she could not put a number on how many doses she could have missed because everyone was different, but it had to have been more than a couple of weeks. She stated her TSH could be more normalized with in 4-6 weeks. She stated Resident #1 would not be back at her baseline, but on her medication she will have improved drastically. Review of the facility's Abuse and Neglect Policy, Revised December of 2016, reflected the following: Our residents have the right to be free from abuse, neglect . Review of the facility's Administering Medications Policy, revised December of 2012, reflected the following: 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. The ADM and ADON were notified on 07/24/24 at 4:50 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/27/24 at 12:30 PM: Impact Statement: On 7/24/24 an abbreviated survey was initiated, and the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to not keeping resident free from neglect. How were other residents at risk affected by this deficient practice identified? A. The VP of Clinical in-serviced the DON on audits of thyroid medication orders and the Medication Administration policy and ensuring residents receive their medications on 7/24/24 prior to in servicing staff. B. The facility DON/Designee completed an audit of thyroid medication orders for the residents currently residing in the facility to ensure the residents are receiving their medications. This was completed on 7/24/24. C. An Abuse/Neglect prohibition in-service was conducted by the Administrator with facility staff to include prn staff and newly hired staff on 7/24/24. The facility does not utilize agency. Any staff to include newly hired staff, prn staff not in attendance will be required to receive the in-service prior to working their next scheduled shift. What corrective actions have been implemented for the identified resident? Resident #1 Medication Error report completed, physician and RP notified by the ADON. The DON in-serviced 7/24/24 the licensed nursing staff on Medication Administration. What corrective actions were taken? 1. The following actions were initiated immediately on 7/24/24. a. Initiated in-services on 7/24/24 with licensed nurses to include prn staff and newly hired staff by Director of Nursing on Administering Medications and ensuring residents receive their medications during the hour before to hour after time frame. Newly hired licensed nurses and medication aides, prn staff will be in serviced during the on boarding process by DON/designee on Medication Administration policy. The DON/designee will complete Medication Pass Observations during orientation utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. The facility does not utilize agency. DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. 2. The VP of Clinical in-serviced the DON on the Medication Administration policy and ensuring residents receive their medications on 7/24/24. b. On 7/24/24 the DON initiated in-services for the Medication Aides on Administering Medications and ensuring residents receive their medications during the hour before to hour after time frame. The DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. Random Med Pass Observations will be conducted weekly x 4 weeks with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, they will be addressed immediately by the DON or ADON. Starting on 7/24/24 DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. 3. Newly hired licensed nurses and medication aides, prn staff and agency staff will be in serviced during the on boarding process by DON/designee on Medication Administration policy. The DON/designee will complete Medication Pass Observations during orientation utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. 4. The DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides utilizing the medication pass observation tool. If licensed nurses or medication aides pass, competency will be demonstrated. If licensed nurses or medication aides fail, DON/Designee will retrain with return demonstration; and another Medication Pass Observation will be conducted until competency demonstrated. Random Med Pass Observations will be conducted ongoing weekly with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, they will be addressed immediately by the DON or ADON. 5. On 7/24/24 the DON/Designee initiated in-services with licensed nurses and medication aides, on Abuse and Neglect Policy and Procedures with a pre and posttest attached; competency demonstrated as seen by test results. 6. On 7/24/24 the Administrator/Designee initiated life satisfactions surveys with no concerns noted. 7. How will the system be monitored to ensure compliance? A. DON/Administrator will review the results of the Medication Pass Observations that will be completed for the next six weeks. If discrepancies are identified, they will be addressed immediately, and physician notified. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 7/24/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. The Surveyor monitored the POR on 07/28/24 as followed: During interviews on 07/28/24 from 11:42 AM - 2:32 PM with one RN, three LVNs, two MAs, and three CNAs from different shifts, all stated they were in-serviced before their shift. They all knew who the Abuse and Neglect Coordinator was (the ADM) and gave examples of abuse and neglect such as not changing a resident's brief in a timely manner, verbal, physical, psychosocial, and mental abuse. All stated they would never check off a MAR if they did not administer the medication. All stated the importance of residents receiving their ordered medications. Review of an in-service entitled Medication Administration, dated 07/24/24 and conducted by the VPCS, reflected the DON was reeducated on their Medication Administration policy. Review of in-services entitled Abuse and Neglect, dated 07/24/24 and 07/25/24 and conducted by the ADM, reflected all nursing staff were reeducated on the facility's Abuse and Neglect policy. Review of Abuse and Neglect Post Test Competencies, dated 07/24/24 and 07/25/24, reflected all staff took a post-test after being in-serviced and passed. Review of Life Satisfaction Surveys, dated 07/26/24, reflected all residents were interviewed with no concerns. Review of in-services entitled Medication Administration, dated 07/24/24 and 07/25/24 and conducted by the DON, reflected nurses and medication aides were reeducated on checking the MAR throughout shift for any medications due and checking the MAR/TAR at the end of the shift for any omissions. Review of the facility's Medication MAR to Card Audit, on 7/26/24, reflected the medication carts (four) had been audited on 07/24/24 and 07/25/24 to match the MAR to the medication cards. Review of Medication Pass Observations, dated 07/24/24 - 07/26/24, reflected nurses and medication aides had to conduct a medication pass check-off. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to administer Resident #1's Levothyroxine (medication used to treat hypothyroidism) for an unknown period of time at the end of June 2024 and beginning of July 2024. This subsequently led to her TSH (Thyroid Stimulating Hormone) levels elevating to 28.62 (normal range is .450 - 5.330), resulting in a change of condition where she became fatigued, dizzy, and depressed. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including hypothyroidism (a condition resulting from decreased production of thyroid hormones) and a history of thyroid cancer resulting in a thyroidectomy (complete or partial removal of the thyroid gland). Review of Resident #1's quarterly MDS assessment, dated 06/22/24, reflected a BIMS of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 03/26/24, reflected she had hypothyroidism with an intervention of administering thyroid replacement medication which would help restore the level of thyroid hormone produced by the thyroid gland. Review of Resident #1's physician order, dated 02/09/24, reflected Levothyroxine Sodium Oral Tablet - 150 MCG - one time a day for hypothyroidism. Review of Resident #1's progress notes, dated 06/28/24 and documented by LVN A, reflected the following: [Resident #1] had c/o nausea with small emesis . [Resident #1] was given Zofran and Tylenol for the headache . Review of Resident #1's progress notes, dated 07/09/24 and documented by LVN A, reflected the following: [Resident #1] notified this nurse and aide that she feels like her mental health is going down. She is requesting to see or speak to someone about it. She stated she just wants to give up . Note left in the social worker's office for eval . Review of Resident #1's psychiatric diagnostic assessment, dated 07/10/24, reflected the following: Reason for referral: depression, withdrawal, appetite disturbance, weight loss, refusal/low motivation to participate in rehab therapy . Review of Resident #1's physician order, dated 06/30/24, reflected Remeron Oral Tablet - 15 MG - give 1 tablet by mouth one time a day for depression. Review of Resident #1's physician order, dated 07/10/24, reflected Sertraline HCl Oral Tablet - 50 MG - give 1 tablet by mouth one time a day for depressive symptoms. Review of Resident #1's lab results, dated 07/15/24, reflected a high level of TSH32 - 28.62 (normal range is .450 - 5.330). Review of Resident #1's progress notes, dated 07/15/24 and documented by the NP, reflected the following: [Resident #1] needs to be getting her levothyroxine, spoke with ADON concerning this. Re-check TSH in 4 weeks. During a telephone interview on 07/24/24 with Resident #1's RP, she toward the end of June (2024), the noticed Resident #1 had a change in condition. She stated she felt weak, terrible, achy, depressed, and like she wanted to die. She stated it affected her enough that she took herself off therapy services. She stated although she was now receiving her thyroid medication , she was still not herself as it would take months to get her levels back to normal. During an interview on 07/24/24 at 12:15 PM, Resident #1's PA stated he saw the residents one time a week and the NP saw the residents the other four days but she was on vacation. He stated he was not aware of the situation where Resident #1 went an extendedperienced period of time without her thyroid medication. He stated a negative outcome of not being administered thyroid medication when you had been on it for a long period of time and were dependent on it like someone like Resident #1 could be a thyroid crisis, depression, mood problems, and there could be no thyroid hormones in the body which could cause fatigue. He stated he believed her mood could have been affected. He stated after being without the medication for an extended period of time, it could take up to six months to readjust the TSH levels. He stated checking off in the MAR that it was given when it actually was not would be a huge medication error. During an interview on 07/24/24 at 1:52 PM, Resident #1 stated she had not been aware she was not receiving her thyroid medication but had noticed how much complications it had caused. She stated about three weeks prior to when they realized she had not been receiving the medication, she had become really exhausted, was dizzy, had a lost of appetite, and did not even have the energy to go to therapy. She stated she still felt affected by it as she continued to be fatigued and out of it. She stated it has caused her to be scared to trust the nurses to make sure she was receiving her ordered medications. During an interview on 07/24/24 at 2:32 PM, the ADON stated the NP brought to her attention that Resident #1's thyroid level was extremely elevated which indicated she had not been receiving her thyroid medications . She stated Resident #1 had been complaining of feeling down, so she looked at everything. She stated when she looked in the medication cart, she found a blister pack with only four missing pills and she could not find the previous blister back from the month prior (June 2024). She stated it was hard to say how many doses she missed but believed it could have been 5-8 doses. She stated not receiving thyroid medication for an extended period time could lead to someone not feeling good, tired, and weak. She stated the nurse she believed that was not administering the medication (LVN B ) no longer worked there. She stated she did conduct a full cart audit on that medication cart but none of the other carts. During an interview on 07/24/24 at 4:32 PM, the DON stated on 07/12/24 the NP notified her that there were only two pills missing from Resident #1's thyroid medication blister pack. She stated the ADON looked into it and they had been delivered on 06/28/24. She stated she believed Resident #1 only could have gone 7-12 days without the medication, but it was not guaranteed. She stated a negative outcome of not receiving the medication for an extended period of time could be feeling tired or depression issues but did not believe that was the case for Resident #1 since it could have only been five days that she had gone without. During a telephone interview on 07/29/24 at 11:58 AM, Resident #1's NP stated Resident #1 had been admitted to the facility over five months ago and she was stable until her depression spiked within the last month. She stated Resident #1 was a good historian and told her at the beginning of July (2024) that for the past few weeks she had been feeling more depressed and felt it getting worse and worse. She stated it was to the point where she did not want to get out of bed. She stated once she ordered lab work and her TSH came back extremely high, it was evident that she had not been receiving her thyroid medication, especially with the symptoms she had been experiencing. She stated she could not put a number on how many doses she could have missed because everyone was different, but it had to have been more than a couple of weeks. She stated her TSH could be more normalized with 4-6 weeks. She stated Resident #1 would not be back at her baseline, but on her medication she will have improved drastically. Review of the facility's Administering Medications Policy, revised December of 2012, reflected the following: 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. Review of the Mayo Clinic website, accessed 08/12/24, hypothyroidism that is not treated can lead to goiter (a condition that may cause problems with swallowing or breathing), heart disease and heart failure, and peripheral neuropathy (nerve damage causing pain, numbness, and tingling in the arms and legs). The ADM and ADON were notified on 07/24/24 at 4:50 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 07/27/24 at 12:30 PM: Impact Statement: On 7/24/24 an abbreviated survey was initiated, and the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to not providing pharmaceutical services to meet the needs of a resident. How were other residents at risk affected by this deficient practice identified? D. The VP of Clinical in-serviced the DON on completing an audit on thyroid medication orders and the Medication Administration policy and ensuring residents receive their medications on 7/24/24, prior to in-servicing staff. B. The facility DON/Designee completed an audit of thyroid medication orders for the residents currently residing in the facility to ensure the residents are receiving their medications. This was completed on 7/24/24. What corrective actions have been implemented for the identified resident? Resident #1 Medication Error report completed physician and RP notified by the ADON. Order to recheck thyroid lab on 8/16/24 received. Don/Designee will ensure new order is completed. The DON in-serviced 7/24/24 the licensed nursing staff on Medication Administration. What corrective actions were taken? 8. The following actions were initiated immediately on 7/24/24. c. Initiated in-services on 7/24/24 with licensed nurses by Director of Nursing on Administering Medications and ensuring residents receive their medications during the one hour before and one hour after time frame. Licenses nurses vocalized understanding and signed in-service as confirmation of education and competency. Starting on 7/24/24, DON/designee will conduct randomized MAR to card audits three times a week for 4 weeks, and then periodically to assure residents are getting medications. d. On 7/24/24 The VP of Clinical in serviced the DON on Administering Medications and ensuring residents receive their medications prior to in-servicing staff. e. On 7/24/24 the DON initiated in-services for the Medication Aides on Administering Medications and ensuring residents receive their medications during the one hour before and one hour after time frame. Medication Aides vocalized understanding and signed in-service as confirmation of education and competency. The understanding verification will be completed and documented using a Medication Administration Competency skill check list. f. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process by DON/designee on Medication Administration policy. Licenses nurses and medication aides will vocalize understanding and signed in-service as confirmation of education and competency. The DON/designee will complete a Medication Pass Observation on a competency skill list document during orientation. VP of clinical trained DON on medication administration policy prior to DON in-servicing staff on 7/24/24. g. Starting on 7/25/24 the DON/Designee will complete Medication Pass Observations with the licensed nurses and Medication Aides for four weeks. Random Med Pass Observations will be conducted weekly ongoing thereafter with the licensed nurses and medication aides to ensure the medication administration policy is followed and that residents are receiving their medication as ordered. If discrepancies are identified, the DON and/or ADON will address immediately. 9. How will the system be monitored to ensure compliance? B. DON/Administrator will review the results of the Medication Pass Observations that will be completed for the next four weeks. If discrepancies are identified, they will be addressed immediately, and physician notified. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 7/24/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. The Surveyor monitored the POR as followed: During interviews on 07/28/24 from 11:42 AM - 2:32 PM with one RN, three LVNs, two MAs, and three CNAs from different shifts, all stated they were in-serviced before their shift. All stated they would never check off a MAR if they did not administer the medication. All stated the importance of residents receiving their ordered medications. Review of an in-serviced entitled Medication Administration, dated 07/24/24 and conducted by the VPCS, reflected the DON was reeducated on their Medication Administration policy. Review of in-services entitled Medication Administration, dated 07/24/25 and 07/25/24 and conducted by the DON, reflected nurses and medication aides were reeducated on checking the MAR throughout shift for any medications due and checking the MAR/TAR at the end of the shift for any omissions. Review of the facility's Medication MAR to Card Audit, on 7/26/24, reflected the medication carts (four) had been audited on 07/24/24 and 07/25/24 to match the MAR to the medication cards. Review of Medication Pass Observations, dated 07/24/24 - 07/26/24, reflected nurses and medication aides had to conduct a medication pass check-off. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:50 PM. While the IJ was removed on 07/29/24 at 12:15 PM, the facility remained out of compliance at a severity level of no actual harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice for 2 of 6 residents (Residents #1 and Resident #2) reviewed for respiratory care. 1. The facility failed to ensure Resident #1 received weekly filter cleanings for her BiPAP machine (A BiPAP Machine is a respiratory machine used to provide positive airway pressure through a mask, worn while sleeping, to provide airway pressure during inhalation and exhalation to keep the user's throat open from collapsing.). 2. The facility failed to ensure Resident #2 received weekly filter cleanings for her CPAP machine (A CPAP Machine was a respiratory machine used to provide positive airway pressure through a mask, worn while sleeping, to provide airway pressure during inhalation and exhalation to keep the user's throat open from collapsing.) An IJ was identified on 5/9/2024. The IJ Template was provided to the facility on 5/9/2024 at 6:01 PM. While the IJ was removed on 5/10/2024, the facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of isolated because all staff had not been trained on the POR. This placed residents receiving BiPAP/CPAP therapy at risk for infection and exacerbation of respiratory distress. Findings included: 1. Record review of Resident #1's Quarterly MDS, dated [DATE], indicated the resident was a [AGE] year-old female that admitted to the facility on [DATE]. She was diagnosed with both Acute, and Chronic, Respiratory failure with hypoxia (which was a life-threatening condition where the lungs could not provide enough oxygen to the body) and Obstructive Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway while sleeping.) Section C., Cognitive Patterns: Resident #1 had a BIMS Score of 14. A BIMS Score of 14 indicated the resident did not have cognitive impairment. Resident # 1 was not coded as a having a BiPAP. Record review of Resident #1's CP reflected a [Focus] area, revised 3/18/2024, evidenced by the resident having utilized a BiPAP Machine and was high-risk for infection and aspiration. The [Goal,] revised on 3/18/2024, indicated the resident would not show signs of infection. An intervention for nursing staff, initiated on 6/15/2023, indicated nursing staff was to wake resident to make sure the BiPAP was on. An [Intervention] for nursing staff, initiated on 5/31/2023, indicated staff was to ensure the BiPAP Machine was at the correct settings, per order. Record review of Resident #1's Order Summary Report, dated 5/9/2024, indicated an order, made 12/23/2023, to change BiPAP tubing every 3 months. Record review of Resident #1's vital signs in PCC at the facility, dated 3/4/2024, indicated Resident #1's O2 saturations (the amount of oxygen in her blood) was 82%. Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/4/2024 to 3/14/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident was admitted to the ICU and was intubated (a tube placed through the resident's airway to breathe.) She was extubated (removal of the tube placed in resident's airway) on 3/5/2024 and discharged to a regular hospital bed on 3/6/2024. The resident received her BiPAP machine, from the nursing facility, and the machine had performed well. Resident was diagnosed with pneumonia (which was an infection in the lungs caused by bacteria, viruses, or fungi) on 3/7/2024. The hospital summary stated the resident's responsible parties [alleged the nursing facility had not been successful in the correct placement of the resident's BiPAP mask.] Record review of Resident #1's Order Summary indicated an order, revised on 3/18/2024 to start 3/24/2024, to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday. An order, revised on 3/18/2024 to start on 3/24/2024, indicated the residents BiPAP machine settings were supposed to be 15 IPAP and 4 EPAP. (These setting controlled positive airway pressure for inhaling and exhaling, respectfully.) Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/24/2024 (documented complete by LVN A.) Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 3/27/2024 to 3/30/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations (the amount of oxygen in her blood) was 89 %. Resident was intubated on 3/27/2024 in the emergency room. Record review of Resident #1's treatment record, March 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 3/31/2024 (documented by LVN E). Record review of Resident #1's hospital records indicated Resident #1 admitted to the hospital, on 4/6/2024 to 4/16/2024, for Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Resident expressed SOB. Her O2 saturations were 78 % on the way to the hospital. Having arrived, her O2 saturations were 49%. She was noted to be cyanotic (blue or purplish skin due to deficient levels of oxygen in the blood) at the face, lips, and ears. Resident was intubated for concern for severe hypercapnia (elevated carbon dioxide.) The hospital summary indicated the resident had active bilateral pneumonia. Record review of Resident #1's treatment record, April 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 4/7/2024 (documented by LVN A,) 4/14/2024 (documented by LVN E,) 4/21/2024 (documented by LVN F,) and 4/28/2024 (documented by LVN G.) Record review of Resident #1's treatment record, May 2024, indicated her BiPAP mask, tubing, filter, and water were changed/cleaned on 5/5/2024 (documented by LVN E.) Interview and observations on 5/9/2024 at 9:30 AM with Resident #1 revealed her in bed, the back of the bed was elevated at a 45-degree angle, and she had continuous oxygen via nasal canula (oxygen delivery through a tube inserted in each nostril.) Resident # 1 stated she had been to the hospital 3 times in the last 3 months due to respiratory distress. She stated the reason for the hospitalizations was due to inconsistent use of her BiPAP mask; and that staff had not made sure she was wearing it like she should. She went to the hospital on 3/4/2024 due to low oxygen levels, while there, an RP brought her BiPAP machine from the nursing facility to the hospital. The hospital staff changed the settings and utilized the resident utilized the BiPAP machine while there. She stated she had to go to the hospital two more times due to similar instances of respiratory distress. She denied having seen nursing staff clean her BiPAP Machine or change the filter. She did not know how to check the settings on the machine, and she was not sure who to ask to make sure the settings were correct. The filter for her BiPAP Machine, which was a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper air pressure flow. The filter was black with discoloration. The settings on the BIPAP were 16 IPAP (Inhale) and 8 EPAP (Exhale.) She did not have any filters, masks, or tubing in her room or in her possession. Phone interview on 5/9/2024 at 11:00 AM with the facility's MD revealed Resident #1 had been to the hospital on 3 separate occasions since 3/4/2024. Her diagnoses were Pneumonia, Congestive Heart Failure (which was a long-term condition that happened when the heart could not pump blood well enough to give your body a normal supply,) and Chronic Obstructive Pulmonary Disease (COPD, which was a respiratory condition characterized by persistent breathlessness and cough.). The MD stated dirty BiPAP filters were most likely not the sole reason that was causing Resident #1's exacerbated shortness of breath and respiratory distress, but more than likely a contributor. Interview on 5/9/2024 at 12:10 PM with MSMR revealed that any replacement materials for Resident #1's BiPAP machine would come from the local BiPAP/CPAP machine company. She stated she did not have any masks, tubing, or filters on hand. She stated she had not ordered any filters. The company did come to the facility to size Resident #1 for the right mask size, but the topic of filters never came up. The facility did not have any supplies for Resident #1's BiPAP Machine on hand. Interview and observation on 5/9/2024 at 12:35 PM with the ADON in Resident #1's room revealed the BiPAP Machine filter was very dirty and did not appear to have been changed weekly. The IPAP 16 (Inhale) and EPAP 8 (Exhale) were not congruent with the orders listed in PCC. The ADON stated the orders to clean BiPAP mask, tubing, filter, and water canister weekly every night shift on Sunday were located on the treatment record but was unable to verbalize the location of the replacement filters. The ADON stated the new filters should have been requested through MSMR in medical supply. 2. Record reviews of Resident #2's Quarterly MDS, dated [DATE] indicated the resident was a [AGE] year-old female that admitted to the facility on [DATE]. She was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) (which was a respiratory condition characterized by persistent breathlessness and cough,) and Obstructive Sleep Apnea (which was a medical condition marked by throat muscles having relaxed and having blocked the person's airway.) Section C., Cognitive Patterns: Resident #2 had a BIMS Score of 14. A BIMS Score of 14 indicated the resident did not have cognitive impairment. Resident #2 was not coded as wearing a CPAP. Record review of Resident #2's CP reflected a [Focus] area, revised 12/14/2023, evidenced by having been at risk for ineffective airway clearance D/T COPD and Sleep Apnea. The [Goal,] revised on 12/12/2023, indicated the resident would display normal breathing. An intervention for nursing staff, initiated on 12/14/2023, indicated staff was supposed to maintain CPAP per orders. Record review of Resident #2's May 2024 treatment record, under the heading of [Schedule for May 2024,] Resident #2 was ordered to have her mask cleaned, tubing cleaned, filter cleaned, and water chamber weekly. The start date of the scheduled treatment began on 12/17/2023. Record review or Resident #2's treatment record, dated March 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 3/3/2024 (documented by LVN H,) 3/10/2024 (documented by LVN I,) 3/17/2024 (documented by LVN H,) 3/24/2024 (documented by LVN I,) and 3/31/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated April 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 4/7/2024 (documented by LVN I,) 4/14/2024 (documented by LVN J,) 4/21/2024 (documented by LVN I,) and 4/28/2024 (documented by LVN H.) Record review or Resident #2's treatment record, dated May 2024, indicated her CPAP mask, tubing, filter, and water chamber was cleaned on 5/5/2024 (documented by LVN I.) Interview and observation on 5/9/2024 at 3:34 PM with Resident #2 revealed her lying in her bed watching television. She stated she utilized a CPAP machine daily and pointed to it on a table next to her bed. The filter for her CPAP Machine, which was supposed to be a small rectangular mesh cloth, was designed to fit in a small rectangular compartment on the back side of the machine. The filter was designed to clean room air going into the machine used to produce the proper positive airway pressure flow. When the compartment was opened, there was not a filter in the required location. Resident #2 stated she had not observed staff having cleaned her CPAP machine or having changed the filter weekly. Resident #2 denied any exacerbation of her COPD or problems with the sleep apnea. Record review of the facility's BIPAP/CPAP policy, dated April 2010, indicated BiPAP/CPAP were used to provide the spontaneously breathing resident with continuous positive airway pressure, with or without supplemented oxygen. To improve arterial oxidization in residents with respiratory insufficiencies, obstructive sleep apneas, and restrictive/obstructive lung diseases. The purpose is to promote resident comfort and safety. Review the physician's order to determine the oxygen concentration and flow, and the pressure, such as CPAP, IPAP, and EPAP. The policy indicated filters were required for BIPAP/CPAP supply. Record review on 5/20/2024 of URL: Sleepfoundation.org; BiPAP/ CPAP machines were both forms of positive airway pressure therapy, which used compressed air to open and support the upper airway during sleep. A portable machine generated the pressurized air and directed it to the user's airway via a hose and mask system. Both systems used similar masks, hoses, and other accessories. The machines were humid and often warm, having made them the perfect home for mold, bacteria, viruses, and other harmful microbes. Having cleaned your machine components regularly washed these microbes away and prevented them from reaching dangerous levels, but having neglected your machine's hygiene could have led to both acute and chronic respiratory illnesses. Record review on 5/20/2024 of URL: National Library of Medicine, Pulse Oximetry-Stat Pearls (on-line school for physicians) - NCBI Bookshelf (nih.gov), the normal oxygen levels displayed on a pulse oximeter (a tool to measure the oxygen in the blood) were commonly supposed to range from 95% to 100%. Oxygen saturation was an essential element of patient care. Oxygen was tightly regulated within the body because hypoxemia (low levels of oxygen) could have led to many acute adverse effects on individual organ systems. These included the brain, heart, and kidneys. Interview on 5/9/2024 at 6:01 PM with the ADM revealed that Resident #1 and Resident #2 had not been receiving respiratory care per physician orders. Neither Resident #1, nor Resident #2, had been receiving BiPAP or CPAP care per physician orders. The facility did not possess replacement filters for either CPAP or BiPAP equipment, but the nursing staff was checking off treatments on the nurse's treatment record for Resident #1 and Resident #2, having indicated they had been changed/cleaned. Resident #1 had been hospitalized on [DATE] for respiratory distress, 3/27/2024 for respiratory distress, and 4/6/2024 for respiratory distress. All of which, a contributing factor could have been the result of dirty respiratory care equipment. It was determined that criteria had been met to initiate an IJ. The IJ was called and the administer was presented with the IJ template at 6:01 PM. The following POR by the facility was accepted on 5/10/2024 at 1:14 PM. The notification of IJ states as follows: Statement of deficient practice: F695: The facility failed to ensure its BiPAP/CPAP users received respiratory care in accordance with highest professional standards which placed Resident #1 at risk of exacerbation of her SOB, having resulted in Acute/Chronic hypoxic (low levels of oxygen) hypercapnic (elevated carbon dioxide) respiratory failure. Impact Statement: On 5/09/24 an abbreviated survey was initiated on 5/09/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to a significant medication error. 1. How were other residents at risk affected by this deficient practice identified? The facility Administrator, DON/Designee completed an audit of all Residents with BiPAP/CPAP orders ordered in the last 30 days to ensure the residents have not had an adverse effect from their normal baseline 5/09/24. Residents with BiPAP/CPAP orders have the potential to be affected by this deficient practice, 2 of the residents who were identified as having BiPAP/CPAP orders were not affected. 2. What corrective actions have been implemented for the identified resident? Resident #1's BiPAP settings were adjusted by the BiPAP/CPAP company technician, to meet physician orders, BiPAP machine filter was cleaned by facility ADON, along with the tubing. Resident #1 is currently in the facility and stable condition as of 5/9/24. On 5/9/24, replacement filters were obtained from facility DME company by central supply clerk, who will also monitor inventory of filters weekly to ensure facility has adequate stock. Regional [NAME] President in-serviced Administrator and DON/Designee on the identification of new BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment on 5/9/24. On 5/9/24, Administrator, DON/Designee in-serviced the licensed nursing staff on the identification of new BiPAP orders and verification of settings, as well as the proper cleaning methods and frequency of cleaning of BiPAP equipment. What corrective actions were taken? 3. The following actions were initiated immediately on 5/09/2024. a. Nursing management was educated on 5/09/2024 by the Administrator, on identifying and reviewing all new orders for BiPAP/CPAP machines, during daily clinical meeting, to ensure BiPAP orders are followed per physician orders. b. Initiated in-services on 5/09/24 with licensed nurses, by Administrator, on proper cleaning methods of BiPAP equipment (masks, hoses, filters) and frequency of weekly filter changes, both to be completed by licensed nurses. c. Newly hired licensed nurses will be in serviced during the onboarding process by DON on identifying and reviewing all new orders to ensure BiPAP settings are being followed and set appropriately on BiPAP equipment. d. PRN and Agency nurses will be in-serviced by DON/Designee, prior to working designated shifts, on identifying and reviewing all new orders to ensure BiPAP settings are being followed and filters are being cleaned weekly. 4. How will the system be monitored to ensure compliance? a. DON/Designee Will review the Order List Report for newly received orders and compare it to resident new BiPAP orders daily for 4 weeks. If discrepancies are identified, we will notify the physician immediately for clarification, Quality Assurance An impromptu Quality Assurance and Performance Improvement review (quick meeting) of the plan of removal was completed on 5/09/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. Monitoring began 5/10/2024 at 1:14 PM. Interview on 5/10/2024 at 1:50 PM with LVN B revealed nursing staff was made aware of BiPAP/CPAP orders when new residents come to the facility with their orders, or they have had a sleep study while a resident. New orders were under the orders tab in PCC. Settings were found on the machine and staff needed to confirm they match the orders. Tubing and masks get cleaned every week by taking the masks apart and rinsing it. Tubing and masks get cleaned one time a week: the filter and water container 1 x week. The facility has the equipment they needed to maintain the machines. LVN B attended an in-service on 5/10/2024 given by the ADON. Interview on 5/10/2024 at 2:05 PM with LVN C revealed the nursing staff was made aware of new BiPAP/CPAP orders through PCC or paper orders. New orders in PCC would be highlighted in red. The machine had buttons for setting and those settings were supposed to match those on the orders. Nursing staff checked orders for treatments each week. Nursing staff cleaned the mask with soap and water each week and let air dry. Cleaning consisted of having disconnected the tubing from them machine and having washed it with warm soapy water weekly. The filter was rinsed and placed between two paper towels to dry. Wet filters did not go back into the machine, which would be bad. LVN C attended an in-service today, 5/10/2024 for BiPAP/CPAP care by the ADON. Day shift started cleaning the BiPAP/CPAP during the day on Tuesday. Interview on 5/10/2024 at 2:15PM with LVN D revealed nursing staff was made aware of BiPAP/CPAP orders when a resident arrived from the hospital, admitted , if ordered by the medical director, or ordered by the nurse practitioner. New orders were found in PCC; PCC to be checked daily for new orders. The settings for the BiPAP/CPAP machine were found on the machine and the settings needed to match what was in the orders. Masks were supposed to be cleaned each week with soap and water. The tubing was supposed to be rest with water each week and the filter was rinsed with water each week. The mask and the tubing were supposed to be exchanged once a month. LVN D attended an in-service earlier this week on BiPAP/CPAP care. The DON provided the training. Interview on 5/10/2024 at 2:25 PM with the RN revealed new BiPAP/CPAP orders would show up on the administration record, under new orders, or pop up under the To Do List. The settings on the BiPAP/CPAP were accessible from the machine itself. Those numbers had to match what was on the orders. Every week, nursing staff was supposed to clean the mask, the tubing, and the filter. All items needed to be air dried. The RN stated she attended an in-service today, 5/10/2024, presented by the ADON. Interview on 5/10/2024 at 2:40 PM with the ADON revealed all new BiPAP/CPAP orders were supposed to be listed on the 24-hour report, which was a report having pertained residents' medical changes. New BiPAP/CPAP users also could have had orders when they returned from the hospital or having had seen the doctor. Those new orders were listed in PCC. New orders needed confirmation, so they needed follow up. BiPAP/CPAP settings were found on the machine. New admissions were asked for paperwork regarding their BiPAP/CPAP settings. The settings on the machine needed to match those on the orders. The hoses, the mask, in the filters needed to be cleaned with soap and water weekly; and air dried as much as possible. The ADON was briefed on the BiPAP/CPAP policies by the DON; The ADON in-serviced the staff. Interview on 5/10/2024 at 2:55 PM with the DON revealed new BiPAP/CPAP orders were found on the 24-hour report, put into PCC, and flagged for confirmation and items needed to be completed while on shift. The machine settings were found on the machine itself, and those settings needed to match those that were in the order. Once a week, she cleaned the mask with soap and water. The filters were rinsed with water weekly also and patted dry before having placed them back in the machine. The DON attended an in-service for BiPAP/CPAP yesterday, 5/9/2024, by the RVP. Interview and observation on 5/10/2024 at 5:05 PM with the MRMS revealed he monitored the respiratory supplies daily and weekly. The O2 company came to the facility and serviced the machines once a month. The MRMS displayed the supply of BiPAP/CPAP hoses and various other tubing for respiratory equipment. She stated the BiPAP/CPAP filters were delivered on 5/9/2024. Record review of BiPAP/CPAP in-service, performed by the ADM to the ADONs on 5/9/2024, for BiPAP/CPAP: Identify and review all new BiPAP/CPAP orders. Record review of BiPAP/CPAP in-service performed by the ADM and the ADON to the Licensed Nursing Staff, performed on 5/9/2024, for BiPAP/CPAP: Identify and review all new orders. Cleaning. Replacement supplies. Record review of BiPAP/CPAP invoice, dated 5/9/2024 and 5/10/2024, delivering BiPAP/CPAP tubing and filters. Record review of BiPAP/CPAP in-service performed by the RVP to the ADM and DON, dated 5/9/2024. New orders, settings, cleaning, and filter replacement. Record review of ADON confirmation of cleaning Resident #1's machine, dated 5/9/2024. Record review of ADON confirmation of audit for BiPAP/CPAP filters, dated 5/14/2024. Record review of DON plans, undated, for new hires, shift workers, and PRN staff. Record review of the QAPI Team members email review, dated 5/92024, having discussed the F695 POR. Interview and observation on 5/10/2024 at 5:10 PM with Resident #1 revealed she was in bed, clean, and in no distress. The BiPAP machine was a new device; hose and mask were clean placed in a plastic bag. Resident voiced no complaints and stated she was pleased with having clean equipment now. The ADM was informed the Immediate Jeopardy was removed on 5/10/2024 at 5:30 PM. The facility remained out of compliance at a scope of no actual harm with potential for more than minimal harm and a severity level of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Interview and record review on 5/13/2024 at 4:20 PM with LVN A revealed she had signed off treatment for Resident #1's BiPAP on 3/24/2024 and 4/7/2024. She stated the order to clean the machine, and change the filter out weekly, were on the nurse's treatment record. She recalled checking off the treatments and recalled not having clean filters to exchange. She stated she had informed the ADON. There were no filters on hand to change out the old. Interview and observation on 5/14/2024 at 11:15 AM with Resident #2 revealed she had a new CPAP machine, and the machine had a clean filter in place. She was getting used to the new mask. Interview on 5/14/2024 at 2:25 PM with the DON revealed cleaning masks, tubing, and changing filters were important to keep BiPAP/CPAP therapy equipment clean. Clean equipment reduced the risk of infection and kept the air flow optimum. The facility had a policy covering the BIPAP/CPAP therapy and the nursing staff was not following the facility policy. The residents who were using BiPAP/CPAP treatments were placed at risk for portals for infection.

**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 significant medication errors for 1 of 6 residents (Resident #234) reviewed for medication errors. The facility failed to accurately transcribe amitriptyline 10mg by mouth at bedtime and instead transcribed amitriptyline 300mg by mouth twice daily. The facility administered 300mg of amitriptyline to Resident #234 which caused an overdose that sent the resident to the hospital with abnormal labs and cardiac arrhythmia. This failure could place residents at risk for complications and possible death. This failure resulted in an identification of an Immediate Jeopardy (IJ) On 2/21/2024 @ 5:25pm. While the IJ was removed on 02 /24/24 @ 6:10 PM, the facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The findings include: Record review of Resident #234's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #234 had diagnoses which included NSTEMI (heart attack), metabolic encephalopathy (a chemical imbalance of the brain causing confusion), anemia (low red blood cells), dementia, and type 2 diabetes (elevated blood sugar). Record review of Resident #234 admission MDS assessment, dated 2/5/24, reflected Resident #234 had a BIMS score of 8, which indicated Resident #234 was cognitively impaired. Resident #234 required substantial max assistance with personal hygiene upper and lower body dressing. Record review of a progress note dated 2/5/24 at 9:30 AM, by LVN W, reflected Resident #234's family member brought a medication list from home and requested Amitriptyline (an antidepressant) be given as he had previously been on medication at home. Record review of Resident #234's order recap report, dated 2/1/24-2/22/24, reflected the resident had an order received 2/5/24 by LVN W for Amitriptyline Oral Tablet 150 MG (Amitriptyline) Give 2 tablets to equal 300mg by mouth every morning and at bedtime for depression. Record review of the Medication Administration log for February 2024 reflected Resident #234 received 300mg of amitriptyline by mouth on 2/6/24 at 9 am. Record review of the facility progress notes, dated 2/6/24 at 1:30 by LVN W, reflected the resident was found slow to respond, drowsy and lethargic. The Nurse Practitioner was notified, and an order was given to transport Resident #234 to the hospital. Record review of Resident #234 census reflected the resident was sent to the hospital on 2/6/24 and readmitted [DATE]. Record review of hospital records, dated 2/6/24, reflected Resident #234 presented to the ER with an accidental drug overdose when a transcription error was created unintentionally at the nursing facility transcribing amitriptyline 300 mg by mouth twice daily. Resident #234 appeared drowsy, and speech slurred. Per records his family members stated he was finally seeming like his old self until he received his medication around 10:30 AM. Following this he became progressively somnolent and eventually slumped over. Initial assessment Resident #234 was hypertensive (elevated blood pressure) and drowsy with slurred speech with abnormal EKG . Poison control was contacted, and the resident required 2 ampules of bicarb (a medication used to assist the body in disposing of the excessive medication) and repeated EKGs and orders to maintain potassium level greater than 4. Record review of hospital labs, dated 2/6/24, reflected: potassium level of 3.4 (low level causing heart irregularity), glucose level of 171(high blood sugar), carbon dioxide level of 21 (Meaning the blood is too acidic). Hospital vital signs reflected Resident #234 had elevated blood pressure and elevated respirations. Record review of hospital medication administration, dated 2/6/24, reflected Resident #234 required potassium chloride drip via IV to maintain his potassium level greater than 4, and supplemental bicarb also IV, to counter act the effects of the amitriptyline. In a record review of hospitals After Visit Summary, dated 2/13/24, reflected Resident #234's hospital admitting diagnosis was acute drug overdose, accidental or unintentional initial encounter. The Hospital instructions were to stop amitriptyline 10mg and the medication was discontinued. During an observation on 2/21/24 at 10:10 AM revealed Resident #234's was lying in bed and was sleepy and confused Resident #234 was not interview able. In an interview on 02/21/24 at 10:32 AM with the NP revealed the facility notified the NP of a concern due to Resident #234's increased lethargy. The NP stated Resident #234s family member had concerns the resident was over sedated. The NP stated she asked if Resident #234 had his morning medications. The NP stated she pulled Resident #234's medication profile and reviewed his medications, she questioned the orders that were input on 2/5/24 for Amitriptyline 150mg 2 tabs bid. The NP stated the order should have been for 10mg by mouth at bedtime as she had given the verbal order. Resident #234 received 1 dose of 300mg of amitriptyline on 2/6/24. The NP stated she ordered the resident to be sent to the hospital for evaluation of adverse effects related to medications error. An interview was attempted with LVN W by phone on 02/21/24 at 10:45 AM was unsuccessful. In an interview on 02/21/24 at 11:15 AM with LVN X, the former ADON, she reported on February 6th Resident #234 received a dose of amitriptyline 300mg as the order was reading from the medication administration record. LVN X reported Resident #234 became lethargic and LVN W, who was on duty, notified the NP. At that time, the NP reviewed medications, she noted the amitriptyline correctly transcribed. LVN X stated Resident #234 was lethargic. The NP gave orders to send Resident #234 to the hospital. EMS was notified and the resident went to the hospital via ambulance. The Family was notified of the incident and the DON was notified of the incident. There was an internal investigation she is not sure where it is. LVN X explained the process for checking orders included checking the 24-hour report. She reported there was no order reports that they were aware of that were ran. LVN X reported occasionally nurse managers work the floor. The new admissions were double checked by another nurse not necessarily a nurse manager, but just a second set of eyes on new admit orders, there was a clinical follow up sheet where they notify the nurses of missing assessments but not necessarily orders. LVN X stated the negative effects for not checking orders would include a risk of overdose causing altered mental status hospitalization or even worse. In an interview with Resident #234s' family, on 2/21/24 at 2:29 PM revealed on 2/5/24 Resident #234 was given a new order for amitriptyline 10mg 1 tab by mouth at bedtime. On 2/6/24 Resident #234 took his morning medications and within 30 minutes became lethargic and weak. Upon notification of the Nurse Practitioner, it was discovered Resident #234 was given 300mg of amitriptyline. Resident #234 was sent to the hospital and admitted with accidental drug overdose. During an interview on 02/21/24 at 2:34 PM with the DON, she stated typically a nurse manager should review orders in the computer. There was an order listing report that could be ran for 24 hours daily to review the previous days orders and double check for correctness or clarification of orders if needed. This order report should be reviewed by nurse managers, the practitioners had the capability to input their own orders into the computer and the facility was stressing the importance of this to avoid this type of medication error Both ADONs were new, and the Administrator were new as well, the negative outcome would depend on the medications. During an interview with the Administrator n 02/21/24 at 2:48 PM, he stated he was aware of the incident with Resident #234. He stated he understood there was an investigation completed. He was not sure where the report or investigation was. He stated he was not a clinician so he was not sure what kind of negative outcome there would have been for the medication error. He stated he did not feel qualified to answer that question. Record review of a medication error report, dated 2/6/24, reflected the following corrective actions were taken: 1) An Inservice was completed to ensure verbal orders are read back for accuracy. 2) to put in orders nursing administration to check orders daily. Record review of an unsigned in service, dated 02/6/24, reflected the staff were educated in handwritten in-services with the following directions: 1) Ensure verbal orders are read back for accuracy. 2) Pay attention to what you are doing (avoid distractions) 3) Look at order being placed at a minimum of two times (when put into system and before sending to pharmacy) 4) All and any questions related to dosage ASK! In a record review of the facility policy Adverse Consequences and Medication Errors reflected a Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with the physician's order, manufacturers specifications or accepted professional standards and principles of the professionals' providing services. An example of medication error would include e) wrong dosage . This was determined to be an Immediate Jeopardy (IJ) on 02/22/24 at 5:25 PM. The ADM and DON were notified. The ADM was provided with the IJ template on 02/22/24 at 5:25 PM. The following Plan of Removal submitted by the facility was accepted on 02/23/24 at 1:08 PM : Impact Statement: On 2/21/24 an abbreviated survey was initiated on 2/21/24 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to a significant medication error. How were other residents at risk affected by this deficient practice identified? The facility DON/Designee completed an audit of all new medication orders ordered in the last 30 days to ensure the residents have not had an adverse effect from their normal baseline 2/21/22. Residents with new medication orders have the potential to be affected by this deficient practice, 68 of the residents who were identified as having new medication orders were not affected. What corrective actions have been implemented for the identified resident? Resident #234 was sent to the hospital on 2/6/24 for evaluation. Resident #234 was readmitted to the facility on [DATE] in stable condition. The previous DON in-serviced 2/6/22 the licensed nursing staff on accurate drug transcription and dosage identification when new orders are received for antidepressant medications completed 2/21/24. What corrective actions were taken? 1. The following actions were initiated immediately on 2/21/2024. a. Director of Nursing was educated on 2/21/2024 by Clinical Services Director on identifying and reviewing all new orders daily to ensure drug transcription and dosage are within the recommended range. Completed 2/21/24. b. Initiated in-services on 2/21/24 with licensed nurses by Director of Nursing identifying and reviewing all new medication orders to ensure drug transcription and dosage are within the recommended range. Completed 2/21/24. c. On 2/21/24 the DON in-serviced all Medication Aides on notifying charge nurse if discrepancies in dosages verses written orders with medications are identified and reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders. Completed 2/21/24. d. Newly hired licensed nurses and medication aides will be in serviced during the on boarding process by DON on identifying and reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders. Completion- Ongoing Licensed nurses and medication aides in serviced by DON/ Designee on Medication administration. Reviewing all new orders to include antidepressant medication to ensure drug transcription and dosage are within the recommended range and medication administration medications, encompassing a comprehensive review of correct medication dosages cross-referenced with orders prior to administering. Completed 2/21/24. 2. How will the system be monitored to ensure compliance? A. DON/Designee Will review the Order List Report for all Newly received orders and compare it to resident for 4 weeks . If discrepancies are identified, we will notify the physician immediately for clarification before administering. Staff will receive further training on our Medication Administration Policy and disciplinary action up to termination. When discrepancies with medications are identified, the CMA will notify the charge nurse, the charge nurse will notify the physician if no response from the physician within two hours, then we will notify medical director prior to medication administration. Completion- Ongoing Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 2/21/24 with the Medical Director. The Medical Director has reviewed and agrees with this plan of removal. This plan will be monitored monthly during Quality Assurance and Performance Improvement meetings ongoing for any further education identified. Monitoring of the POR included the following: Interview and record review on 2/24/2024 at 1:00 PM with the DON revealed she and the CSD provided in-service trainings to the CMAs, RNs, and the LVNs on 2/21/2024. The in-service trainings were conducted face to face, or over the telephone. The trainings covered the facility's Administering Medication Policy as well as special instructions to ensure verbal orders were verified before entering them into the MAR and the NMAR. The DON stated she was trained one-to-one by the CSD to ensure approval orders were repeated back to the giver for verification before inputting the order into the computer. Nurses were supposed to ask questions of the provider if they did not understand the order, the order dosage, or if it looked inappropriate. New orders were supposed to be documented in the residence chart. The documentation was supposed to contain the order, who gave the order, who took the order, and that a family member, or responsible party, was notified. Lastly, the nurse was supposed to provide follow up visits for three days and document those findings in the residence medical record. Interview and record review on 2/24/2024 at 1:15 PM with CMA R, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, the medication aide was to alert charge nurse for clarification. CMA R stated the training pertained to bring any discrepancy with a medication dosage, versus the written order, to the attention of the charge nurse for clarification. She was directed to question any new medication order that looked out of the ordinary. She was re-trained to verify the medication packaging was for the right resident, right medication, right dosage, right time, and right route before being administered. She was educated to report observations of lethargic residents, or residents who displayed unusual behaviors, to the nursing staff immediately. CMA R's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 1:35 PM with CMA Q, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert the charge nurse for clarification. CMA Q stated she was instructed to report any discrepancies with medication, or medication dosages to the charge nurse. She was re-trained to make sure the medication orders on the MAR matched the medication packaging for the right resident, the right dosage, right time, and right route before being administered. Nursing staff needed to be informed immediately if a resident was lethargic residents or displayed unusual behaviors. CMA Q's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 2:15 PM with CMA S, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA S stated she was supposed to question any medication order that did not look right, or had an unusual dosage, and bring that to the attention of the charge nurse for clarification. Each medication administration was supposed to be checked 3 times for the right resident, right medication, right dosage, right time, and right route before being administered. CMA S's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 2:30 PM with CMA T, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. Any issue or concerns with a medication, or medication dosage were supposed to be brought to the attention of the charge nurse for clarification. Any observations of lethargic residents, or overly medicated residents, were to be reported the nursing staff immediately. CMA T's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 3:00 PM with LVN K, revealed she worked both 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM shifts on a PRN basis. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN K stated the training covered medication transcription and that she was supposed to read back and verify all orders were correct before putting them into the computer. She was instructed to ask questions of the provider if she did not understand the order, or if the order and dosage did not look appropriate. The entry into the computer would state the order, who took the order, who gave the order, and that the responsible party was notified. Follow up visits for residents with new medication were to take place for three days and each follow-up needed to be documented in the resident's chart. If they had questions about a medication and were unable to contact the provider after 2 hours of attempts, she was told she could call the medical director directly. Interview and record review on 2/24/2024 at 3:27 PM with LVN L, revealed he worked 6:00 AM to 6:00 PM shifts on a PRN basis. He participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN L stated the training pertained to verifying orders by repeating them back to the provider for clarification before entering them into the computer. If an order did not look correct, or if the dosage appeared to be wrong, he was instructed to ask questions to make sure. All new orders were to be documented in the resident's chart with the order itself, the person who gave the order, the person who took the order, and that the responsible party was informed. Follow-up visits were to be conducted, and documented, for residents who received [NAME] medications for 3 days. LVN L's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 3:51 PM with RN C revealed she worked the 6:00 AM to 6:00 PM. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. Orders were supposed to be repeated back to the provider to make sure the order was correct before putting it into the computer. If a medication, or dosage, did not look correct, she was supposed to ask for verification from the provider. All medication orders received were supposed to be documented in the resident's chart and were to state the order itself, the person who gave the order, the person who took the order, and that the responsible party was informed. Each resident, who received a new medication, received a follow up visit for three days to document the medication and its effects. If she were unable to contact a provider with questions about medications after two hours, she was told she could contact the medical director. RN C's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:05 PM with CMA U, revealed she worked a 6:00 AM to 2:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA U stated the training instructed her to let the nursing staff know if she thought a medication, or a medication dose, did not look correct. She was supposed to review the medication package and verify it 3 times with the resident to make sure of the right resident, right medication, right dosage, right time, and right route before being administered. Residents who appeared lethargic or overly medicated were supposed to be reported to the charge nurse immediately. CMA U's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:31 PM with LVN J revealed, he worked 6:00 PM to 6:00 AM shifts. He participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN J explained that he was supposed to listen to the order, write it down, and repeat it back to the provider before entering it into the computer. It was ok to ask questions if he did not understand the order of if it did not make sense. New medication orders were supposed to be entered into the resident's chart and contain the order, who gave the order, who took the order, and that the family was notified. Each resident who received a new medication was supposed to receive follow-up visits for 3 days and each visit was supposed to be supported with documentation in the resident's chart. If he had a question about an order and could not reach the provider, he was told to reach to to the medical director for help. LVN J's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:38 PM with LVN I, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN I stated the training covered medication order transcription and how to repeat the order to the provider for confirmation before entering it into the computer. The training instructed her to ask questions of the provider if they did not understand the order, or if the order and dosage did not look appropriate. New medication orders were documented in the residence chart and were supposed to include the order, who gave the order, who took the order, and that a family member was notified. Each resident received 3 days of follow-up visits and each visit was supposed to be documented on the medication and how it was working. If she had a question about a medication and could not reach the provider, she was instructed to reach out to the medical director for assistance. LVN I's name was annotated on the in-service document. Telephone interview and record review on 2/24/2024 at 4:50 PM with CMA V, revealed she worked a 2:00 PM to 10:00 PM shift, which rotated through every day of the week. She participated in an in-service training, dated 2/21/2024, which pertained to the facility's Administering Medication Policy and if there was a discrepancy in a medication dosage versus written orders, medication aide was to alert charge nurse for clarification. CMA V stated she was trained to question any medication order that did not look correct, or any dosage that seemed too high. Any issue or concerns with medications were supposed to be reported to the charge nurse immediately. CMA V stated she checked medications 3 times to make sure they were the right resident, right medication, right dosage, right time, and right route before being administered. Any resident who appeared groggy, or behaved out of character, was supposed to be reported to the nursing staff immediately. CMA V's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 5:50 PM with LVN G, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN G stated the training directed nursing staff to repeat medication orders and confirm they were correct before placing them into the computer. If something did not seem right, they were supposed to question the order for accuracy. All new orders were supposed to be entered in the resident's chart to include the order, who took the order, who gave the order, and that the family was notified. Resident with new medication orders received 3 days of follow-up visits, all documented, to check on the resident and how the medication was working. If a nurse could not reach a provider for a question about a medication, she was told to call the medical director for assistance. LVN G's name was annotated on the in-service document. Interview and record review on 2/24/2024 at 6:00 PM with LVN H, revealed she worked 6:00 PM to 6:00 AM shifts. She participated in an in-service training, dated 2/21/2024, which pertained to Medication Transcription. LVN H was trained to read back and verify medication orders before having placed them into the computer. Ask questions to the provider or if they did not understand the order, or if the order and dosage did not look appropriate; Document new orders in the residence chart to clarify which nurse received the order, who gave the order, the written order itself, and having notified the family or responsible party. Conduct follow up visits for residents for residents with new medication for 3 days and document those follow-up visits in the residence chart. If they were unable to contact a provider with questions about medications, they were instructed to reach out to the medical director. LVN H's name was annotated on the in-service document. While the IJ was removed on 02 /24/24 @ 6:10 PM, The facility remained at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.