**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 of 6 residents (Resident #43, Resident #45, and Resident #7) reviewed for pressure ulcers. - The facility failed to provide daily wound care for Resident #43 on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24, resulting in worsening of his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers. - The facility failed to receive Resident #43's biopsy/culture results for his R heel that was performed 9/30/24, until 10/24/24. - The facility failed to start Resident 43's antibiotic for MRSA and osteomyelitis (bone infection) to his R heel until 10/31/24, when results were received on 10/24/24. - The facility failed to have the Wound Care MD see Resident #43 after 10/7/24 due to not having staff to assist him. - The facility failed to measure Resident #43's wounds throughout October 2024. - The facility failed to prevent a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer to Resident #45's toe while at the facility between 9/9/24 and 10/1/24. - The facility failed to provide daily wound care to Resident #45's R middle toe on 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. - The facility failed to provide daily wound care to Resident #7's Left Lateral Forefoot and Left Sacrum on 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24, which resulted in worsening of the Sacrum pressure ulcer. An Immediate Jeopardy (IJ) was identified on 10/31/2024. The IJ Template was provided to the facility on [DATE] at 4:15pm. While the IJ was removed on 11/2/2024, the facility remained out of compliance at a level of more than minimal harm and a severity of no actual harm with potential for more than minimal harm that not Immediate Jeopardy and a scope of pattern due to the need for implementation of corrective measures and the effectiveness of its corrective plan. Findings included: 1.Record review of Resident #43's undated face sheet revealed he was a [AGE] year-old male admitted originally on 3/3/22, with the most recent admission being 8/30/23. His diagnoses included pressure ulcer of the sacrum (buttocks), type 2 diabetes (body does not produce insulin or is resistant to it), quadriplegia (complete or severe loss of motor function in all four limbs), muscle spasms (involuntary muscle contractions), muscle wasting and atrophy (muscle shrinkage/contraction due to not using), and neuromuscular dysfunction of the bladder (bladder does not work due to nerve issues). Record review of Resident #43's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. He had impairment on both sides of his upper and lower extremities and used an electric wheelchair. The resident was dependent with all ADLs and had a suprapubic catheter (a hole from the bladder through the abdomen to the outside to drain urine) and a colostomy (a hole through the abdomen from the colon to the outside to drain stool). The MDS revealed Resident #43 had 5 Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it ) pressure ulcers, and only 1 was present on admission. Record review of Resident #43's care plan dated 3/10/22 revealed a Focus: The resident has pressure ulcers: L heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Reopened, R heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lower leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R ischium (R side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), L ischium (L side of buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it), R lateral leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) Resident refuses visits from wound care doctor and refuses treatments frequently. (Initiated: 8/10/24, Revised: 10/29/24) Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/30/22, Revised: 9/29/22, Target: 11/26/24). Interventions: Assess/record/monitor wound healing at lease weekly. Measure length, width and depth. Obtain and monitor lab/diagnostic work as ordered, report results to MD and follow up as indicated. Refer to wound care MD. Turn/reposition every 2 hours. Focus: Resident is on antibiotic therapy r/t diagnosis of osteomyelitis (Initiated: 11/12/23, Revised: 10/31/24). Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date (Initiated: 11/12/23, Revised: 2/5/24, Target: 11/26/24). Interventions: Administer medication as ordered. Report pertinent lab results to MD. Focus: The resident has IV access (Initiated: 10/31/24). The resident will not have any complications related to IV therapy through the review date (Initiated: 10/31/24, Target: 11/26/24). Interventions: Administer IV medications as ordered. The resident has PICC line IV access to right upper arm. Record review of Resident #43's Physician Orders revealed the following orders from MD A: - Calcium Alginate-Silver External Pad 2, Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver and santyl (wound care medications), cover with dry dressing. Every day for wound care. Ordered on 6/3/24. - Calcium Alginate, Cleanse wound to R Posterior leg with wound cleanser/ns, pat dry, apply calcium alginate and santyl, cover with dry dressing. Every day for wound care. Ordered on 6/17/24. - Calcium Alginate-Silver External Pad 2'x2', Cleanse wound to R Heel with wound cleanser/ns, pat dry, apply calcium alginate w/ silver (wound care medications), and cover with dry dressing. Every day for wound care. Ordered on 8/19/24. - Cleanse wound to L Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. - Cleanse wound to R Ischium with wound cleanser/ns, pat dry, apply Dakins 125% (wound care medication) and cover with dry dressing. Every day for wound care. Ordered on 10/9/24. - Santyl External Ointment 250U/gm (Collagenase) (wound care medication), Apply to R Heel/Lateral Leg, Every day for wound care. Ordered on 10/9/24. - No orders for any antibiotics were found for his MRSA/osteomyelitis. Record review of Resident #43's Wound Care Note dated 9/30/24, revealed a L Ischium (L side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 5.6cm x 1.9cm x 0.1cm, a R Ischium (R side buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer that was 3.5cm x 3.9cm x 0.1cm, L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 1.2cm x 0.1cm, R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 6.1cm x 5.2cm x 0.4cm, and a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.8cm x 1.9cm x 0.1cm. Debridement (removal of dead tissue) was performed on the L Ischium (L buttock), R Ischium (R buttock), R Heel, and a biopsy (tissue sent to the lab) was taken from the R Heel d/t suspicion of osteomyelitis (bone infection). Wound orders were entered for daily wound care. Record review of Resident #43's October 2024 MAR-TAR revealed blank spots where wound care was not provided to his L Heel, R Heel, R Distal (closest to foot) Leg, R Proximal (furthest away from foot) Leg, L Ischium (buttock), and R Ischium (buttock) pressure ulcers, for the following dates: 10/1/24, 10/6/24, 10/12/24, 10/13/24, and 10/26/24. Record review of Resident #43's Wound Care Note dated 10/7/24, revealed a L Ischium (L buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.6cm x 2cm x 0.1cm, a R Ischium (R buttock) Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 3.7cm x 3cm x 0.1cm, a L Heel Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.2cm x 2.2cm x 0.1cm, a R Heel Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 5.3cm x 3.9cm x 0.2cm, a R Lateral Lower Leg Stage 4 (ulcer extends into the muscle, tendon, or bone, and may expose it) pressure ulcer 2.6cm x 1.5cm x 0.1cm, and a new R Proximal Lateral Lower Leg Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 4.5cm x 1.6cm x 0.1cm. Debridement (removal of dead tissue) was performed on the R Heel and the R Proximal Lateral Lower leg. Record review of Resident #43's medical record, revealed a final report from [lab] dated 10/9/24 was faxed from the Wound Care MD's office to the nursing facility on 10/10/24, with results of acute osteomyelitis (bone infection) that was found during the biopsy (tissue removal sent to lab) on 9/30/24. Record review of Resident #43's Weekly Ulcer Assessments for 10/14/24 and 10/28/24, were the same as the last measurements from the Wound Care MD on 10/7/24. Record review of Resident #43's medical record, revealed culture results from [lab] dated 10/24/24 was faxed from the Wound Care MD's office to the nursing facility on 10/24/24, with results of high amounts of MRSA (a drug resistant bacteria) and multiple other bacteria that was found during the culture on 9/30/24. In an interview and observation with Resident #43 on 10/29/24 at 11:15am, the resident was observed laying on his back receiving wound care by the floor nurse, directed by the ADON. The resident said the facility no longer had a Wound Care Nurse, so the floor nurses had to perform wound care and they did not come every day. He said they were only doing it because State was there and the last time he had received wound care was on 10/27/24. In an interview with Resident #43 on 10/30/24 at 12:15pm, he said the Wound Care MD would not see him because the facility did not have a Wound Care Nurse to help him. He said the Wound Care MD wanted someone to help him position and take orders and the floor nurses were too busy to come help, so the doctor did not have time to wait around and would not see him. The resident also said the staff would get him into his chair and then want him to get back to bed for wound care and then get back into his chair and that was too much work, so a couple times he refused. He said he felt like they would wait for him to get in his chair on purpose so they could offer it then and they know he would refuse. Resident #43 stated he felt like his pressure ulcers had worsened since the Wound Care MD had not seen him since 10/7/24. In an interview with a family member of Resident #43 on 10/30/24 at 1:45pm, who said the facility had a big problem with performing wound care daily since they did not have a wound care nurse. She said Resident #43 may have refused a few times, but he did not refuse often because he has become septic in the past and knew how important wound care was. She said the problem was staff would get him into his chair and then wanted him to get back into bed for wound care, and then get back into his chair. She said that was a lot of work for him and he would not want to do it. She said she did not understand why they would not do his wound care first and then put him in his chair. In an interview with the Wound Care MD on 10/30/24 at 1:48pm, he said he came every Monday to see residents. He said Resident #43 was complex, had a lot of wounds, and needed help getting ready before he arrived. He said he would call the facility and give them an hour notice before he arrived, but the resident still would not be ready when he arrived, and he would not have time to sit around and wait when he had other residents to get to. He said it was hard for nursing staff to keep up with wound care when there was not a dedicated wound care nurse, so it frequently did not get done or fell through the cracks. He said they had not had a wound care nurse in about a month. The Wound Care MD said he received the labs, he thought on 10/24/24 but was not sure when, and the resident had osteomyelitis before. He said he talked to NP B on Monday (10/28/24) and told her to order the antibiotics for the resident. He said he wanted to make sure she ordered the antibiotics, and they did not get missed. In an interview with NP B on 10/30/24 at 2:40pm, she said the Wound Care MD called her to inform her Resident #43 would be on Cipro/Vancomycin (antibiotics for wound infection) but did not tell her to order them. She said the Wound Care MD would inform the nurse at the facility and they would enter the orders. She said she did not enter orders for the Wound Care MD. She said she saw labs come in for the resident but if the Wound Care MD ordered them, he would be responsible for following up on them. In an interview with the DON on 10/30/24 at 3:05pm, she said she was kind of familiar with Resident #43's wounds. She was not sure if the wounds were getting better or worse. She said the floor nurse was the one responsible for measuring the wounds. She said [username] was her and that was who logged all the measurements of Resident #43's wounds for October 2024, so she must have performed the measurements. She said she thought the wounds had not changed. She did not know if the resident had had any labs/biopsies (tissue removal and sent to lab) on any of his wounds. The DON said the Wound Care MD did not give any orders to NP B because she did not work for him. She said the Wound Care MD would tell a nurse at the facility and they would enter the orders, or he would slide the orders under her door, and she would enter them. She said she did not know anything about the antibiotic orders for Resident #43 and she was going to go call the Wound Care MD. In an interview and observation of Resident #43 on 10/30/24 at 4:00pm, he said the DON never measured his wounds and that he had never even seen her face before. Measurements were performed with the DON and the Clinical Resource Nurse and were as follows: L Heel: 3.5 x 2.5 = 8.89cm x 6.35cm R Heel: 6.5 x 5 = 16.51cm x 12.7cm R Distal Leg: 2.5 x 1 = 6.35cm x 2.54 R Proximal Leg: 6 x 1 = 15.24cm x 2.54cm In an observation of Resident #43 on 10/31/24 at 10:00am with the ADON, DON, and the Clinical Resource Nurse the resident's L Ischium (L buttock) and R Ischium (R buttock) were measured as follows: L Ischium (L buttock): 6.5 x 2.5 x .1 = 16.51cm x 6.35cm R Ischium (R buttock): 6 x 3 x .2. = 15.24cm x 7.62cm There was also new maceration (skin breakdown due to moisture) to both sides. The resident was observed with a right upper arm PICC line. In an interview with the DON on 10/31/24 at 10:40am, she said she copied the last measurements the Wound Care MD entered on 10/7/24 and entered those measurements throughout October, because she did not want to enter the wrong information or the wrong staging. She said the wound care nurse left about 3 weeks ago and then before that they had another wound care nurse that was there that left. She said she expected her floor nurses to provide wound care but not touch anything having to do with measurements. She said she would know if the wounds got worse without measuring by noting the smell, drainage, and pain. In an interview with RN C on 10/31/24 at 12:51pm, she said she did not know of any labs/biopsies (tissue removed and sent to lab) that Resident #43 had to his wounds. She looked in his chart and said she did not see anything. She said when cultures/biopsies (tissue removed and sent to lab) are done, they put it on the 24hr report so they can keep track of it. She said the other nurses did not have enough time to perform wound care and that they really need a wound care nurse, but she makes time. She said Resident #43's wound care was mainly done at night, and she did not know of him refusing, maybe once or twice. In an interview with the ADON on 10/31/24 at 1:00pm, she said she did not know anything about the culture/biopsy (tissue removed and sent to lab) results for Resident #43 until the results were recently brought to her attention. She said the Wound Care MD did not communicate well and only communicated with the wound care nurse when they had one. If they did not have a wound care nurse, he kept to himself. She was not sure how it was ordered because there were no orders in the system. She said the results were always sent to the Wound Care MD's office and then they would fax them to the nursing facility. In an interview with the Administrator on 10/31/24 at 1:40pm, she said the ADON, and the floor nurses were assigned to handle the wound care treatment for the residents since they no longer had a wound care nurse. She said the floor nurses were aware they would be providing treatment and if they were not able to round with the Wound Care MD, then the ADON was responsible for rounding and entering orders. She said the ADON, and the DON were responsible for following up on the orders. The Administrator said when the last wound care nurse left there were no loose ends, or anything left outstanding that she was aware of. She said only the Wound Care MD measures the wounds and then the nurse enters the measurements in the system. She said if the Wound Care MD had not seen the resident in a while, like Resident #43, then the DON/ADON should have seen the resident and taken measurements. In an interview with the Wound Care MD on 10/31/24 at 3:15pm, he said he did his own biopsies (tissue removed and sent to lab)/cultures and took them to the lab himself. He said he left a copy of his handwritten notes and a copy of the order at the facility. He said he usually gave it to the wound care nurse but if the wound care nurse was not there, he would give it to the floor nurse. If the floor nurse was not available or he could not find anyone, then he would give it to the DON or slide it under her door. He said he gave it to a floor nurse, but he did not remember who it was. He said the results were faxed to the facility. He said he got a biopsy/culture because the wound was deteriorating, and it appeared to look like it had osteomyelitis. 2.Record review of Resident #45's undated face sheet revealed he was a [AGE] year-old male originally admitted on [DATE], with the most recent admission on [DATE]. He had diagnoses of unspecified dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), pressure induced deep tissue damage of left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), contractures of right and left knees (inelastic fiber-like tissue in the knees preventing normal movement), muscle wasting and atrophy (thinning of your muscle mass), dehydration, type 2 diabetes (body does not produce insulin or resists it), and iron deficiency anemia (body is not producing enough iron). Record review of Resident #45's Annual MDS assessment dated [DATE], revealed a BIMS score was unable to be obtained due to medical issues. The MDS revealed he had severely impaired cognitive skills for daily decision making. He had impairment of both sides of his upper and lower extremities and was dependent with all ADLs. The resident had a nephrostomy (hole into kidney through abdomen to drain urine) and a colostomy (hole from colon through abdomen for stool to collect in bag outside of body). Resident #45 had a Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer that was not present on admission. Record review of Resident #45's care plan dated 4/20/23 revealed a Focus: The resident has a pressure ulcer: R Second toe (Initiated: 4/24/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review period (Initiated: 4/24/24, Revised: 4/24/24, Target: 11/17/24). Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing at least weekly. Measure length, width, and depth. Turn every 2 hours. Record review of Resident #45's Physician Orders from MD A revealed the following orders: - Zinc Oxide External Cream 10%, Cleanse abrasion to left buttock with wound cleanser/ns, pat dry, apply zinc oxide (wound medication). Every shift for wound care. Ordered on 10/27/23. - Cleanse right great toe with normal saline or wound cleanser, pat dry, and apply skin prep, leave open to air. Every day for wound care. Ordered on 9/24/24. - Calcium Alginate, Cleanse right second toe with NS/Wound cleanser, pat dry, apply calcium alginate/silver (wound medications), cover with dry dressing. Every day for wound care. Ordered on 9/29/24. - Skin Prep Spray, Clean posterior left heel with normal saline, pat dry, apply skin prep daily (wound medication), float heels, leave open to air. Every day for deep tissue injury (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). Ordered on 11/1/24. Record review of Resident #45's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/13/24, 10/21/24, 10/23/24, and 10/27/24. Record review of Resident #45's Wound Care Note dated 10/7/24, revealed R Medial (middle) Second Toe Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.1cm x 1.5cm x 0.3cm with bone exposed (Wound Care MD should have classified it as a Stage 4 since bone was exposed). Record review of Resident #45's progress note from MD A dated 10/9/24, revealed a note that read 9-9-24: Since last evaluation, chronic medical conditions remain stable .No present wound issues. Staff reinforcement done to promote turning, pressure relief, skin care and safety. Another note read 10-9-24 Since last eval, chronic medical issues have been stable .Has developed wound on right second toe, followed by wound care service . In an observation of Resident #45 on 10/29/24 at 9:16am, he was lying on his left side in bed, without his pressure relieving boots on. In an observation of Resident #45 on 10/30/24 at 9:06am, he was asleep on his left side with his pressure relieving boots on his nightstand. In an observation of Resident #45 on 11/1/24 at 10:30am, he was lying on his left side with hand splints on and his bilateral boots on. Record review of Resident #45's SBAR dated 11/1/24, revealed he had a skin change which was a deep tissue injury to his left heel (a type of pressure ulcer that occurs when underlying soft tissue is damaged by pressure or shear forces). 3. Record review of Resident #7's undated face sheet revealed she was a [AGE] year-old female originally admitted on [DATE], with the most recent admission date of 7/18/24. She had diagnoses of Alzheimer's disease (brain disorder that gradually destroys memory and thinking skills), muscle wasting and atrophy (thinning of your muscle mass), protein calorie malnutrition (reduced availability of nutrients leads to changes in body), dementia (decline in cognitive abilities, such as thinking, remembering, and reasoning), and cerebral infarction (stroke). Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score was unable to be performed due to medical concerns. She had impairment on both sides of her lower extremities and was bedbound. She was dependent with all ADLs and was always incontinent of bowel and bladder. The MDS revealed she had 2 Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcers that she was not admitted with. Record review of Resident #7's care plan dated 1/31/20, revealed a Focus: The resident has a pressure ulcer to L Lateral (outside) foot, L Sacrum (buttock) (Initiated: 3/6/24, Revised: 10/14/24). Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (Initiated: 3/6/24, Revised: 4/4/24, Target: 12/30/24). Interventions: Administer medications and treatments as ordered. Assess/record/monitor wound healing at lease weekly. Measure length, width, and depth. Enforce turning/repositioning. Record review of Resident #7's Physician Orders revealed the following orders from MD A: - Zinc Oxide External Paste (wound medication), apply to sacrum (buttocks) two times a day. Ordered on 7/18/24. - Zinc Oxide External Cream 10%, cleanse sacrum (buttocks) with wound cleanser/ns, pat dry, apply zinc oxide (wound medication), every shift. Ordered on 7/22/24. - Skin Prep Wipes, apply to right lateral (outside) ankle every day for wound care. Ordered on 7/29/24. - Betadine External Solution, apply to left plantar (bottom) foot every day for wound care. Ordered on 8/26/24. - Cleanse left lateral (outside) foot with normal saline or skin cleanser, apply medi-honey and calcium alginate (wound medications), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/4/24. - Calcium Alginate Powder, cleanse sacrum (buttocks) with normal saline, pat dry, apply calcium alginate (wound medication), cover with dry dressing. Every day for wound care. Ordered on 10/4/24. - Cleanse sacrum (buttocks) with normal saline or skin cleanser, pat dry and apply calcium alginate (wound medication), cover with dry dressing, daily and PRN. Every day for wound care. Ordered on 10/8/24. Record review of resident #7's Wound Care MD Note from 9/30/24, revealed a Left Lateral Forefoot (outside front part of foot) arterial ulcer (due to bad circulation) 2.5cm x 1.2cm x 0.3cm, and a Left Sacrum Stage 3 (deep wound with visible subcutaneous fat, but no exposed bone, tendon, or muscle) pressure ulcer 2.7cm x 1.5cm x 0.1cm. Record review of Resident #7's October 2024 MAR-TAR revealed blank spots where wound care was not provided for the following dates: 10/1/24, 10/6/24, 10/11/24, 10/12/24, 10/13/24, 10/17/24, 10/24/24, 10/27/24, 10/28/24, and 10/29/24. Record review of Resident #7's Weekly Ulcer Assessment performed by the Clinical Resource Nurse on 10/30/24, revealed measurements for the sacrum (buttocks) 9.5cm x 6cm. In an observation of Resident #7 on 10/29/24 at 10:02am, she was asleep on her left side in bed. In an interview with Resident #7's family member on 10/29/24 at 1:48pm, she said she would like to see the resident up in her wheelchair at least once a month. She said the facility never got Resident #7out of bed and into her wheelchair and she laid in bed every day. She said she spoke to the Administrator and DON about it, but still nothing changed. In an observation of Resident #7 on 11/1/24 at 10:35am, she was asleep on her left side in bed. Record review of the facility's policy and procedure on Pressure Injury: Prevention, Assessment and Treatment (Revised 8/12/16) read in part: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone [color], turgor [elasticity of skin] and circulation to prevent breakdown, injury and infection. 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. The nurse will determine if prevention and/or treatment of pressure sore(s) is indicated and notify the Treatment Nurse/designee of any potential problems. 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document Notification . Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: NOTE: Add any interventions to care plan. 1. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. 2. Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV). 11. Director of Nursing or designee to inservice nurses and CNA's on above prevention. 2. Pressure sore identification: Director of Nursing or treatment nurse/designee will classify the pressure injury according to the following descriptions of the different stages. Staging definitions are per the guidelines of the National Pressure injury Advisory Panel February 2016 definitions .7. Nursing Care Plan. 1. Identify the problem of pressure injuries on the Nursing Care Plan 2. Under Nursing Intervention, list physician ordered treatments .Assessment of the pressure injury should also include the site, size, and W x L x D, of the injury. Surrounding tissue, color, exudate [drainage], wound edges, sinus tracts [narrow abnormal channel that co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of five residents reviewed for accidents hazards and supervision, in that: -Resident #2 fell from lift, sustained a head abrasion and L foot fracture during a Hoyer lift transfer (a device designed to assist caregivers in safely transferring patients or individuals with limited mobility) when CNA K operated the Hoyer lift by herself. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 1/2/24 and ended on 1/3/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk of injury and hospitalizations. The findings include: Record review of Resident #2's face sheet dated 6/20/24 revealed an [AGE] year-old female who admitted on [DATE]. Her diagnosis included cerebral infarction (stroke), gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food.), vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), hemiplegia (total or nearly complete paralysis on one side of the body) and hemiparesis (one-sided weakness), and depression. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. She was totally dependent on staff for ADL care including chair/bed to chair transfer. She had no falls since admission/entry or reentry or the prior assessment. Record review of Resident #2's care plan revised on 1/10/24 revealed she had an ADL self-care performance deficit related to impaired cognition, dx: vascular dementia, impaired mobility, hemiplegia, impaired balance, hx: cerebral infarction, incontinence, wheelchair dependent (revised on 10/20/22). She was at risk for injury due to falls related to impaired cognition, impaired mobility, gait/balance problems, hemiplegia, and incontinence. Interventions were: required 2 person assist with transfers and the use of a mechanical lift (initiated 1/10/24). Record review of Resident #2's Event Nurses-Note 12 hr Fall dated 1/2/24 by LVN E read in part, .I was informed by an AID (sic) that resident was on the floor. On entering room, resident was on the floor with a visible wound to the forehead. I provided first aid and obtained vital signs . 19. Gait and Mobility at time of event c. transferring x2 or more staff assist. Record review of CNA K's witness statement dated 1/3/24 read in part, .I went in to (Resident #2's) room and started cleaning her up. (CNA J) came in to assist me. I asked her to get a sling and we put it under (Resident #2). I asked her to go get the Hoyer lift. I hooked (Resident #2) up and (CNA J) went to get the chair. I had her raised up and when I got ready to turn with her, she slipped out of the Hoyer pad. I tried to help but it was too late . Record review of CNA J's undated witness statement read in part, .On Tuesday [DATE] at around 11:55 a.m. I (CNA J) and (CNA K) were getting (Resident #2) out of bed with Hoyer lift. While (CNA K) was operating the Hoyer lift to get (Resident #2) out of bed I stepped out the room as asked to retrieve the wheelchair. As I walked back into the room, I seen the Hoyer lift strap release and (Resident #2) fell to the floor. We immediately called for help and started applying pressure to her wound . In a telephone interview on 6/20/24 at 3:25 p.m. CNA J said on the day of Resident #2's incident, she notified CNA K that she was stepping out of the room to get the wheelchair. She said as soon as she walked back in the room, she saw CNA K lift Resident #2 up so that her bottom was not on the bed. She said there appeared to be some tension and then she fell. She said she was not in the room when CNA K raised the resident up and in that moment the aide was operating the Hoyer alone. She said one of the loops on the Hoyer strap may not have been on correctly. She said she might have seen the sling was not on the loop correctly if she was in the room. She said staff could tell if the sling was not fastened correctly while moving a resident. She said she was trained that while using a Hoyer lift 2 people should be in the room at all times. She said staff normally did not move the resident until everything was set in place. She said staff should never transfer resident by themselves because there could be an accident. Record review of Resident #2's nursing note dated 1/2/24 by LVN E read in part, Resident was transported to (Hospital) on an EMS ambulance that responded to 911 call on behalf of resident. Resident alert and oriented to own ability 3 cm skin tear to right forehead . Record review of Resident #2's hospital records dated 1/2/24 revealed Resident #2 presented to the emergency department after an unwitnessed fall with positive head strike. An x ray of the left ankle was conducted. Findings were a minimally displaced (slight shift in position) intra-articular fracture of the medial malleolus (inner ankle) with large overlying soft tissue swelling. Mild soft tissue swelling over the lateral malleolus (outside ankle), consistent with sprain. Record review of Resident #2's nursing note dated 1/2/24 by the DON read in part, Resident returned from ER, transported via EMS via stretcher, assisted to bed . hospital dx: abrasion to head, left medial malleolar fracture . splint/cast brace in place to left lower extremities. Resident reports pain, medicated with PRN pain management . Record review of the facility's provider investigation report dated 1/10/24 revealed the sling being used on the mechanical lift was potentially not secured correctly at the time of transfer. The sling and lift were determined to be in proper working order. Staff using mechanical lift were immediately re-educated on the proper procedures for using a mechanical lift and competency check was performed for CNA K. CNA J would receive a competency check on her next scheduled shift. The findings were confirmed. In an observation and attempted interview on 4/16/24 at 2:00 p.m. of Resident #2 revealed she was lying in bed on her right side. Resident nodded yes when asked if she was ok. She was unable to say how she fell. Interview on 6/20/24 at 3:51 p.m. the ADON said CNA K and another aide transferred Resident #2 and she slid to the floor and hit her head. She said there should be two people at all times during a Hoyer transfer because you never know what could happen with the lift. She said the resident could fall if only one person was operating it. She said the facility always educated the staff on two person Hoyer lift transfers. She said she and other nurses ensured the aides were transferring residents properly via Hoyer lift. She said CNA K no longer worked at the facility. Interview on 6/20/24 at 3:58 p.m. the Administrator said he did not remember the details of the incident. He said additional training was certainly conducted after the incident. He said a Hoyer lift transfer required 2 people at all times for safety. Attempted telephone interview on 6/20/24 at 4:26 p.m. with CNA K was unsuccessful. Surveyor was unable to leave voicemail. Record review of the facility's Inservice binder revealed the following in services were conducted prior to Resident #2's incident on 1/2/24: *Safe Patient Handling - 7/30/23, *Fall Prevention - 7/24/23, *Transfer Training - 7/3/23, *(Hoyer) sling care - 7/3/23, *Moving a Resident, Bed to Chair/Chair to Bed - 7/3/23, *Safe Patient Handling - 7/3/23, *Hydraulic Lift - 7/3/23. Record review of the facility's undated Hydraulic Lift policy read in part, The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair .The number of staff to provide assistance with the transfer should be determined by the manufacturer recommendations . Goals: 1. The resident will achieve safe transfer to bed or chair via a mechanical lift device . Procedure: 2. Involve as many staff members as needed to ensure feelings of security by the resident .6. Place the chair next to the head of the bed with the front facing the foot . lock the wheelchair. 7. Raise the bed to accommodate the lift under the bed .11. Check to be sure that the hooks with open ends are turned away from the resident . 12. Pump the life while holding the steering arm until a sitting position is assumed and the buttocks are lifted off the bed . It was determined these failures placed Resident #2 in an IJ situation from 1/2/24 to 1/3/24. The Administrator was notified by telephone and provided with the IJ template on July 9, 2024 at 4:30 p.m. via email. The facility took the following action to correct the non-compliance on 1/3/24. Record review of the provider investigation report dated 1/10/24 read in part, . Provider Response: upon notification of the fracture, the event was reported to TX HHSC. In-services were initiated regarding transfer training. Slings in the facility were inspected for wear and tear . and determined to be in proper working order, including the sling that was used on (Resident #2). Mechanical lifts were inspected . and determined to be in proper working order, including the mechanical lift being used for transfer of (Resident #2) . Investigation summary: . revealed the sling being used on the mechanical lift was potentially not secured correctly at the time of transfer. The sling and lift were determined to be in proper working order. Staff using mechanical lift were immediately re-educated on the proper procedures for using a mechanical lift and competency check was performed for (CNA K). (CNA J) will also receive competency check on her next scheduled shift . Provider Action Taken Post-Investigation: . no further complications or events have occurred since 1/2/24 for this resident or any resident being transferred with a mechanical lift. Transfer training and competency checks continue to be performed for CNA staff . Record review of the facility's in-service training attendance roster revealed a Hoyer lift training was conducted on 1/3/23 (sic). The in-service was on proper placement of sling, how to safely operate Hoyer lift and secure patient in sling, bed, proper positioning, requires 2 people for safe use of Hoyer. There were 12 CNA signatures which included CNA K and CNA J. Record review of Resident #2's care plan revised on 1/10/24 revealed she was at risk for injury due to falls related to impaired cognition, impaired mobility, gait/balance problems, hemiplegia, and incontinence. Interventions were: required 2 person assist with transfers and the use of a mechanical lift. Interview on 6/20/24 at 12:47 p.m. CNA D said Hoyer lift transfers required 2 people. She explained the Hoyer lift procedure and said she checked the Hoyer lift and slings for any wear and tear. She said any concerns would be reported to Central supply staff. In an observation on 6/20/24 at 1:40 p.m. of CNA P and CNA M revealed they transferred Resident #2 from her wheelchair to her bed using a Hoyer lift safely and without incident. The resident no longer had a brace on her leg. Interview on 6/20/24 at 2:09 p.m. Medical Records who also works as a CNA said Hoyer lift transfers always required 2 persons. She said she checked the Hoyer slings for any rips or tears. She said she would notify the Administrator or DON about the integrity of the sling. Interview on 6/20/24 at 2:35 p.m. RN K said two persons were required for Hoyer transfer. She said she checked for any holes on the sling and strap defects. She said if there was a concern during transfer, she would immediately stop and correct the problem, get another pad/Hoyer lift to prevent injury. In a telephone interview on 6/20/24 at 3:25 p.m. CNA J said after the incident with Resident #2 the DON conducted an in-service on Hoyer transfer. She was reminded there should be 2 people to conduct a Hoyer transfer and to not move the individual without 2 people. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 12 residents (Resident #62, Resident #217 and Resident #317) reviewed for pain management. - The facility failed to acquire, dispense, and timely administer pain medications and failed to assess Resident #317's pain resulting in pain of 10 out of 10. - The facility failed to assess and document Resident #62 pain accurately or at all. - The facility failed to assess and document Resident #217's pain. An IJ was identified on 09/06/23. The IJ template was provided to the facility on [DATE] at 04:20 PM. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal These failures could place residents at risk for uncontrolled, irretractable pain, and decreased quality of life. Findings Include: Resident #317 Record review of Resident #317's Face Sheet dated 09/11/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's admission Note dated 09/05/23 at 2:51 PM revealed, Resident #317 admitted to the facility on [DATE] at 01:38 PM from a hospital. Record review of Resident #317's Progress Notes dated 09/05/23 at 4:34 PM revealed, Medications reconciled with NP. Triplicate request given to NP for Oxycodone, Norco, Methadone, and Xanax. There was no documentation of Resident #317's pain. Record review of Resident #317's Progress Notes dated 09/05/23 at 9:06 PM revealed, Methadone 5 mg was not available new admission and NP is aware. Record review of Resident #317's Progress Notes dated 09/06/23 at 5:15 AM revealed, the facility was waiting for delivery of Methadone 5 mg from the facility. Record review of Resident #317's Order Summary Report dated 09/06/23 at 09:20 AM revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6. Record review of Resident #317's MAR printed 09/06/23 at 09:21 AM revealed, - Resident #317 was not administered his Methadone 7.5 mg scheduled for 09/05/23 at 10:00 PM. - Resident #317 was not administered his Methadone 7.5 mg scheduled for 09/06/23 at 06:00 AM. Record review of Resident #317's Medication Administration Audit Report dated 09/09/23 at 12:00 PM revealed, Resident #317 received Methadone 7.5 mg- scheduled for 09/06/23 at 02:00 PM at 03:11 PM. There was no documentation for the reason why the medication was administered late. Record review of Resident #317's Clinical Assessments printed 09/06/23 at 09:33 AM revealed, a pain assessment was not completed upon Resident #317's admission into the facility. Record review of Resident #317's admission Note dated on 09/05/23 and signed by LVN H revealed, Resident #317 reported constant pain up to 10 out of 10 in the last 5 days leading to his admission on [DATE]. There was no documented pain scale for the resident's pain at admission. Record review of Resident #317's Pain Score printed 09/06/23 at 09:33 AM revealed, no documented pain scores for Resident #317 since admission. Record review of Resident #317's Pharmacy Records faxed 09/20/23 at 10:40 AM revealed, - The Medical Director send an eScript for Hydrocodone/Acetaminophen 10-325 mg- 1 tablet by mouth every 8 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:48 (over 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director send an eScript for Oxycodone 5 mg- 1 tablet by mouth every 6 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director send an eScript for Methadone 7.5 5 mg- 1 tablet by mouth every 8 hours with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM by LVN B. An observation and interview on 09/06/23 at 07:37 AM revealed, MA B informed LVN A that Resident #317 was complaining of pain. LVN A told the surveyor that Resident #317 arrived to the facility the previous afternoon and his pain medications had not yet arrived from the pharmacy. An observation and interview on 09/06/23 at 08:25 AM revealed, Resident #317 lying in bed with his face slightly protruding from under the sheets. He had a grimace on his face and could be heard saying oh shit intermittently. Resident #317 said he had not received his pain medications Methadone, Oxycodone and Hydrocodone/Acetaminophen since the morning of his admission [DATE]) and reported pain at a 10 out of 10. Resident #317 said he had not been offered or received any alternative pain medications like Tramadol or Tylenol #3. Interview on 09/06/23 at 08:30 AM, LVN A looked at Resident #317's MAR and said the resident did not have any orders for alternative pain medications and he had not been offered any alternatives. She said Resident #317 had orders for PRN Hydrocodone/Oxycodone and scheduled Methadone and he had not received them since he admitted to the facility yesterday. Interview on 09/06/23 at 08:48 AM, the Pharmacist said Resident #317 had not received his Hydrocodone, Methadone and Oxycodone because the pharmacy was pending a prescription so NP A was notified that a triplicate prescription was necessary. He said that as of that moment the pharmacy had not received an electronic prescription. He said in Texas LTC (facilities like nursing homes or assisted living facilities) facilities are allowed to call in/fax in emergency CIIs (schedule 2 controlled substances which include naracotics with high addictive potential) but nothing had been sent in at the time of our conversation. Interview on 09/06/23 at 09:02 AM, the DON said when a resident arrives at the facility the admitting nurse must reconcile the medications with the NP and once confirmed the orders are entered into the EMR. She said if a resident has orders for a narcotic medication, the information is provided to the NP and the provider will have to send an eScript while non-controlled substances can be found in the stat kit (emergency medication dispensing system). The DON said if the pharmacy received a medication order before 06:00 PM the medication would be delivered on the same day, but if the order arrives later the medication can be sent to the facility as a stat delivery. Interview on 09/06/23 at 09:10 AM, NP A said the medical director should have sent the order for Resident #317's medication to the pharmacy. She said since the medication had not arrived at the facility Resident #317 should be offered appropriate alternatives like Tramadol 50 mg and Tylenol #3 should be offered based on the resident's pain. NP A said based on Resident #317's previous pain medication use plain Acetaminophen is not appropriate coverage for his pain. She said she saw the resident yesterday as he arrived at the facility and he was not experiencing pain at the time. When the surveyor notified NP A of Resident #317's reported pain at 10 out of 10 NP A said that was the first she had heard of the resident experiencing pain. NP A said she would contact the Medical Director to follow up on Resident #317's prescriptions. Interview at 09/06/23 at 12:25 PM, the DON said Resident #317 had been offered pain medications this morning because he was reporting pain at 10 out of 10. She said he was offered Tramadol but he declined. When asked if Resident #317 had an active order for Tramadol in this system, she said not because the order was just received from the NP so nursing staff had not had the chance to enter it into the EMR. The DON said the facility did not perform pain assessments every shift, at there was no assigned task for nursing staff to ask residents if they were experiencing pain. When the surveyor asked the DON how nursing staff would know if a resident was in pain if they didn't ask about pain, she would not answer. Resident #62 Record review of Resident #62's face sheet revealed a [AGE] year-old male who admitted into the facility on [DATE] and was diagnosed with Unspecified Dementia, Anorexia, Hyperlipidemia, Chronic Kidney Disease. Record review of Resident #62's care plan, dated 08/16/2023, revealed the resident had potential for uncontrolled pain related to fractured right hip, the goal was for the resident to, .verbalize adequate relief of pain ., and the intervention was to, Administer analgesia as per orders. Give ½ hour before treatments or care, anticipate resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions, monitor/document for probable cause of each pain episode. Remove/limit causes where possible . Resident #62 had an order for Tylenol Extra Strength 500 MG for Pain. Date initiated 05/17/2023, Tylenol 325 MG as needed for Pain. Date Initiated 08/01/2023, Tylenol with Codeine #3 300-30 MG as needed for Pain/Discomfort. Date initiated 08/01/2023 Record review of Resident #62's Pain Level Summary from 08/01/2023-09/18/2023, the resident's pain level was only documented on 08/01/2023, 08/03/2023, 08/28/2023, 08/29/2023, 08/31/2023, and 09/01/2023. An observation on 09/07/23 at 08:25 AM revealed, MA D administering medication to Resident #62. She retrieved 1 tablet of Acetaminophen 500 mg as well as 4 other solid form medications and administered it to Resident #62; MA D did not ask Resident #62 any questions prior to administering the medications, she did not ask the resident about his pain. After medication administration she exited the room and documented the medications administered recording a pain score at 0 when she administered Resident #62's Acetaminophen 500 mg even though she never asked him about his pain. Interview on 09/15/23 at 09:16 AM, MA D said she administered Acetaminophen to Resident #62 on 09/07/23 she did not ask about his pain and did not remember recording a pain score for him. She said nurses are expected to document accurately and she should not have documented a pain score since she did not ask the resident. MA D said failure to document accurately could lead to records that do not reflect what was done. Interview on 09/18/23 at 09:58 AM, the DON said nurses are expected to document accurately to reflect what is going on with the patient and what was communicated. She said documentation should only reflect the actions taken. Interview on 09/10/23 at 11:55 AM, the surveyor notified the DON and Regional Clinical Nurse that residents receiving pain management reported they were not assessed for their pain and some resident's reported uncontrolled and new pain. The surveyor specifically notified the facility on Residents #10,#29 and #35. The Regional Clinical Nurse said they would audit their resident's receiving pain management to address the identified issues. Interview on 09/18/23 at 02:06 PM, the DON said medications should be administered +/- 1 hour of the scheduled time and failure to administer medications timely could change their therapeutic window for medications with multiple doses administered during the day leaving residents in pain, and conditions untreated. Resident #217 Record review of Resident #217 revealed a [AGE] year-old male was admitted into the facility on [DATE] and was diagnosed with dementia, acute kidney failure, dysphasia, muscle wasting, and cachexia. Record review of Resident #217's MDS, dated [DATE], revealed the resident's BIMS assessment and pain assessment was not completed due to the resident being rarely/never understood. The staff assessment for pain was completed and showed resident had no signs observed or documented related to pain such as: non-verbal sounds (e.g., crying, whining, gasping, moaning or groaning), vocal complaints of pain, facial expression (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) and protective body movements or postures (e.g., bracing guarding, rubbing or massaging). Record review of Resident #217's physician's orders revealed the resident had an active order for two Tylenol oral tablets 325 MG via PEG-tube two times a day for pain starting 04/26/2023. Record review of the Resident #217's pain assessments, from 04/20/2023 - 09/07/2023, revealed only pain assessment was documented on 04/20/2023, upon admission, and was rated at a 0. There was no other pain assessment performed. An observation and interview with Resident #217 on 09/07/2023 at 8:07 AM, the resident was lying in a fetal position due to multiple contractures, receiving enteral feeding via PEG tube. Resident was observed frowning and sighing. When asked if he was uncomfortable, he did not respond. When asked if he was in pain, he frown and nodded his head, yes. LVN G was called to observe the resident and she stated frowning, facial grimacing was the resident's baseline behavior. She stated it is more related to the resident's depression. She stated the resident does, however, experience pain due to his contractures, but he had been already placed on a regimen of two Tylenol tablet twice a day. She stated since then, the resident has not had a need for increased pain management. She stated she did not perform pain assessments on Resident #217, but she can tell if the resident is pain whenever she repositions him and moans and groans more loudly, but that had not been a problem as of recent. Interview with the MDS nurse on 09/18/2023 at 12:39 PM she stated anyone who is ordered medication or has potential pain-related diseases, they should have a pain management section on their care plan and be assessed for pain on the MDS as well. She stated there a visual pain assessments that can be used on nonverbal residents. She stated due to lack of documentation related to pain for Resident #217, she would have to rely on staff interviews to accurately assess the resident, but she cannot remember if she talked to any staff about Resident #217 and she has no documented interviews that she had about Resident #217. She said she had not expressed her concerns about lack of documentation to the DON or corporate MDS staff. Interview with the DON on 09/18/2023 at 9:53 AM, she stated Resident #217's care plan should have stated the resident was at risk for pain related to contracture and goal would be to keep the resident as pain free as possible through the next assessment date, to notify doctor if there was an increase in pain and maybe a PRN medication for breakthrough pain. She said care plans should address concerns for patients the goals, interventions which are then made accessible to the nursing staff caring for the residents. She stated acute concerns that come up between assessment periods are care planned by nurse management, herself and the ADONs, and chronic concerns are care planned through the MDS assessment. Risk to patient, they can get missed with interventions for unnoticed pain. Record review of the facility policy titled 'Pain Management, Assessment Scale' revised 11/25/16 revealed, 1- assess resident's physical symptoms of pain, physical complaints, and daily activities. 9- have the resident rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. 12- talk with the resident about pain and assess for pain relief after interventions. Record review of the facility policy titled 'Medication Reconciliation' revised 11/14/16 revealed, At any. time a change is made to a patients medication regimen, practitioners must ensure that the change is made carefully, is documented, and accords with prescribing instructions for the relevant medications Record review of MA D's Medication Aide Proficiency dated 03/15/23 revealed, MA D had satisfactory competency for skills : 7- documents accurately and 22- checks MARs for accuracy. Record review of the facility police titled Medication Orders with no revision date revealed, the following steps are initiated to complete documentation: clarify the order, enter orders on the medication order and receipt record, call (or fax) the medication order to the provider pharmacy. Accept verbal orders for schedule II medications only in an emergency, to be followed with a written order from the prescriber within (72) hours. The Pharmacy will need to talk directly to the physician on all Emergency Schedule II medication orders. The policy did not address submission of eScript(electronic prescriptions) to the pharmacy. On 09/06/23 at 04:20 PM the Administrator and was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on 09/07/23 at 03:58 PM and read: IJ Component: F697 Pain Management: Facility failed to acquire and dispense Oxycodone, Methadone, and Hydrocodone as ordered upon admission for resident #317. Facility failed to enter an order for alternative pain medication for resident #317. Facility provider failed to submit a prescription to the pharmacy for resident #317. Facility failed to monitor Resident #317's pain level while waiting for delivery of pain medication. Immediate Actions: 1. Resident #317 received pain medication on September 6, 2023 at 12:30pm. 2. Pain assessment was completed and documented on September 6, 2023 at 5:33pm. 3. Change of condition (Pain SBAR) for resident #317 was assessed and documented on September 6, 2023 at 5:40pm. 4. Resident #317's Physician was notified of resident's pain on September 6, 2023 at 5:41pm Facility Plan to ensure compliance: 1. Abuse and Neglect policy in-service initiated on 9/6/23. The Regional Compliance Nurse and Area Director of Operations provided in-service to DON, ADON, and Administrator. DON/ADON will in-service facility staff thereafter. 2. Receipt of Pain Medication orders in-service initiated on 9/6/23 to include ensuring pharmacy has received the order and verifying that the required items (i.e Script) was received by pharmacy. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 3. Notifying physician of estimated timeframe to get medications in-service initiated on 9/6/23. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in- serviced as needed thereafter. 4. Notifying pharmacy of new orders in-service initiated on 9/6/23 to include notifying pharmacy of any new order, including pain medication, received after 4pm. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 5. Contacting Physician for Alternative Pain Medication that is appropriate based on the resident's pain needs in-service initiated on 9/7/23 to include obtaining a new order for an available pain medication from the Stat-safe (facility's emergency medication kit). Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/7/23. DON/ADON will in-service charge nurses to ensure compliance with this procedure by end of day on 9/7/23. Charge nurses will be in-serviced as needed thereafter. 6. Offering prescribed alternative pain medication in-service initiated on 9/6/23. Regional Compliance Nurse in-serviced DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 7. Pain assessment in-service, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD) in-service initiated on 9/6/23. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in- service direct care staff to include CNAs, CMAs, and Charge Nurses (LVN/RNs) in person and/or by phone to ensure compliance with this procedure as of 9/7/23. 8. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow- up documentation that contains a Pain Assessment element in the EMR. 9. Charge Nurses will notify practitioner of pain not controlled adequately on current treatment plan. If physician's recommendations do not meet the resident's needs, residents will be transferred to hospital for evaluation and treatment of uncontrolled pain. 10. All nurses not in-serviced on 9/6/23 will be in-serviced prior to their next shift. 11. The Medical Director, was notified by Administrator on 9/6/23 at 5:55pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/6/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. 13. A complete audit of medication availability was completed on 9/7/23 to ensure all medications were available, including pain medications. MONITORING: Record review of the facility schedule revelaed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. Interview on 09/08/23 at 12:30 PM (day shift), LVN E said he received training on neglect approximately a week ago. He said he was trained on pain management, new admission orders on 09/05/23. He said the training addressed escalating uncontrolled pain to the MD. LVN E said most of the time the facility does not have medication on hand residents who admit to the facility with CII medications so it is important to ask for an alternative. He said if a medication had not arrived from the pharmacy nursing staff must notified the MD for an alternative medication or a stat order. LVN E said plain Acetaminophen is not an appropriate alternative for residents who are not opioid naïve, so nurses should ask the provider for Tramadol or Tylenol #3. He said pain can be assessed by asking a resident to rate their pain on a scale of 0-10 or assessments of facial expression, body postering for those that are non-vocal, He said there is no EMR related task to assess a resident's pain but nurses should ask about pain pre and post scheduled and PRN medications. LVN E said the efficacy of a pain medication is measured by asking for a pain assessment 1 hr. after oral pain medication is administered and all reported pain should be documented in the residents' EMR. Interview on 09/08/23 at 12:27 PM (day shift), LVN C said the last time she received an in-service on neglect was last week. She said she recently received training on admission meds, escalation to the MD for unavailable meds and pain assessments. SLVN C said if a resident's pain medication is not available nursing staff must immediately call for an alternative like T tramadol and Tylenol #3. She said resident's should be assessed pre and 1 hour post pain medication administration and the provider should be notified of uncontrolled pain. Interview on 09/08/23 at 12:35 PM (day shift), LVN H said she received an in-service on neglect on 09/08/23. She said she also received training on admission meds, focusing on pain medications, and pain management. She said when a resident admits, a CII prescription should be immediately received and the pharmacy should be contacted for an ETA. LVN H said if the medication is unavailable nursing staff should contact the provider requesting an alternative like Tramadol or Tylenol #3. She said pain should be assess before medication administration and 1 our post administration through visual and verbal assessments. LVN H said if pain was not adequately controlled the resident's provider should be contacted and pain should be documented in the EMR as vitals or in a nursing note. Interview on 09/09/23 at 12:56 PM, the DON said the facility completed a cart audit to ensure that all residents medications were present as well as audited resident's pain assessments. She said nursing staff are expected to ask resident's for their pain score 0-10 and there are non-pharmacological and pharmacological treatment. The DON said after administering pain medications nursing staff should follow up with the resident in 30 minutes and pain should be documented in the progress notes or daily skilled notes. The DON said nursing staff are not asking every resident about pain but only does on a pain management program. Interview on 09/09/23 at 01:18 PM, the Regional Clinical Nurse said the facility has identified a failure in its pain management system. He said the audits have shown nursing staff were not documenting pain, assessing residents for pain or performing post administration assessments of the efficacy of a medication. The Regional Clinical Nurse said the facility put systems in place to monitor the pain management system. Interview on 09/09/23 at 07:10 PM (night shift), the Medical Records Staff said she received an in-service on neglect, pharmacy services, physician notifications, admissions medications and pain management on 09/08/23. The training addressed acquisition of pain medications for new admissions, getting alternative medications for unavailable medications, completing pain assessments, provider notification of ineffective pain control and documentation of pain in the EMR. Interview on 09/09/23 at 07:18 PM (night shift), LVN F said she received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of days ago. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. Interview on 09/09/23 at 07:28 PM (night shift), LVN I said received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of earlier in the week. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. An observation and interview on 09/10/23 at 11:20 AM revealed, Resident #35 lying in bed well-groomed with visible burns to the face and body. The resident said he did not feel his pain was well controlled and the facility staff never asked him about his pain. Resident #35 said he had never thought of informing the staff that his pain was not controlled and the facility needs to do better to control his pain. An observation and interview on 09/10/23 at 11:21 AM revealed, Resident #25 lying in bed in no immediate distress. She said she received Tylenol three times a day and her pain was well controlled. Resident #25 said she was happy with her pain medication but the facility staff never asks her about her pain, they just administer her medication. An observation and interview on 09/10/23 at 11:28 AM revealed, Resident #10 lying in bed in no immediate distress. She said her pain was not ok and the facility could do better since they don't follow up on her pain. Resident #10 said she is fine when she gets her pain medications and she hasn't not been asked about her pain nor does she report her pain to others. An observation and interview on 09/10/23 at 11:37 AM revealed, Resident #29 lying in bed in a contracted position. She said gets her pain medication on time now and her pain is much better. Resident #29 said when she first started the facility would run out of her pain medications and it takes at least 1 hour for her to receive her medications. She said no one asks her about her pain and she had bad aching pain. Resident #29 could not elaborate on her pain any further. Interview on 09/10/23 at 11:55 AM, the surveyor notified the DON and Regional Clinical Nurse that residents receiving pain management reported they were not assessed for their pain and some resident's reported uncontrolled and new pain. The surveyor specifically notified the facility on Residents #10,#29 and #35. The Regional Clinical Nurse said they would audit their resident's receiving pain management to address the identified issues. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 revealed, the Administrator, the DON and ADON A were trained on neglect. The training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - LVN C, LVN E, RN E, CNA U, CNA M, CNA T, LVN G, LVN B, MA B, MA A, RN E, LVN C, CNA C, RN A, CNA J, Medical Records Staff, CNA H, Hospitality Aide and CNA I. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of 4 of 10 residents (Resident #24, Resident #54, Resident #61 and Resident #317) reviewed for pharmaceutical services. - The facility failed to acquire, dispense, and timely administer medications to Resident #317 upon admission resulting in pain of 10 out of 10. An IJ was identified on 09/06/23. While the IJ was removed on 09/11/23 at 1:57 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and uncontrolled pain. Non-IJ - The facility failed to administer Pantoprazole, a medication used to treat acid reflux, timely to Resident #24 - The facility failed to administer Pantoprazole timely to Resident #54 - The facility failed to administer medications timely to Resident #61 These failures could place residents receiving medication at risk of inadequate therapeutic outcomes and acid reflux. Findings included: Record review of Resident #317's Face Sheet dated 09/11/23 revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's admission Note dated 09/05/23 at 2:51 PM revealed, Resident #317 admitted to the facility on [DATE] at 01:38 PM from a hospital. Record review of Resident #317's Progress Notes dated 09/05/23 at 9:06 PM revealed, Methadone 5 mg was not available new admission and NP is aware. Record review of Resident #317's Progress Notes dated 09/06/23 at 5:15 AM revealed, the facility was waiting for delivery of Methadone 5 mg from the facility. Record review of Resident #317's Progress Notes dated 09/05/23 at 4:34 PM revealed, Medications reconciled with NP. Triplicate request given to NP for Oxycodone, Norco, Methadone, and Xanax. There was no documentation of Resident #317's pain. Record review of Resident #6's Order Summary Report dated 09/06/23 at 09:20 AM revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6. - Methocarbamol 750 mg- 1 tablet by mouth three times a day for muscle spasms. - Augmentin XR 100-62.5 mg- 1 tablet every 12 hours for osteomyelitis (bacterial bone infection) - Melatonin 1 mg/mL- give 2.5 mL by mouth at bedtime for sleep. - Celecoxib- give 1 capsule by mouth two times a day for pain. - PEG 3350- 17 gm two times a day for bowel regimen - Baclofen 5 mg- 4 tables by mouth four times a day for muscle spasms. - Pantoprazole 40 mg DR- 1 tablet by mouth one time a day for GERD. - Enoxaparin 4mg/0.4mL- inject 1 syringe SQ for blood thinning - Multivitamin w/ Minerals- 1 tablet by mouth in the morning for wound care. - Vitamin C 500 mg- 1 tablet by mouth for wound care - Zinc Sulfate 220 mg- 1 tablet be mouth in the morning for wound care. - Lactobacillus- 2 capsules by mouth one time a day as a probiotic. - Docusate - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain). Record review of Resident #317's MAR printed 09/06/23 at 09:21 AM revealed Resident #317 did not receive the following medications: - Melatonin 1mg/mL scheduled for 09/05/23 at Bedtime - Augmentin XR scheduled for 09/05/23 at 06:00 PM - Methocarbamol 750 mg scheduled for 09/05/23 at 06:00 PM - Methadone 7.5 mg scheduled for 09/05/23 at 10:00 PM. - Methadone 7.5 mg scheduled for 09/06/23 at 06:00 AM. - Augmentin XR scheduled for 09/06/23 at 06:00 AM Record review of Resident #317's Medication Administration Audit Report dated 09/09/23 at 12:00 PM revealed, Resident #317 received medications late on 23 occasions between 09/05/23 and 09/09/23 at 12:00 PM without a documented reason: 1. Methadone 7.5 mg- scheduled for 09/06/23 at 02:00 PM and administered at 03:11 PM. 2. Gabapentin 400 mg- Scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 3. Methocarbamol 750- Scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 4. Baclofen 5 mg- scheduled for 09/05/23 at 04:00 PM and administered at 06:32 PM. 5. Baclofen 5 mg- scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 6. Baclofen 5 mg- scheduled for 09/08/23 at 04:00 PM and administered at 06:06 PM. 7. Celecoxib- scheduled for 09/05/23 at 04:00 and administered at 05:04 PM. 8. Celecoxib- scheduled for 09/06/23 at 08:00 AM and administered at 09:23 AM. 9. Celecoxib- scheduled for 09/08/23 at 04:00 PM and administered at 06:06 PM. 10. Acetaminophen 500- Scheduled for 09/08/23 at 10:00 PM and administered at 11:14 PM. 11. PEG 3350- scheduled for 09/05/23 at 04:00 and administered at 06:32 PM. 12. PEG 3350- scheduled for 09/06/23 at 08:00 AM and administered at 09:19 AM. 13. PEG 3350- scheduled for 09/06/23 at 06:00 PM and administered at 07:31 PM. 14. Pantoprazole 40 mg- scheduled for 09/06/23 at 06:30 AM administered at 09:19 AM. 15. Pantoprazole 40 mg- scheduled for 09/07/23 at 06:30 AM administered at 07:50 AM. 16. Pantoprazole 40 mg- scheduled for 09/08/23 at 06:30 AM administered at 07:40 AM. 17. Enoxaparin 40 mg/0.4 mL- Scheduled for 09/06/23 at 06:30 AM and administered at 12:24 PM 18. Multivitamins- scheduled for 09/06/23 at 07:00 AM and administered at 09:19 AM. 19. Multivitamins- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. 20. Vitamin C 500 mg- scheduled for 09/06/23 at 07:00 AM and administered at 09:19 AM. 21. Vitamin C 500 mg- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. 22. Zinc Sulfate 220 mg- scheduled for 09/06/23 at 07:00 AM and administered at 09:20 AM. 23. Zinc Sulfate 220 mg- scheduled for 09/09/23 at 07:00 AM and administered at 08:31 AM. Record review of Resident #317's Pharmacy Records faxed 09/20/23 at 10:40 AM revealed: - The Medical Director sent an eScript for Hydrocodone/Acetaminophen 10-325 mg- 1 tablet by mouth every 8 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:48 (over 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director sent an eScript for Oxycodone 5 mg- 1 tablet by mouth every 6 hours as needed for pain with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM. - The Medical Director sent an eScript for Methadone 7.5 5 mg- 1 tablet by mouth every 8 hours with an effective date of 09/06/23 on 09/06/23 at 09:33 (almost 18 hours after Resident #317 arrived at the facility). The medication was sent as a stat order and was received at the facility on 09/06/23 at 11:59 AM by LVN B. An observation and interview on 09/06/23 at 07:37 AM revealed, MA B informed LVN A that Resident #317 was complaining of pain. LVN A told the surveyor that Resident #317 arrived to the facility the previous afternoon and his pain medications had not yet arrived from the pharmacy. An observation and interview on 09/06/23 at 08:25 AM revealed, Resident #317 lying in bed with his face slightly protruding from under the sheets. He had a grimace on his face and could be heard saying oh shit intermittently. Resident #317 said he had not received his pain medications Methadone, Oxycodone and Hydrocodone/Acetaminophen since the morning of his admission [DATE]) and reported pain at a 10 out of 10. Resident #317 said he had not been offered or received any alternative pain medications like Tramadol or Tylenol #3. In an interview on 09/06/23 at 08:30 AM, LVN A looked at Resident #317's MAR and said the resident did not have any orders for alternative pain medications and he had not been offered any alternatives. She said Resident #317 had orders for PRN Hydrocodone/Oxycodone and scheduled Methadone and he had not received them since he admitted to the facility yesterday. In an interview on 09/06/23 at 08:48 AM, the Pharmacist said Resident #317 had not received his Hydrocodone, Methadone and Oxycodone because they pharmacy was pending a prescription so NP A was notified that a triplicate prescription was necessary. He said that as of that moment the pharmacy had not received an electronic prescription. He said in Texas LTC facilities are allowed to call in/fax in emergency CIIs but nothing had been sent in at the time of our conversation. In an interview on 09/06/23 at 09:02 AM, the DON said when a resident arrives at the facility the admitting nurse must reconcile the medications with the NP and once confirmed the orders are entered into the EMR. She said if a resident has orders for a narcotic medication, the information is provided to the NP and the provider will have to send an eScript while non-controlled substances can be found in the stat kit (emergency medication dispensing system). The DON said if the pharmacy received a medication order before 06:00 PM the medication would be delivered on the same day, but if the order arrives later the medication can be sent to the facility as a stat delivery. In an interview on 09/06/23 at 09:10 AM, NP A said the medical director should have sent the order for Resident #317's medication to the pharmacy. She said since the medication had not arrived at the facility Resident #317 should be offered appropriate alternatives like Tramadol 50 mg and Tylenol #3 should be offered based on the resident's pain. NPA said based on Resident #317's previous pain medication use plain Acetaminophen is not appropriate coverage for his pain. She said she saw the resident yesterday as he arrived at the facility and he was not experiencing him pain at the time. When the surveyor notified NP A of Resident #317's reported pain at 10 out of 10 NP A said that was the first she had heard of the resident experiencing pain. NP A said she would contact the Medical Director to follow up on Resident #317's prescriptions. In an interview at 09/06/23 at 12:25 PM, the DON said Resident #317 had been offered pain medications this morning because he was reporting pain at 10 out of 10. She said he was offered Tramadol but he declined. When asked if Resident #317 had an active order for Tramadol in this system, she said not because the order was just received from the NP so nursing staff had not had the chance to enter it into the EMR. Record review of the facility policy titled 'Medication Reconciliation' revised 11/14/16 revealed, medications reconciliation should be performed every time a patient is admitted to a facility. Record review of the facility police titled Medication Orders with no revision date revealed, the following steps are initiated to complete documentation: clarify the order, enter orders on the medication order and receipt record, call (or fax) the medication order to the provider pharmacy. Accept verbal orders for schedule II medications only in an emergency, to be followed with a written order from the prescriber within (72) hours. The Pharmacy will need to talk directly to the physician on all Emergency Schedule II medication orders. On 09/06/2023 at 4:20 PM the Administrator was notified of the IJ due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on 09/07/23 at 03:58 PM and read: IJ Component: F755 Pharmacy Services: Facility failed to acquire and dispense Oxycodone, Methadone, and Hydrocodone as ordered upon admission for resident #317. Facility failed to enter an order for alternative pain medication for resident #317. Facility provider failed to submit a prescription to the pharmacy for resident #317. Facility failed to monitor Resident #317's pain level while waiting for delivery of pain medication. Immediate Actions: 1. Resident #317 received pain medication on September 6, 2023 at 12:30pm. 2. Pain assessment was completed and documented on September 6, 2023 at 5:33pm. 3. Change of condition (Pain SBAR) for resident #317 was assessed and documented on September 6, 2023 at 5:40pm. 4. Resident #1's Physician was notified of resident's pain on September 6, 2023 at 5:41pm Facility Plan to ensure compliance: 1. Abuse and Neglect policy in-service initiated on 9/6/23. The Regional Compliance Nurse and Area Director of Operations provided in-service to DON, ADON, and Administrator. DON/ADON will in-service facility staff thereafter. 2. Receipt of Pain Medication orders in-service initiated on 9/6/23 to include ensuring pharmacy has received the order and verifying that the required items (i.e Script) was received by pharmacy. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 3. Notifying physician of estimated timeframe to get medications in-service initiated on 9/6/23. The Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance for this procedure as of 9/7/23. Charge nurses will be in- serviced as needed thereafter. 4. Notifying pharmacy of new orders in-service initiated on 9/6/23 to include notifying pharmacy of any new order, including pain medication, received after 4pm. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 5. Contacting Physician for Alternative Pain Medication that is appropriate based on the resident's pain needs in-service initiated on 9/7/23 to include obtaining a new order for an available pain medication from the Stat-safe (facility's emergency medication kit). Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/7/23. DON/ADON will in-service charge nurses to ensure compliance with this procedure by end of day on 9/7/23. Charge nurses will be in-serviced as needed thereafter. 6. Offering prescribed alternative pain medication in-service initiated on 9/6/23. Regional Compliance Nurse in-serviced DON, ADON, and Administrator on 9/6/23. DON/ADON have in-serviced charge nurses in person and/or by phone to ensure compliance with this procedure as of 9/7/23. Charge nurses will be in-serviced as needed thereafter. 7. Pain assessment in-service, to include verbal and non-verbal signs of pain and reporting pain to provider (NP/MD) in-service initiated on 9/6/23. Regional Compliance Nurse provided in-service to DON/ADON and Administrator on 9/6/23. DON/ADON have in- service direct care staff to include CNAs, CMAs, and Charge Nurses (LVN/RNs) in person and/or by phone to ensure compliance with this procedure as of 9/7/23. 8. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow- up documentation that contains a Pain Assessment element in the EMR the facility's electronic medical record (EMR). 9. Charge Nurses will notify practitioner of pain not controlled adequately on current treatment plan. If physician's recommendations do not meet the resident's needs, residents will be transferred to hospital for evaluation and treatment of uncontrolled pain. 10. All nurses not in-serviced on 9/6/23 will be in-serviced prior to their next shift. 11. The Medical Director, was notified by Administrator on 9/6/23 at 5:55pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/6/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. 13. A complete audit of medication availability was completed on 9/7/23 to ensure all medications were available, including pain medications. Monitoring: Record review of the facility schedule revealed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. In an interview on 09/08/23 at 12:30 PM, LVN E said he received training on neglect approximately a week ago. He said he was trained on pain management, new admission orders on 09/05/23. He said the training addressed escalating uncontrolled pain to the MD. LVN E said most of the time the facility does not have medication on hand residents who admit to the facility with CII medications so it is important to ask for an alternative. He said if a medication had not arrived from the pharmacy nursing staff must notified the MD for an alternative medication or a stat order. LVN E said plain Acetaminophen is not an appropriate alternative for residents who are not opioid naïve, so nurses should ask the provider for Tramadol or Tylenol #3. He said pain can be assessed by asking a resident to rate their pain on a scale of 0-10 or assessments of facial expression, body postering for those that are non-vocal, He said there is no EMR related task to assess a resident's pain but nurses should ask about pain pre and post scheduled and PRN medications. LVN E said the efficacy of a pain medication is measured by asking for a pain assessment 1 hr. after oral pain medication is administered and all reported pain should be documented in the residents' EMR. In an interview on 09/08/23 at 12:27 PM, LVN C said the last time she received an in-service on neglect was last week. She said she recently received training on admission meds, escalation to the MD for unavailable meds and pain assessments. SLVN C said if a resident's pain medication is not available nursing staff must immediately call for an alternative like T tramadol and Tylenol #3. She said resident's should be assessed pre and 1 hour post pain medication administration and the provider should be notified of uncontrolled pain. In an interview on 09/08/23 at 12:35 PM, LVN H said she received an in-service on neglect on 09/08/23. She said she also received training on admission meds, focusing on pain medications, and pain management. She said when a resident admits, a CII prescription should be immediately received and the pharmacy should be contacted for an ETA. LVN H said if the medication is unavailable nursing staff should contact the provider requesting an alternative like Tramadol or Tylenol #3. She said pain should be assess before medication administration and 1 our post administration through visual and verbal assessments. LVN H said if pain was not adequately controlled the resident's provider should be contacted and pain should be documented in the EMR as vitals or in a nursing note. In an interview on 09/09/23 at 12:56 PM, the DON said the facility completed a cart audit to ensure that all residents medications were present as well as audited resident's pain assessments. She said nursing staff are expected to ask resident's for their pain score 0-10 and there are non-pharmacological and pharmacological treatment. The DON said after administering pain medications nursing staff should follow up with the resident in 30 minutes and pain should be documented in the progress notes or daily skilled notes. The DON said nursing staff are not asking every resident about pain but only does on a pain management program. In an interview on 09/09/23 at 01:18 PM, the Regional Clinical Nurse said the facility has identified a failure in it's pain management system. He said the audits have shown nursing staff were not documenting pain, assessing residents for pain or performing post administration assessments of the efficacy of a medication. The Regional Clinical Nurse said the facility put systems in place to monitor the pain management system. In an interview on 09/09/23 at 07:10 PM, the Medical Records Staff said she received an in-service on neglect, pharmacy services, physician notifications, admissions medications and pain management on 09/08/23. The training addressed acquisition of pain medications for new admissions, getting alternative medications for unavailable medications, completing pain assessments, provider notification of ineffective pain control and documentation of pain in the EMR. In an interview on 09/09/23 at 07:18 PM, LVN F said she received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of days ago. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. In an interview on 09/09/23 at 07:28 PM, LVN I said received training on neglect, pharmacy services, physician notifications, admissions medications and pain management a couple of earlier in the week. She said the training addressed the acquisition of pain medications, use of alternatives if pain medications are not available, notification of providers of unavailable pain medications, completion of pain assessments and notification of providers of ineffective pain control. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 revealed, the Administrator, the DON and ADON A were trained on neglect. The training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility in-service document titled Abuse/Neglect dated 09/06/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - LVN C, LVN E, RN E, CNA U, CNA M, CNA T, LVN G, LVN B, MA B, MA A, RN E, LVN C, CNA C, RN A, CNA J, Medical Records Staff, CNA H, Hospitality Aide and CNA I. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on alternative pain medications. The training read, the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if a alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. Record review of the facility in-service document titled New Med Orders dated 09/06/23 presented by the Regional Clinical Nurse revealed, the Administrator, the DON and ADON A were trained on medication orders. The training read, any new order for medications after 4 pm require a follow up phone call to the pharmacy. This is to ensure the pharmacy after-hours is aware of the need for medication and is sent out timely. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. - LVN G, LVN B, Medical Records Staff, RN C, RN A, CNA Q, LVN A and Treatment Nurse B. Record review of the facility in-service document titled Pain Assessments dated 09/06/23 presented by the DON revealed, the following staff were trained on pain assessment and the training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse - RN E, LVN E, LVN C, CNA M, CNA T and CNA U. Record review of the facility in-service document titled Pain Medication Orders dated 09/06/23 presented by the DON revealed, the following staff were trained on pain medication order. the training read, when an order for pain medication has been received by the nurse, the nurse must ensure the pharmacy has received the order and verified that required items such as the prescription have been received as well. If unavailable the nurse must notify the provider and DON for follow up and document in the clinical Record. - RN E, LVN E, LVN C. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/06/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. -RN E, LVN C and LVN E. Record review of the facility in-service document titled Pain Assessments dated 09/07/23 presented by the Regional Clinical Nurse revealed, MDS Nurse A, CNA G and CNA D were trained on pain assessments. The training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/07/23 presented by the MDS Nurse A was trained on alternative pain medications. The training read, the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. Record review of the facility in-service document titled Pain Assessments dated 09/07/23 presented by the DON revealed, the following staff were trained on pain assessments and the training read, pain assessments are incorporated into every assessment completed in the EMR. If pain is triggered and is new onset pain or worsened pain the nurse must follow up and report to the provider. CNAs observing/hearing signs of pain should report to the nurse. - LVN A, LVN B, LVN C, CNA J, CNA H, MA D, MA B, RN C, RN A, Hospitality Aide, CNA Q, Treatment Nurse B, CNA C and CNA K. Record review of the facility in-service document titled Pain Assessment- Unresponsive to Treatment Plan dated 09/07/23 presented by the DON revealed, the following staff were trained on unresponsive pain management. The training read, if ordered pain modality is not effective the patient should be transferred out to the hospital - LVN G, LVN B, Medical Records Staff, RN C, RN A, CNA Q, LVN A and Treatment Nurse B. Record review of the facility in-service document titled Pain Medication Orders dated 09/07/23 presented by the DON revealed, the following staff were trained on pain medication order. the training read, when an order for pain medication has been received by the nurse, the nurse must ensure the pharmacy has received the order and verified that required items such as the prescription have been received as well. If unavailable the nurse must notify the provider and DON for follow up and document in the clinical Record. - RN E, LVN E, LVN C. Record review of the facility in-service document titled Abuse/Neglect dated 09/07/23 presented by the DON revealed, The following staff were trained on neglect and the training read neglect is a failure to provide goods and services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - [NAME] A, [NAME] B, [NAME] C, Dietary Staff A and Dietary Staff B, MDS Nurse A, LVN G, CNA D, Rehab Director, PT A, PTA A, OT A, Floor Tech A, HR Coordinator, Activities Director and Food Nutrition Director. Record review of the facility in-service document titled Pain Medication Orders- Alternative dated 09/07/23 presented by the DON revealed, the following staff were trained on alternative pain medications and the training read, , the pharmacy should be contacted for an ETA when receiving an order for pain medication and the provider should be notified to see if an alternative is available in the e-kit. The nurse should enter the order into the EMR and then offer the substitute to the resident. - LVN H, LVN B, Medical Records Staff, Treatment Nurse B and LVN G. Record review of the facility Medication admission Audit dated 09/07/23 signed by the DON revealed, the facility[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consult with 1 of 16 residents (Resident #8) representatives when there was a significant change in the resident's physical status and a need to alter treatment significantly, in that: - The facility failed to notify Resident #8 family of a PEG tube was deemed non-functional for over 5 months resulting in multiple infections at the site of the G-tube and the resident was ultimately hospitalized when Resident #8's tube became dislodged and caused a partial bowel obstruction. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/12/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure caused Resident #8 to experience hospitalization and a decline in ADLs and placed other residents at risk of not receiving adequate medical care in a timely manner. Findings include: Record review of Resident #8's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease (progressive mental deterioration), cerebral infarction (stroke), dysphasia (difficulty swallowing) and paralytic ileus (impaired motor activity of the bowel). Record review of Resident #8's MDS, dated [DATE], the resident was identified to have a feeding tube. Record review of Resident #8's care plan, undated, revealed the resident had no care plan related to tube feedings. Record review of Resident #8's clinical physician orders, undated, revealed the resident had the following diet orders: - NPO diet from 01/31/2020 to 2/18/2020 - Regular mechanical soft diet with ground meat texture from 2/2/2023 to 4/3/2023 - Regular diet or Heart healthy diet, puree texture, regular consistency from 4/3/2023 to 8/18/2023 Observation of Resident #8 on 09/05/2023 at 10:30AM, he was lying in bed, with a PEG tube in place, and the resident was non-verbal. Record review of resident #8's order summary report, dated 3/1/2023 - 08/18/2023, revealed the resident did not have any enteral feed orders prescribed from 3/1/2023 until day of discharge on [DATE], and the resident took all medications by mouth. Record review of Resident #8's nurses notes, revealed the resident was assessed by the NP on 02/04/2023, who noted the resident had a diet order of dysphagia advanced texture, was eating fair and had a peg-tube in place but not in use. NP's plan of care regarding Malnutrition/Dysphagia including monitoring weights, peg flushes and dressing changes per protocol. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for KUB STAT Dx. Check Peg tube placement one time for 1 day, on 03/06/2023. Record review of Resident #8's Nurses Notes, revealed the NP assessed the resident for a Peg Tube Malfunction on 03/07/2023 and noted, . Nursing reported peg tube appears to be displaced from normal position yesterday . KUB performed and recommended gastrograffin [a constrast medium used for x-ray imaging] for definitive placement verification . Nursing to notify RP of order, will proceed if RP agreeable, peg tube not currently in use . In the NP's assessment and plan regarding her peg tube, she noted, . KUB performed, will await approval before proceeding with gastrograffin . Peg appears to be in normal position as when last assessed by myself . Order given not to use peg tube for now . Abdominal exam benign . Record review of Resident #8's progress notes, revealed the NP assessed the resident on 03/09/2023 and noted the resident was lying in bed being fed by a staff. The NP also noted, . RP does not desire to proceed with additional X-ray procedure to confirm placement of peg tube . Will DC all peg tube orders . No acute concerns or complaints . In the NP's assessment and plan regarding her peg tube, she noted, . RP declines any additional studies for peg tube . DC all peg tube orders . Apply abdominal binder . Monitor provider for any changes . Record review of Resident #8's progress notes, revealed LVN G wrote a note on 03/09/2023 that stated, . NP . here in the building this am to visit resident NP . called RP . to ask if she wanted resident to be sent out for gtube replacement or removal RP . stated no then RP . also came to this facility to visit resident and stated she does not want anything done to the gtube removed or replaced she only wants gtube site clean. NP gave new order to d/c all gtube orders . Record review of Resident #8's progress notes, revealed the NP assessed Resident #8 on 07/26/2023, reason being for rash, drainage from peg site . The NP wrote: . Peg Tube Infection - Noted to have breakdown around peg tube with purulent drainage - Continue Doxycycline - Peg site care daily - Non-functioning peg tube Record review of Resident #8's progress notes on 08/02/2023, the NP documented her assessment of PEG tube infection and wrote about her conversation she had with Resident #8's RP, in which she wrote: . #Peg Tube Infection - Improved - Continue Doxycycline until 8/5 - Peg site care daily - Non-functioning peg tube - F/U with [GI] RP conversation: Per nursing RP is requesting removal of PEG tube. Call placed to RP. Spoke with [Responsible Party] Discussed risk and benefits of peg tube placement. Patient has periods of being uncooperative, agitated, and refusing to eat and drink. RP is agreeable to have peg tube placed as it is non-functioning at this time . Record review of Resident #8's progress notes, revealed on 08/13/2023, LVN E noted, . increased redness around stoma, skin irritation . profuse sticky drainage . There was no documentation of notification to the family. Record review of Resident #8's progress notes, revealed on 08/16/2023, LVN D noted resident was found at 6:00AM with tubing from her old non-functioning PEG tube in her hand while asleep. She also noted, . redness, irritation and profuse sticky drainage . Resident currently on antibiotic therapy related to infection at Peg tube site . LVN D also noted the catheter tip was not in place on the tubing. On 08/16/2023, LVN E also documented, .Resident pulled out her peg tube last night . looks like she had the tip of peg tube did not came out . LVN E noted Resident #8 was transferred out to the hospital ER for evaluation and treatment by 11:30AM. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for transfer resident to [hospital] ER for evaluations and peg tube replacement, on 08/16/2023. Record review of Resident #8's hospital records, dated 08/22/2023, revealed the resident was admitted into the hospital on [DATE], and a physician wrote, . [AGE] year-old female with a past medical history of hypertension, severe dementia, cholecystectomy presents to the hospital with a dislodged gastrostomy . CAT scan completed on arrival demonstrated that the gastrostomy tube was located at the terminal ileum [end of small intestine located before the entrance to the colon]. Gastroenterology consulted for the findings above . Assessment: Partial bowel obstruction secondary to dislodgement of PEG tube. Colonoscopy completed yesterday . On 08/21/2022, another physician noted, . PEG tube from ileocecal valve . Patient underwent colonoscopic retrieval of the PEG tube successfully . Interview with a Family Member on 09/06/23 at 03:29 PM she said Resident #8's PEG tube was placed 3 years ago but had since not been removed to serve as a backup in case the resident were to ever refuse food or medication. She said she ate by mouth and was never notified by staff of them needing to use her PEG tube due to the resident refusing meals or medications. She said she never requested to have the PEG tube removed because it not her call, considering she had no medical background. She said when the Resident was discharged to the hospital on [DATE], she was told by the facility nurses the resident pulled her PEG tube out, however, she learned from the hospital staff that a piece of the PEG tube had broken off and the CT scan showed it was in her intestines. She said a few days before the resident's hospitalization, she noticed her PEG tube was leaking, with thick, off-yellow pus and the resident stoma site appeared red and raw with rashes on her abdomen. She said she did not tell the nurses what she saw because she assumed the nurses were taking care of it. She said she did not feel persuaded to keep it in and it was never a topic of discussion because of how independent the resident had always been. She said the resident has shown to have a decline since returning to the hospital and was no longer eating like she used to. In a Telephone Interview with the Medical Director on 09/07/23 at 02:09 PM, he said for residents who used PEG tubes needed to have to water flushes, be monitored for signs of infection, and if the PEG tube was not used or non-functioning, and the patient was eating well by mouth, the tube should be removed due to risks of infections around the stoma site. He said, at the least, the PEG tube should have been flushed to ensure there were no blockages or increased risks of infection. In a Telephone Interview with NP B on 09/07/23 at 02:38 PM, she said the risks of using a PEG tube included bowel obstructions, infections, perforation, and aspiration. She said Resident #8's PEG tube remained in place because the family member did not want the resident to be sent out for any procedures due to her age. She said the family member, who made the decisions for the resident, did not allow the resident to be sent out until the tube was pulled on 08/16/2023. She said the tube became non-functional in March 2023 when the resident pulled on the tube because she could not confirm the tube was still placed correctly in the resident's stomach. She said if she could not confirm placement, she did not want the PEG tube to be used. She said Resident #8 also had an order for an abdominal binder in place to help prevent the Resident from pulling the PEG tube. She stated she later ordered for the abdominal binder to be taken off to allow excoriated and rash on the skin, caused by the drainage from the PEG tube site, on the abdomen to be left open to air to heal. She said any moist dark areas on the skins can be at risk of skin breakdown and fungus. When asked if the abdominal binder contributed to the rash, she refused to answer. She said the rashes and excoriation on the abdomen and stoma site would not have been a core reason to have the PEG tube removed, but it could have served as an argument to encourage PEG tube removal. She said she did not recall having another conversation with the family member about the risks and benefits removing the non-functional PEG tube until it was pulled out on 08/16/2023. NP B stated she did not believe she talked to the family member about the resident PEG tube site infections but believed the facility nursing staff were talking to the family about it. In a Telephone Interview with the family member on 09/07/23 at 02:25 PM, she said she was never informed of the risks of leaving a PEG tube in place for Resident #8 and she was never told that it was nonfunctional. She said she vaguely remembered being called by a physician's assistant or nurse practitioner asking if they could do some testing to related to concerns about the PEG tube and she gave them the okay to do so, but there was no follow up afterwards. The family member said she thought this whole time the PEG tube was functional and was able to use as back up, and if she would have known it was non-functional, she would have had no problem with them taking it out. In a Telephone Interview with NP B on 09/11/2023 at 10:44 AM, NP B was asked about what she meant in the progress note she wrote on 08/02/2023, she refused provide a description but said she would never convince the family member to keep a non-functional PEG tube in Resident #8. She sd she needed more time to review Resident #8's chart. There was no follow-up interview with NP B. Interview with the DON on 09/18/2023 at 9:53AM, she said Resident #8 had been eating by mouth for at least two years and decisions about the PEG tube were always determined by NP B and the family member. She said, to her knowledge, the family member never wanted the PEG tube removed. While the residents ate by mouth, the nurses were just flushing the PEG tube until the placement could no longer be verified in March. She said NP B wanted to send her out, but the family refused, which could not be disputed. She stated the note written by NP B on 08/02/2023 seemed contradictory to her, but she believed after the first conversation NP B had with the family member in March, she did not see the need for any additional conversations to be had after the family made their decision. She stated changes in conditions should had been documented by nurses in the progress notes or in a SBAR assessment and documentation was supposed to reflect what was going on with the patient and if treatments were effective. She said if the PEG tube site was observed to be draining, it should have been documented daily and any treatments for drainage or rashes related to the PEG tube that were ordered, should have been reported to Resident #8's RP as a notice as to what was going on with the patient. The DON stated she believed the best choice would have been to have the PEG tube taken out and the notifications of rashes and drainage related to the non-functioning PEG tube could have been communicated to the RP to serve as education for reasons why the PEG tube removal would have been beneficial. Record review of the facility's policy on Notifying the Physician of Change in Status, dated March 11, 2013, revealed it said, . 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident had specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to interventions Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions . On 09/08/2023 at 4:00 PM the Administrator was notified of the Immediate Jeopardy (IJ), due to the above failures. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/09/2023 at 1:17 PM. The POR revealed: IJ Component: F693 Enteral Nutrition: Facility failed to ensure Resident #8's enteral feeding was clinically indicated. Immediate Actions: Resident #8's g-tube site was assessed by RN on 9/8/23 for s/s of infection, no adverse findings noted. Facility Plan to ensure compliance: 1. 100% reassessment by RN of all g-tube sites completed 9/8/23, including resident #8. One resident identified with new onset of redness at enteral tube site, new treatment implemented. No other adverse finding noted on reassessment of enteral tube sites noted on 9/8/23. 2. Skin sweep completed on 100% of facility residents on 9/8/23 to ensure all enteral tubes were accounted for. Six residents identified with an enteral tube. No additional tubes were identified on a resident residing in the facility as of 9/8/23. 3. Residents with enteral tubes/enteral feedings reviewed for appropriate treatment on 9/8/23. Six of the facility residents identified as receiving enteral feedings with the majority of nutrition/hydration received via enteral tube for these six residents. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/8/23 regarding Changes/Discontinuation of Enteral tubes/Enteral feedings should be reviewed with family/responsible party to include removal of enteral tube, if appropriate. If disagreements between provider and family/responsible party arise, the Medical Director and the Ombudsman will be involved in a formal care plan to review the plan regarding the enteral tube. 5. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying provider (NP/MD) of any complications with enteral tube and notifying DON/ADON of enteral tube changes to ensure compliance with this procedure. 6. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying the provider (NP/MD) of any change of condition related to enteral tube site and/or feedings to ensure compliance with this procedure. 7. Registered Dietician (RD) will be consulted for residents with enteral feedings to ensure enteral feedings/water flushes meet the resident's needs. Registered Dietician (RD) notified on 9/9/23 of need for reassessment of residents with enteral tubes/enteral feedings and RD will review/reassess residents with enteral tube/enteral feedings on Monday, 9/11/23. 8. Regional Compliance Nurse provided in-service to DON and Administrator on 9/9/23 regarding RD recommendations to include if provider/extender does not approve the RD recommendation, Medical Director will be consulted. 9. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to enteral tubes in [EHR system], the facility's electronic medical record (EMR). 10. All nurses not in service on 9/8/23 will be in-serviced prior to working their next scheduled shift. 11. The Medical Director was notified by Administrator on 9/8/23 at 5:08pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/8/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. IJ MONITORING: Record review of PEG tube assessments, dated 09/08/2023, revealed 6 of 6 residents with PEG tubes, were assessed with enteral feeding orders noted. Record review of enteral feedings assessment completed by Dietitian, dated 09/11/2023, revealed all residents fed via PEG tube had diets assessed and provided recommendations as needed. Record review of in-service, dated 09/08/2023, revealed Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding Changes/Discontinuation of Enteral tubes/Enteral feedings review with family/responsible party to include removal of enteral PEG tube. Record review of in-service on Non-functioning or Not in Use Enteral Tubes, dated 09/08/2023, revealed 10 nursing staff received training on notifying physicians of changes regarding enteral tube feed. Record review of QAPI meeting, dated 09/08/2023, revealed plans to remove immediate jeopardy regarding PEG tubes and neglect were discussed. Interview with the Wound Care Nurse on 09/12/2023 at 4:30 PM, she said she would notify the NP if any change were observed in residents with PEG tubes and write her report and doctor's orders on a progress notes. She said she would observe for changes such as: drainage, redness, odor on the surrounding PEG site, looking for signs of infection. She said if it was observed to be dislodged, she would immediately notify the NP and family and DON, document what she saw, and follow the doctor's orders from there. In an interview with LVN B on 09/12/2023 at 4:44 PM, she said while assessing her patients with PEG tubes, she would look for signs of infection including redness and leaks in the case it is dislodged. She stated in the case where she observes a resident's PEG tube dislodged, she would notify the doctor or NP and turn off feed in the meantime. She said she would document change of condition using a SBAR and nurses notes and would also notify the family. Interview with LVN G 09/12/2023 at 4:51 PM, she said while assessing her patients with PEG tubes, she would look for signs of infection, placement, and skin integrity. She said she would call the NP and let them know about any changes observed and get orders and then do a change of condition note, or SBAR, and notify the family and the DON. She said she was not currently working with any residents who had a PEG tube that was not being used. Observations of Resident #8 on 09/12/2023 at 5:30 PM was observed lying in bed resting while receive continuous enteral feeding vis PEG tube with orders matching the dietitian's recommendations. Interview with RN C on 09/12/2023 at 5:40 PM, she said performed dressing changes on resident with PEG tubes and checked for placement, signs of infection including drainage, bleeding, color, smell, redness or tenderness. She said she would notify the NP or DON if she observed anything abnormal and document findings in the SBAR and progress notes. She said she knew no residents using a nonfunctioning tube feeding on her wing at the time. In an interview with RN A on 09/12/2023 at 6:13 PM, she said she checked peg tube site for dryness, redness, drainage, tenderness, and tube for displacement, feel around and look for signs of pain. She said she would notify the physician for treatment plan, apply dry dressing and ointments as ordered and would document changes in a SBAR or progress note. She said SBARs are used and can trigger for every nurse to notify them of changes in resident from shift to shift. The facility was notified the IJ was removed on 9/12/23 at 6:25 PM however, the facility remained out of compliance, at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 5 residents (CR #19 and Resident #317) reviewed for professional standards. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of Pattern and a severity level of actual harm due to the facility continuing need to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for hypoglycemia, drug overdose, decline in health, hospitalization, and death. Findings include: CR #19 Record review of CR #19's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, and bacterial bone infection. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on [DATE] revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Focus- diagnosis of diabetes, goal- resident will have no complications related to diabetes, interventions- diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. Record review of CR #19's Physician's Orders dated [DATE] revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated [DATE] signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of 60/40, HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on [DATE] and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated [DATE] at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated [DATE] at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB 60/40 manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (07:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to 58/40 so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ½ hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. Interview on [DATE] at 10:18 AM, CR #19 family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival ([DATE]) of severe sepsis. Interview on [DATE] at 12:52 PM, RN C said she found CR #19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet, so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She stated she tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast, and she instead focused on the resident's dropping blood pressure. Interview on [DATE] at 01:25 PM, the DON said after reviewing CR #19's vitals on the day of his hospitalization ([DATE]) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experience, but it was an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's she would expect the nurse to send the resident to the hospital by calling 911 because it was unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in 15-20 minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. Interview on [DATE] at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis, so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident, so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. Interview on [DATE] at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated [DATE] at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain started [DATE]. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety started [DATE]. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms started [DATE]. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain) started [DATE]. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain started [DATE]. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms started [DATE]. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every 2-3 minutes as needed started [DATE]. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain started [DATE]. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6 started [DATE]. Record review of Resident #317's Progress Notes dated [DATE] at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday [DATE] and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated [DATE] revealed, Resident #317 received the following medications the night ([DATE]) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated [DATE] at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack, computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated [DATE] revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317, and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally, and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated [DATE] revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Progress Note dated [DATE] at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinues, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. Observation and Interview on [DATE] at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day ([DATE]) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning ([DATE]) the facility staff tried to wake him up, but he was not moving so they called 911. CR #317 said he was informed that he had an opioid overdose. An Observation on [DATE] at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. Interview on [DATE] at 12:52 PM, RN C said on Saturday morning ([DATE]) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and as making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses, but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said When 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. Interview on [DATE] at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. Interview on [DATE] at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. Interview on [DATE] at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on [DATE] and [DATE]. She said she was just focused on the CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on [DATE] and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated [DATE] revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated [DATE] completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. On [DATE] at 11:00 AM the Administrator and was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The following plan of removal was approved on [DATE] at 11:34 AM and Indicated: IJ Component: F658: Services Provided Meet Professional Standards: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to the ER on [DATE] and did not readmit to the facility. Resident #317 was transferred to the ER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on [DATE]. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on [DATE] to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on [DATE] to assess for s/s of opioid overdose. No resident currently residing in the facility as of [DATE] identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on [DATE] to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on [DATE] regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on [DATE]. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on [DATE]. 7. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on [DATE]. 8. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on [DATE]. 9. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting [DATE] regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on [DATE]. 10. Licensed nurses (RNs/LVNs) will be tested to evaluate competency of the education/in-services initiated on [DATE]. Competency tests will be initiated on [DATE] upon completion of the education with goal for completion by end of day on [DATE]. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on [DATE] will be in-serviced prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on [DATE] at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on [DATE] by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING Interviews conducted on [DATE] from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. Interview on [DATE] at 12:34 revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. Interview on [DATE] at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. Interview on [DATE] at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on [DATE] from 05:28 AM to 06:27 AM revealed the following: - LVN B stated she was re-trained in the administration of Naloxone and showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, stated they received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record reviews completed on [DATE] revealed the following: - on [DATE] the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on [DATE] the DON reviewed all resident orders for Glucagon administration. - on [DATE] the DON completed a Nurse Proficiency Audit on RN C she was found to be satisfactory. - on [DATE] a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on [DATE] the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on [DATE] the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on [DATE] the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on [DATE] the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment, and all mediations were appropriate - on [DATE] at 1:00 PM ADON A, the DON and the Administrator were retrained on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose. - On [DATE] the facility retrained the following staff on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose: MDS Nurse A, RN A, LVN B, LVN A, RN C, LVN D The Administrator was informed the IJ was removed on [DATE] at 06:37 PM. The facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice provided to 3 of 16 residents, (CR #19, Resident #1 and Resident #317), reviewed for quality of Care. - The facility failed to ensure RN C administered Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - The facility failed to ensure RN C sent CR #19 through immediate emergency transport after being diagnoses with critical vitals. - The facility failed to ensure RN C administered Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. -The facility failed to reinstate Resident #1's Metformin after readmission to the facility. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/16/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for a decline in ADL, decline in health, injury and death. Findings include: CR #19 Record review of CR #19's Face Sheet dated 09/11/23 revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, and bacterial bone infection. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on 07/31/23 revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Focus- diagnosis of diabetes, goal- resident will have no complications related to diabetes, interventions- diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. Record review of CR #19's Physician's Orders dated 06/22/23 revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated 08/15/23 signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of 60/40, HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on 08/15/23 and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated 08/15/23 at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated 08/15/23 at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB 60/40 manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (07:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to 58/40 so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ½ hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. Interview on 09/09/23 at 10:18 AM, CR #19 family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival (08/17/2) of severe sepsis. Interview on 09/11/23 at 12:52 PM, RN C said she found CR #!19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet, so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She said she tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast, and she instead focused on the resident's dropping blood pressure. Interview on 09/11/23 at 01:25 PM, the DON said after reviewing CR #19's vitals on the day of his hospitalization (08/15/23) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experience, but it was an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's she would expect the nurse to send the resident to the hospital by calling 911 because it was unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in 15-20 minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. Interview on 09/11/23 at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis, so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident, so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. Interview on 09/18/23 at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated 10/13/22 presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated 12/14/22 presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated 09/11/23 revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated 09/06/23 at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain started 09/05/23. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety started 09/05/23. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms started 09/05/23. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain) started 09/05/23. - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain started 09/05/23. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms started 09/05/23. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every 2-3 minutes as needed started 09/05/23. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain started 09/05/23. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6 started 09/05/23. Record review of Resident #317's Progress Notes dated 09/06/23 at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday 9/5/2023 and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated 09/08/23 revealed, Resident #317 received the following medications the night (09/08/23) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated 09/09/23 at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack, computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated 09/09/23 revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317, and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally, and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated 09/09/23 revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Progress Note dated 09/09/23 at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinues, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. Observation and Interview on 09/09/23 at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day (09/08/23) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning (09/09/23) the facility staff tried to wake him up, but he was not moving so they called 911. CR #317 said he was informed that he had an opioid overdose. An Observation on 09/09/23 at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. Interview on 09/11/23 at 12:52 PM, RN C said on Saturday morning (09/11/23) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and as making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses, but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said When 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. Interview on 09/11/23 at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. Interview on 09/11/23 at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. Interview on 09/13/23 at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on 08/15/23 and 09/12/23. She said she was just focused on the CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on 09/09/23 and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated 11/01/22 revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated 08/01/23 completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female who admitted into the facility on [DATE] and was diagnosed with Type 2 Diabetes with Unspecified Diabetic Retinopathy with Vascular Edema, Anemia and Hypertension. Record review of Resident #1's care plan, dated 09/14/2023, revealed the resident had Diabetes Mellitus, the goal was for the resident to, .have no complications related to diabetes through the review date of 12/05/2023 ., and the intervention was to, Diabetes medication as ordered by doctor. Monitor/document for sides effects and effectiveness . Record review of Resident #1's progress note dated 06/02/2023, revealed the resident readmitted to the facility from the hospital. Resident returned to the facility from the hospital by ambulance. NP notified of the resident's return to the facility. The hospital did not send any orders for the resident's medication. NP stated to reactivate the previous medications the resident was taking at this facility before she went to the hospital . Records review of Resident #1 discontinued orders dated 09/12/2023, revealed Resident #1's metFormin HCI oral Tablet 500 MG order discontinued on 06/02/2023. Record review of revealed Resident #1 did not have an active prescription for Metformin. Interview on 09/12/23 at 01:14 PM, the DON said Resident #1 received Metformin and Insulin for DM management. Interview on 09/13/23 at 02:45 PM, NP A said she was unaware that Resident #1 was no longer receiving Metformin and she did not approve for the medication to be discontinued. She said discontinuation of Metformin was not appropriate because Resident #1 had family members that bring her food throughout the day so Metformin was important to control her blood sugars. NP A said failure to administer Metformin to Resident #1 as ordered placed her at risk of increased blood sugars which could negatively impact wound healing. Interview with the DON on 09/15/2023 at 11:48 AM, revealed the resident returned to the facility she did not come with any discharge records, she stated the hospital faxed over paperwork but the only medication that was listed was the insulin. She stated the metformin medication was not listed on the medication list received from the hospital. She stated she was not aware that the medication was left off the list and she was responsible for ensuring the medication was added to the resident's medication list. The risk of the resident not getting metformin is her blood sugar increasing, she stated the resident has had elevated blood sugar since not being on her medication. Interview on 09/18/23 at 03:06 PM, NP A said Metformin once daily was added back to Resident #1's DM medications. Record review of MAR from June, July an August 2023, revealed that Resident #1 did not receive Metformin. The resident went without Metformin from 06/02/23-09/14/23. Resident #1's first dose was on September 15, 2023. Record review of the facility policy Medication Reconciliation revised 11/14/16. At any time a change is made to a patients medication regiment, practitioners must ensure that the change is made carefully, is documented, and accords with prescribing instructions for the relevant medications. Medications reconciliation should be performed every time a patient is admitted to a facility. It is common for changes to be made to a patient's medications when he or she is hospitalized . Upon transition back to the SNF, medication reconciliation should be performed again and the patient's current medications checked against those he or she was taking before being hospitalized . Nursing staff should notify the practitioner of changes to or omissions from the medication regimen and verify whether the practitioner wishes to reorder any medications that were stopped during the patient's hospitalization. On 09/13/23 at 11:00 AM the Administrator and was notified of the IJ. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The following plan of removal was approved on 09/14/23 at 11:34 AM and Indicated: IJ Component: F658: Services Provided Meet Professional Standards: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to the ER on [DATE] and did not readmit to the facility. Resident #317 was transferred to the ER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on 9/12/23. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on 9/13/23 to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on 9/13/23 to assess for s/s of opioid overdose. No resident currently residing in the facility as of 9/13/23 identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on 9/14/23 to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/13/23 regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 9/13/23 regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on 9/14/23. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 9/13/23 regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on 9/14/23. 7. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 9/13/23 regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on 9/14/23. 8. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 9/13/23 regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on 9/14/23. 9. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 9/13/23 regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on 9/14/23. 10. Licensed nurses (RNs/LVNs) will be tested to evaluate competency of the education/in-services initiated on 9/13/23. Competency tests will be initiated on 9/13/23 upon completion of the education with goal for completion by end of day on 9/14/23. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on 9/13/23 will be in-serviced prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on 9/13/23 at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on 9/13/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING: Interviews conducted on 09/15/23 from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. Interview on 09/15/23 at 12:34 revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. Interview on 09/15/23 at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. Interview on 09/15/23 at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on 09/16/23 from 05:28 AM to 06:27 AM revealed the following: - LVN B stated she was re-trained in the administration of Naloxone and showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, stated they received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record reviews completed on 09/15/23 revealed the following: - on 09/13/23 the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on 09/13/23 the DON reviewed all resident orders for Glucagon administration. - on 09/13/23 the DON completed a Nurse Proficiency Audit on RN C she was found to be satisfactory. - on 9/13/23 a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on 09/13/23 the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on 09/13/23 the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on 09/14/23 the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on 09/14/23 the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment, and all mediations were appropriate[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for 1 of 6 residents (Resident #8) reviewed for enteral nutrition, the facility failed to ensure whoever was able to eat enough was not fed by enteral methods unless the resident's clinical condition demonstrated that the enteral feeding was clinically indicated and consented to by the resident, in that: - Resident #8 had a PEG tube deemed non-functional for over 5 months without enteral feeds or water flushes. - Resident #8 experienced multiple episodes of infections at her PEG tube site. - The NP convinced Resident #8's RP to not remove PEG tube in case it needed to be used for emergency enteral feedings or medications. She did not communicate resident's complications related to PEG tube or that it was non-functional. - Resident #8 was found on 08/16/2023 with PEG tube pulled out with tip broken off and was hospitalized as a result. - Resident #8 experienced a decline in ADLs as evidenced by downgrade from Regular heart healthy pureed diet to enteral feeds after tube replacement post- partial bowel obstruction. An Immediate Jeopardy (IJ) was identified on 09/08/23 at 4:05PM. While the IJ was removed on 09/12/23 at 06:25 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures placed residents at risk for a decline in ADL, decline in health, injury and death. Findings include: Resident #8 Record review of Resident #8's face sheet revealed a [AGE] year old female who was admitted into the facility on [DATE] and was diagnosed with Alzheimer's disease (progressive mental deterioration), cerebral infarction (stroke), dysphasia (difficulty swallowing) and paralytic ileus (impaired motor activity of the bowel). Observation of Resident #8 on 09/05/2023 at 10:30AM, the resident was lying in bed, being fed enteral feed continously via PEG tube in place, and the resident was non-verbal at the time. Record review of Resident #8's MDS, dated [DATE], the resident was identified to have a feeding tube. Record review of Resident #8's care plan, undated, revealed the resident had no care plan related to tube feedings. Record review of Resident #8's clinical physician orders, undated, revealed the resident's history of diet orders included: - NPO diet from 01/31/2020 to 2/18/2020 - Regular mechanical soft diet with ground meat texture from 2/2/2023 to 4/3/2023 - Regular diet or Heart healthy diet, puree texture, regular consistency from 4/3/2023 to 8/18/2023. - Enteral feed order of 1.5cal/ml isosource at 50ml/hr for 22 hours every shift from 09/01/2023 to present. Record review of Resident #8's order summary report, dated 3/1/2023 - 08/18/2023, revealed the resident did not have any enteral feed orders prescribed from 3/1/2023 until day of discharge on [DATE], and the resident took all medications by mouth. Record review of Resident #8's nurses notes, dated 02/03/2023 - 03/06/2023, revealed the resident was assessed by the NP on 02/04/2023, who noted the resident had a diet order of dysphagia advanced texture, was eating fair and had a peg-tube in place but not in use. NP's plan of care regarding Malnutrition/Dysphagia including monitoring weights, peg flushes and dressing changes per protocol. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for KUB STAT Dx. Check Peg tube placement one time for 1 day, on 03/06/2023. Record review of Resident #8's nurses notes, dated 03/06/2023 - 04/06/2023, revealed the NP assessed the resident for a Peg Tube Malfunction on 03/07/2023 and noted, . Nursing reported peg tube appears to be displaced from normal position yesterday . KUB performed and recommended gastrograffin [a contrast medium used for x-ray imaging] for definitive placement verification . Nursing to notify RP of order, will proceed if RP agreeable, peg tube not currently in use . In the NP's assessment and plan regarding her peg tube, she noted, . KUB performed, will await approval before proceeding with gastrograffin . Peg appears to be in normal position as when last assessed by myself . Order given not to use peg tube for now . Abdominal exam benign . Record review of Resident #8's progress notes, dated 03/06/2023 - 04/06/2023, revealed the NP assessed the resident on 03/09/2023 and noted the resident was lying in bed being fed by a staff. The NP also noted, . RP does not desire to proceed with additional X-ray procedure to confirm placement of peg tube . Will DC all peg tube orders . No acute concerns or complaints . In the NP's assessment and plan regarding her peg tube, she noted, . RP declines any additional studies for peg tube . DC all peg tube orders . Apply abdominal binder . Monitor provider for any changes . Record review of Resident #8's progress notes, dated 03/06/2023 - 04/06/2023, revealed LVN G wrote a note on 03/09/2023 that stated, . NP . here in the building this am to visit resident NP . called RP . to ask if she wanted resident to be sent out for gtube replacement or removal RP . stated no then RP . also came to this facility to visit resident and stated she does not want anything done to the gtube removed or replaced she only wants gtube site clean. NP gave new order to d/c all gtube orders . Record review of Resident #8's progress notes, dated 06/07/2023 - 07/08/2023, revealed, RN F wrote, RESIDENT IS AGITATED AND WOULD NOT ALLOW ME TO DRESS HER G-TUBE. SMALL AMOUNT OF BRIGHT RED BLOOD NOTED TO SHIRT. SMALL AMOUNT OF BLOOD NOTED AROUND G-TUBE INSERTION SITE. WAS ABLE TO CLEAN AREA. NO OPEN AREA NOTED. RESIDENT ARM REST AGAINST G-TUBE AND MAY HAVE CAUSED IRRITATION. NO ACTIVE BLEEDING NOTED AFTER CLEANED. Record review of Resident #8's progress notes, dated 07/08/2023 - 08/08/2023, revealed the NP assessed Resident #8 on 07/26/2023, reason being for rash, drainage from peg site . The NP wrote: . Peg Tube Infection - Noted to have breakdown around peg tube with purulent drainage - Continue Doxycycline - Peg site care daily - Non-functioning peg tube Record review of Resident #8's physician's orders, dated 03/01/2023 - 08/16/2023, it revealed the resident was ordered: - Clotrimazole External Cream 1% was ordered on 07/26/2023 and was to be applied periumbilical area topically two times a day for infection. The treatment lasted for 14 days; 07/26/2023 - 08/09/2023. -Doxycycline Hyclate Oral Capsule (100mg) was ordered on 07/26/2023, to be administered by mouth two time a day for peg tube infection for 10 days. Instructions were given to cleanse peg tube site with normal saline, pat dry and apply dressing until healed. The treatment lasted 10 days; from 07/26/2023 - 08/05/2023. Record review of Resident #8's progress notes on 08/02/2023, the NP documented her assessment of PEG tube infection and wrote about her conversation she had with Resident #8's RP, in which she wrote: . #Peg Tube Infection - Improved - Continue Doxycycline until 8/5 - Peg site care daily - Non-functioning peg tube - F/U with [GI] RP conversation: Per nursing RP is requesting removal of PEG tube. Call placed to RP. Spoke with [Responsible Party] Discussed risk and benefits of peg tube placement. Patient has periods of being uncooperative, agitated, and refusing to eat and drink. RP is agreeable to have peg tube placed as it is non-functioning at this time . Record review of Resident #8's progress notes, dated 08/08/2023 - 09/08/2023, revealed on 08/13/2023, LVN E noted, . increased redness around stoma, skin irritation . profuse sticky drainage . Record review of Resident #8's physician's orders, dated 03/01/2023 - 08/16/2023, it revealed the resident was ordered: - Doxycycline Hyclate Oral Capsule (100mg) was ordered on 08/13/2023, to be administered by mouth two time a day for peg tube stoma infection for 7 days. The treatment lasted 4 days and was discontinued to resident's discharge to hospital. Record review of Resident #8's progress notes, dated 08/08/2023 - 09/08/2023, revealed on 08/16/2023, LVN D noted resident was found at 6:00AM with tubing from her old non-functioning PEG tube in her hand while asleep. She also noted, . redness, irritation and profuse sticky drainage . Resident currently on antibiotic therapy related to infection at Peg tube site . LVN D also noted the catheter tip was not in place on the tubing. On 08/16/2023, LVN E also documented, .Resident pulled out her peg tube last night . looks like she had the tip of peg tube did not came out . LVN E noted Resident #8 was transferred out to the hospital ER for evaluation and treatment by 11:30AM. Record review of Resident #8's physician orders, dated 03/01/2023 to 09/09/2023, revealed the resident had an order for transfer resident to [hospital] ER for evaluations and peg tube replacement, on 08/16/2023. Record review of Resident #8's hospital records, dated 08/22/2023, revealed the resident was admitted into the hospital on [DATE], and a physician wrote, . [AGE] year-old female with a past medical history of hypertension, severe dementia, cholecystectomy presents to the hospital with a dislodged gastrostomy . CAT scan completed on arrival demonstrated that the gastrostomy tube was located at the terminal ileum [end of small intestine located before the entrance to the colon]. Gastroenterology consulted for the findings above . Assessment: Partial bowel obstruction secondary to dislodgement of PEG tube. Colonoscopy completed yesterday . On 08/21/2022, another physician noted, . PEG tube from ileocecal valve . Patient underwent colonoscopic retrieval of the PEG tube successfully . Interview with a family member on 09/06/23 at 03:29 PM, she said Resident #8's PEG tube was placed 3 years ago but had since not been removed to serve as a backup in case the resident were to ever refuse food or medication. She said she ate by mouth and was never notified by staff of them needing to use her PEG tube due to the resident refusing meals or medications. She said she never requested to have the PEG tube removed because it not her call, considering she had no medical background. She said when the resident was discharged to the hospital on [DATE], she learned from the hospital staff that a piece of the PEG tube had broken off and the CT scan showed it was in her intestines. She said a few days before the resident's hospitalization, she noticed her PEG tube was leaking, with thick, off-yellow pus and the resident stoma site appeared red and raw with rashes on her abdomen. She said she did not tell the nurses what she saw because she assumed the nurses were taking care of it. She said she did not feel persuaded to keep it in and it was never a topic of discussion because of how independent the resident had always been. She said the resident has shown to have a decline since returning to the hospital is no longer eating like she used to. Interview with LVN G on 09/07/23 at 01:43 PM, she said if a patient has a PEG tube that is not being used, nurses should keep flushing if there is an order to keep the line clean and prevent blockages because it can clog up. She said Resident #8's family did not want the PEG tube out because the resident was due to her age, therefore, they wanted to prevent any unnecessary surgical procedures. She said she only kept flushing Resident #8's PEG tube it only if it was in the doctor's order. LVN G said the risks of keeping a non-functioning tube in place was infection and aspiration. She said she had seen Resident #8 with some excoriation to abdomen and around the PEG tube site and had orders to apply cream to around the PEG tube site. She said the resident had since experienced a decline following her hospitalization, she could talk and eat by mouth before, but has snow been on enteral feeds via PEG tube. Interview with LVN E on 09/18/23 at 12:58 PM, he said he worked often with Resident #8 and saw the resident's tube was pulled out after LVN D reported the incident to him during shift change. He said he had called the NP and told it appeared as if a piece of the PEG tube was missing. The NP later ordered for the resident's transfer to the ER for evaluation and he notified the resident's family. He said at the time of assessment, the resident had clear drainage the stoma site. The resident had a history of drainage for a period of time before her discharge and was prescribed antibiotics and daily cleaning of the stoma. He said the resident always ate by mouth and did not have any enteral feeds. Interview with LVN D on 09/18/23 at 01:19 PM, she said the only peg tube care she provided for Resident #8 was dressing changes as ordered. She said she did not flush the pegs tube or use it to administer medication. She said she saw drainage on the date she pulled the PEG tube out. She said the PEG tube was pulled out at around the time of shift change at 6AM, and she noticed the tip of the PEG tube was not intact. She notified the doctor by leaving a message and she texted the NP, but eventually LVN E followed up with the NP to have the resident transferred to the hospital. In a phone interview with the Medical Director on 09/07/23 at 02:09 PM, he said for residents who used PEG tubes, they were to have to water flushes in place, have monitoring for signs of infection, and If the PEG tube was not being used, if it was non-functioning, and/or the patient was eating well by mouth, the tube should be removed due to risks of infections around the stoma site. He said, at the least, the PEG tube should have been flushed to ensure there were no blockages or increased risks of infection. In a phone in interview with NP B on 09/07/23 at 02:38 PM, she said the risks of using a PEG tube included bowel obstructions, infections, perforation, and aspiration. She said Resident #8's PEG tube remained in place because the family member did not want the resident to be sent out for any procedures due to her age. She said the family member, who makes the decisions for the resident, did not allow the resident out until the tube broke on 08/16/2023. She said the tube became non-functional in March when the resident pulled on the tube because she could not confirm the tube was still placed correctly in the resident's stomach. She said if could not confirm placement, she did not want the PEG tube to be used. She said Resident #8 also had an order for an abdominal binder in place to help prevent the Resident from pulling the PEG tube. She said she later ordered for the abdominal binder to be taken off to allow excoriated and rashy skin, caused by the drainage from the PEG tube site, on the abdomen to be left open to air to heal. She said any moist dark areas on the skins can be at risk of skin breakdown and fungus. When asked if the abdominal binder contributed to the rash, she refused to answer. She said the rashes and excoriation on the abdomen and stoma site would not have been a core reason to have the PEG tube removed, but it could have served as an argument to encourage PEG tube removal. She said she did not recall having another conversation with the family member about the risks and benefits removing the non-functional PEG tube until it was pulled out on 08/16/2023. NP B said she did not believe she talked to the family member about the resident PEG tube site infections but believed the facility nursing staff were talking to the family about it. In an phone interview with the family member on 09/07/23 at 02:25 PM, she said she was never informed of the risks of leaving a PEG tube in place for Resident #8 and she was never told that it was nonfunctional. She said she vaguely remembered being called by a physician's assistant or nurse practitioner asking if they could do some testing to related to concerns about the PEG tube and she gave them the okay to do so, but there was no follow up afterwards. The family member said she thought this whole time the PEG tube was functional and was able to use as back up, and if she would have known it was non-functional she would have had no problem with them taking it out. In a phone interview with NP B on 09/11/2023 at 10:44 AM, when asked about what she meant in the progress note she wrote on 08/02/2023, she refused to provide a description but said she would never convince the family member to keep a non-functional PEG tube in Resident #8. She said she needed more time to review Resident #8's chart. There was no follow-up interview with NP B. In an interview with the DON on 09/18/2023 at 9:53 AM, she said Resident #8 had been eating by mouth for at least two years and decisions about the PEG tube were always determined by NP B and the family member. She said, to her knowledge, the family member never wanted the PEG tube removed. While the resident ate by mouth, the nurses were just flushing the PEG tube until the placement could no longer be verified in March. She said NP B wanted to send her out, but the family refused, which could not be disputed. She said the note written by NP B on 08/02/2023 seemed contradictory to her, but she believed after the first conversation NP B had with the family member in March, she did not see the need for any additional conversations to be had after the family made their decision. She said changes in conditions should had been documented by nurses in the progress notes or in a SBAR assessment and documentation was supposed to reflect what was going on with the patient and if treatments were effective. She said if the PEG tube site was observed to be draining, it should have been documented daily and any treatments for drainage or rashes related to the PEG tube that were ordered, should have been reported to Resident #8's RP as a notice as to what was going on with the patient. The DON said she believed the best choice would have been to have the PEG tube taken out and the notifications of rashes and drainage related to the non-functioning PEG tube could have been communicated to the RP to serve as education for reasons why the PEG tube removal would have been beneficial. Record review of the facility's policy on Gastrostomy Tube Care, dated February 2007, revealed goals of the policy was, . 1. The resident will maintain nutritional status, within optimal parameters via gastrostomy feedings. 2. The resident will be free of infections at the gastrostomy site. 3. The resident will maintain intact skin free from breakdown at the stoma site . It also stated, . Gastrostomy is a surgically created abdominal opening into the stomach for the purpose of administering feedings. A stoma is created to allow for long-term feedings . it can also contain an inflatable tube inserted into the stomach and skin disc to secure the position of the tube for the purpose of feedings Check tube placement . if the tube has moved or has come out, do not use and call the physician. On 09/08/2023 at 4:00 PM the Administrator was notified of the Immediate Jeopardy (IJ), due to the above failures. The IJ template was left with the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 09/09/2023 at 1:17 PM. The POR revealed: IJ Component: F693 Enteral Nutrition: Facility failed to ensure Resident #8's enteral feeding was clinically indicated. Immediate Actions: Resident #8's g-tube site was assessed by RN on 9/8/23 for s/s of infection, no adverse findings noted. Facility Plan to ensure compliance: 1. 100% reassessment by RN of all g-tube sites completed 9/8/23, including resident #8. One resident identified with new onset of redness at enteral tube site, new treatment implemented. No other adverse finding noted on reassessment of enteral tube sites noted on 9/8/23. 2. Skin sweep completed on 100% of facility residents on 9/8/23 to ensure all enteral tubes were accounted for. Six residents identified with an enteral tube. No additional tubes were identified on a resident residing in the facility as of 9/8/23. 3. Residents with enteral tubes/enteral feedings reviewed for appropriate treatment on 9/8/23. Six of the facility residents identified as receiving enteral feedings with the majority of nutrition/hydration received via enteral tube for these six residents. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 9/8/23 regarding Changes/Discontinuation of Enteral tubes/Enteral feedings should be reviewed with family/responsible party to include removal of enteral tube, if appropriate. If disagreements between provider and family/responsible party arise, the Medical Director and the Ombudsman will be involved in a formal care plan to review the plan regarding the enteral tube. 5. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying provider (NP/MD) of any complications with enteral tube and notifying DON/ADON of enteral tube changes to ensure compliance with this procedure. 6. DON/ADON have in-serviced charge nurses by phone and/or in person as of 9/8/23 regarding notifying the provider (NP/MD) of any change of condition related to enteral tube site and/or feedings to ensure compliance with this procedure. 7. Registered Dietician (RD) will be consulted for residents with enteral feedings to ensure enteral feedings/water flushes meet the resident's needs. Registered Dietician (RD) notified on 9/9/23 of need for reassessment of residents with enteral tubes/enteral feedings and RD will review/reassess residents with enteral tube/enteral feedings on Monday, 9/11/23. 8. Regional Compliance Nurse provided in-service to DON and Administrator on 9/9/23 regarding RD recommendations to include if provider/extender does not approve the RD recommendation, Medical Director will be consulted. 9. Charge Nurses will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to enteral tubes in [EHR system], the facility's electronic medical record (EMR). 10. All nurses not in service on 9/8/23 will be in-serviced prior to working their next scheduled shift. 11. The Medical Director was notified by Administrator on 9/8/23 at 5:08pm on the immediate jeopardy citation. 12. An Ad-hoc QAPI meeting was held on 9/8/23 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. MONITORING: Record review of PEG tube assessments, dated 09/08/2023, revealed 6 of 6 residents with PEG tubes, were assessed with enteral feeding orders noted. Record review of enteral feedings assessment completed by Dietitian, dated 09/11/2023, revealed all residents fed via PEG tube had diets assessed and provided recommendations as needed. Record review of in-service, dated 09/08/2023, revealed Regional Compliance Nurse provided in-service to DON, ADON, and Administrator regarding Changes/Discontinuation of Enteral tubes/Enteral feedings review with family/responsible party to include removal of enteral PEG tube. Record review of in-service on Non-functioning or Not in Use Enteral Tubes, dated 09/08/2023, revealed 10 nursing staff received training on notifying physicians of changes regarding enteral tube feed. Record review of QAPI meeting, dated 09/08/2023, revealed plans to remove immediate jeopardy regarding PEG tubes and neglect were discussed. Interview with the Wound Care Nurse on 09/12/2023 at 4:30 PM, she said she would notify the NP if any change were observed in residents with PEG tubes and write her report and doctor's orders on a progress notes. She said she would observe for changes such as: drainage, redness, odor on the surrounding PEG site, looking for signs of infection. She said if it was observed to be dislodged, she would immediately notify the NP and family and DON, document what she saw, and follow the doctor's orders from there. Interview with LVN B on 09/12/2023 at 4:44 PM, said while assessing her patients with PEG tubes, she would look for signs of infection including redness and leaks in the case it is dislodged. She said in the case where she observes a resident's PEG tube dislodged, she would notify the doctor or NP and turn off feed in the meantime. She said she would document change of condition using a SBAR and nurses notes and would also notify the family. Interview with LVN G 09/12/2023 at 4:51 PM, she while assessing her patients with PEG tubes, she would look for signs of infection, placement, and skin integrity. She said she would call the NP and let them know about any changes observed and get orders and then do a change of condition note, or SBAR, and notify the family and the DON. She stated she was not currently working with any residents who had a PEG tube that was not being used. Observations of Resident #8 on 09/12/2023 at 5:30 PM was observed lying in bed resting while receive continuous enteral feeding vis PEG tube with orders matching the dietitian's recommendations. Interview with RN C on 09/12/2023 at 5:40 PM, she said performed dressing changes on resident with PEG tubes and checked for placement, signs of infection including drainage, bleeding, color, smell, redness or tenderness. She said she would notify the NP or DON if she observed anything abnormal and document findings in the SBAR and progress notes. She said she knew no residents using a nonfunctioning tube feeding on her wing at the time. Interview with RN A on 09/12/2023 at 6:13 PM, she said she checked peg tube site for dryness, redness, drainage, tenderness, and tube for displacement, feel around and look for signs of pain. She said she would notify the physician for treatment plan, apply dry dressing and ointments as ordered and would document changes in a SBAR or progress note. She said SBARs are used and can trigger for every nurse to notify them of changes in resident from shift to shift. The facility was notified the IJ was removed on 9/12/23 at 6:25 PM however, the facility remained out of compliance, at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 6 staff ( RN C) and 2 of 5 residents ( CR #19 and Resident #317) reviewed for nursing competency. - RN C failed to administer Glucagon, an injectable hormone used to raise blood sugars, to CR #19 when he suffered from a BS of 62. - RN C failed to send CR #19 through 911 emergency transport after being diagnosed with critical vitals. - RN C failed to administer Naloxone, a medication used to treat opioid overdose, when Resident #317 experienced an opioid overdose. An IJ was identified on [DATE] at 09:00 AM. While the IJ was removed on [DATE] at 06:37 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk for hypoglycemia, drug overdose, decline in health and death. Findings included: CR #19 Record review of CR #19's Face Sheet dated [DATE] revealed, an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: gangrene, absence of right leg below knee, MDD, panic disorder, hypertension, stage 4 pressure ulcers, bacterial bone infection and type 2 diabetes. The resident was transferred to the hospital on [DATE] at 08:50 PM. Record review of CR #19's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and frequently incontinent of both bladder and bowel. Record review of CR #19's Discharge Return Anticipated MDS dated [DATE] revealed, the resident had an unplanned discharge to an acute hospital, the resident had a fever and no documented falls since prior assessment. CR #19 had 4 stage four pressure ulcers of which 3 were facility acquired and 1 facility acquired unstageable ulcer. Record review of CR #19's Care Plan last reviewed on [DATE] revealed, focus- advance directive as evidenced by full code, focus- pressure ulcers. Record review of CR #19's Physician's Orders dated [DATE] revealed, Glucagon Emergency Kit 1 MG- Inject 1 mg IM every 12 hours as needed for s/s of hypoglycemia, unresponsive and BS </= 70, recheck BS in 15 minutes and notify MD. Glucose Gel 40%- give 15 grams every 15 minutes as needed for s/s hypoglycemia and responsive, May administer 2nd dose and recheck in 15 minutes, notify MD only if not above 70. Record review of CR #19's SBAR note dated [DATE] signed by RN C revealed, CR #19 suffered from: mental status change, respiratory change-suspected infection, cardiovascular change, fever with unknown focus of infection, neurological change, BP of 60/40, HR 107 and irregular, RR of 20, oral temperature of 101.1 and a BS of 62. All vitals were collected at 07:23 PM. CR #19 had decreased level of consciousness (very lethargic), had increased confusion/disorientation, experienced rigors (shaking chills), experienced SOB, weakness or hemiparesis. RN C documented that the symptoms first appeared on [DATE] and no ordered treatments/medications had been attempted to help resolve the symptoms. NP A was notified at 07:49 PM and a request was made to transfer the resident to the hospital. Record review of CR #19's Transfer Notification dated [DATE] at 08:50 PM signed by RN C revealed, CR #19 was transferred to a hospital on [DATE] at 08:50 PM related to lethargy, hypotension, rapid shallow breathing, elevated heart rate and body temperature. There was no documentation of hypoglycemia. Record review of CR #19's Progress Notes dated [DATE] at 8:55 PM signed by RN C revealed, While making rounds to administer medication, resident was found lying in bed very lethargic and hard to arouse. Further assessment PB 60/40 manually, T 101.1, P 107, R 20, O2 Sat 97% on room air, and BS 62 mg/dl at around 1923 (07:23 AM). NP A was notified of CR #19's change in condition at about 1938 (7:38 PM) and an order was given to send the resident out via contracted EMS while monitoring BP. CR #19 started exhibiting muscle tremors, increased SOB and BP lowered to 58/40 so NP A was notified of the further change of condition. CR #19 was transferred to the ER via 911 EMS at 8:50 PM, almost 1 ½ hours after symptoms were first observed. There was no documentation of treatment of CR #19's low blood sugar. Record review of CR #19's August MAR revealed, CR #19 was never administered Glucagon. In an interview on [DATE] at 10:18 AM, CR #19's family member said while at the facility CR #19 had multiple pressure wounds and was hospitalized for the wounds on multiple occasions. CR #19's family member said when the resident would go to the hospital his wounds would get better but would worsen when he returned to the facility. She said her father was transferred to the hospital on [DATE] where he was diagnosed with sepsis which the hospital tried to treat with dialysis and antibiotics. CR #19's family member said the resident expired in the hospital 2 days after arrival ([DATE]) of severe sepsis. In an interview on [DATE] at 12:52 PM, RN C said she found CR #19 unresponsive with critical values. She said he had low blood pressure, an elevated heart rate, was running a fever, had blood sugar lower than 70 and was in and out of consciousness She said she contacted NP A who said to monitor CR #19's blood pressure and send him out, she did not remember if NP A said the resident should be sent out using a contracted transport company of 911. She said she called the contracted EMS company to send him to the hospital and continued to monitor the resident. RN C said on following rounds she observed CR #19 to be suffering from tremors and the contracted service was not there yet so she called 911 to send him out. RN C said that CR #19's symptoms appeared to indicate sepsis and looking back she would have sent him out initially using 911. She stated she instead tried to give him Glucagon gel by mouth but due to the resident's condition, it could not be administered that method. RN C said she did not think to administer glucagon by injection because things were moving too fast and she instead focused on the resident's dropping blood pressure. In an interview with the DON on [DATE] at 01:25 PM, after reviewing CR #19's vitals on the day of his hospitalization ([DATE]) the nurse should have administered Glucagon to the resident to treat his hypoglycemia. She said nursing staff do not specifically have training on how to manage emergency situations like what CR #19 experienced but it is an expected nurse competency. The DON said there was nothing stopping RN C from administering Glucagon to CR #19 since the resident had an active order for the medication. She said based on CR #19's symptoms she would expect the nurse to send the resident to the hospital by calling 911 because it is unknown how long the contracted EMS service would take. The DON said if a contracted EMS service was called and had not arrived in 15-20 minutes then 911 should have been called She said the time it took for CR #19 to be transferred to the hospital was too long. The DON said delay in transfer to the hospital could result in CR #19 experiencing further decline since his BP could not be treated at the facility and failure to treat CR #19's low blood sugar could lead to further hypoglycemia. In an interview on [DATE] at 04:00 PM, NP A said she was notified by a nurse that CR #19 was experiencing signs and symptoms of infection and sepsis so she gave the order to send the resident to the hospital for emergency care. She said the facility had standard orders for Glucagon which were stored on their carts so CR #19 should have been treated for his hypoglycemia regardless of his critical vitals. When the surveyor notified NP A of the vitals reported by RN C at the time of the incident, NP A said with those vitals the facility would not be able to treat the resident so he had to be hospitalized . NP A said she did not specify the method of transfer to the nurse (contract vs. 911) but based on CR #19's critical vitals the expectation was that the resident be sent out by calling 911. She said any delay in transfer to the hospital would result in a delay in identification and treatment of acute issues. In an interview on [DATE] at 02:22 PM, the Administrator said the facility did not have a policy addressing critical labs/vitals. Record review of the facility in-service titled Medication Safety Alert dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on the administration of Gvoke an antihypoglycemic agents indicated for severe hypoglycemia. Gvoke pre-filled is for subcutaneous injection only and should be administered as soon as possible when server hypoglycemia is recognized. Gvoke is premixed and ready for immediate us. Attached was a policy on Diabetes Management that defined hypoglycemia as BS </= 70. Record review of the facility in-service titled Diabetes management education and the use of Glucagon dated [DATE] presented by the Director of Clinical Education revealed, RN C was trained on diabetes management and hypoglycemia. Glucagon injection is an emergency medicine used to treat severe hypoglycemia in diabetes patients treated with insulin who have passed out or cannot take some form of sugar by mouth. Administer Glucagon as directed per physician orders. Notify Physician if Blood sugar less than 70 or per physicians orders, if unresponsive or unable to swallow position on side and give Glucagon 1 mg IM or as directed per physician orders. This is a Medical Emergency requiring close observation and/or 911. Resident #317 Record review of Resident #317's Face Sheet dated [DATE] revealed, a [AGE] year-old male who admitted to the facility with diagnoses which included: anemia, paraplegia, colostomy and stage 4 pressure ulcer of the back. Record review of Resident #317's undated Care Plan revealed, focus- potential for uncontrolled pain due to osteomyelitis, muscle spasms, pressure ulcer and surgical wound upon admission; interventions- administer analgesia as ordered, monitor/document for side effects of pain medication. Focus- use of anti-anxiety medications, interventions- give anti-anxiety medications as ordered and monitor/document side effects. Record review of Resident #317's Order Summary Report dated [DATE] at 09:20 Am revealed the following active orders: - Acetaminophen 500 mg- 2 tablets by mouth every 8 hours for pain. - Alprazolam 1 mg- 1 tablet by mouth every 8 hours as needed for anxiety. - Baclofen 5 mg- give 4 tablets by mouth four times a day for muscle spasms. - Gabapentin 400 mg- 2 capsules by mouth three times a day for neuropathy (nerve pain). - Methadone 5 mg- give 7.5 mg by mouth every 8 hours for pain. - Methocarbamol 750 mg- give 1 tablet by mouth three times a day for muscle spasms. - Naloxone 4mg/0.1 ML- 0.1 mL alternating nostrils every 2 minutes as needed for opioid overdose may repat every 2-3 minutes as needed. - Hydrocodone/Acetaminophen 10-325 mg- give 1 tablet by mouth every 8 hours as needed for pain. - Oxycodone 5 mg- give 1 tablet by mouth every 6 hours as needed for pain score 4-6. Record review of Resident #317's Progress Notes dated [DATE] at 12:47 PM signed by NP C revealed, Reviewed Prescription Monitoring Program and patient is at high risk for unintentional overdose with a score of 650 above average. Risk for unintentional overdose discussed with patient, and he reports that he has been taking medications for a long time and that he never overdosed before. PMP monitoring only shows Hydrocodone, and Alprazolam that has been prescribed by his PCP in the community, in which his PCP ordered him Alprazolam yesterday [DATE] and was filled at pharmacy. Narcan nasal spray is ordered as needed. Record review of Resident #317's MAR dated [DATE] revealed, Resident #317 received the following medications the night ([DATE]) before his overdose - Gabapentin 800 mg- scheduled for 06:00 PM. - Methocarbamol 750 mg- scheduled for 06:00 PM. - Baclofen 20 mg - scheduled for 06:00 PM. - Methadone 7 mg- scheduled for 10:00 PM. Record review of Resident #317's Progress Note dated [DATE] at 04:18 AM signed by RN C revealed, Resident transferred to [Hospital] via 911 EMS at approximately 04:18a.m. for further evaluation and treatment related to decreased level of consciousness and respiratory distress. EMS personnel given copy of resident's face sheet, order summary, and clinical notes containing past medical history. Resident's personal belongings including two backpacks, one [NAME] pack,computer laptop, cell phone, earbuds, wrist watch, colostomy supplies, and several bottles of prescription medication remained behind in resident's room. [NP A] notified of [Resident #317] emergency transfer to [Hospital] at approximately 04:30a.m. Record review of the Hospital Ambulance Record dated [DATE] for Resident #317 revealed, Primary impression- overdose other opioids. Narrative- the fire department was dispatched to the facility for a cardiac arrest. Resident #317 was found to be drowsy with deep snoring and the nursing staff said they were unsuccessful in waking Resident #317 and he might have had a seizure. Review of the Resident #317's chart showed multiple medications for sleep, pain and muscle reactions and the resident had constricted pupils. Resident #317 was administered 1 mg of Naloxone Intranasally and the patients response improved; he was easily arousable to verbal and talked to the crew without falling asleep. Record review of the Hospital ED Record dated [DATE] revealed, Resident #317 was found unresponsive and hard to arouse at the facility and the EMS administered 1 mg of Naloxone. Record review of the Resident #317's Progress Note dated [DATE] at 08:10 AM revealed, Resident #317 returned to the facility in elate and high spirit. Resident #317 was diagnosed with opiate overuse in the hospital and NP A gave new orders to check the residents vitals and signs/symptoms of CNS depression on each shift. NP A ordered Resident #317's Oxycodone & Xanax 1 mg to be discontinued, Methocarbamol 750 mg decreased from three times daily to two times daily and a new order for Xanax 0.5 mg every 12 hours. An observation and interview on [DATE] at 11:40 AM revealed, Resident #317 lying on stomach in bed in no immediate distress. He said the previous day ([DATE]) when he was asleep his mother placed his prescriptions in his backpack because she did not know what to do with it. He said this morning ([DATE]) the facility staff tried to wake him up but he was not moving so they called 911. Resident #317 said he was informed that he had an opioid overdose. An observation on [DATE] at 12:03 PM revealed, a ziplock bag containing Resident #317's following home medications: - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 43 tablets remaining. - 1 bottle of Gabapentin 300 mg filled for 810 capsules with 3 capsules remaining. - 1 bottle of Gabapentin 800 mg filled for 180 tablets with 56 tablets remaining. - 1 bottle of Naproxen 500 mg filled for 180 tablets with 116 tablets remaining. - 1 bottle of Baclofen 20 mg filled for 180 tablets with 169 tablets remaining. - 1 bottle of Alprazolam/Xanax filled for 270 tablets with 197 tablets remaining. In an interview on [DATE] at 12:52 PM, RN C said on Saturday morning ([DATE]) during her hourly monitoring of residents she observed Resident #317 sitting in bed slumped over, unresponsive and slipping in and out of consciousness. She said he was breathing strange, would not wake up and was making gurgling/chocking sounds. RN C said she immediately placed him on oxygen, talked to him and tried to wake him which he could not so she made a judgement call to call 911. She said based on his symptoms she suspected he had a seizure/blood sugar or medication related overdose. Specifically to medications RN C knew the resident was on multiple pain medications like oxycodone/methadone/hydrocodone and Xanax/baclofen/methocarbamol. RN C said all these medications in unison can lead to respiratory depression and CNS depression. RN C A said the facility has Naloxone available to treat overdoses but she did not administer Naloxone to Resident #317. She said she was supposed to give Narcan immediately and call 911 but did not because there was just a lot going on. RN C said when 911 arrived she told them she suspected either a seizure or overdose and looking back she should have administered Narcan. After the resident left the DON said to check his belongings in case he took something and she found several bottles of medications including Gabapentin, and Ativan. She counted it all and gave it to the DON. RN C said failure to administer Naloxone in response to an opioid overdose is dangerous and the resident could experience increased slurred speech/difficulty breathing, lose consciousness, and it could lead to death. In an interview on [DATE] at 01:25 PM, the DON said signs and symptoms of opioid overdose included: shallow breathing and the resident being un-responsive. She said based on the information RN C provided about the incident Resident #317 showed symptoms of an opioid overdose. The DON said when a resident shows signs and symptoms of an opioid overdose the nurse must administer Naloxone, and RN C did not administer Naloxone to Resident #317. She said calling 911 was absolutely not an excuse for failure to render services during emergency situations. The DON said nursing staff was trained on the use of Naloxone at the end of 2022 when the facility started receiving Naloxone, and no training was performed after that. In an interview on [DATE] at 04:00 PM, NP A said Resident #317 suffered an overdose after consuming medications that the facility was unaware of. She said signs of overdose included respiratory distress and the facility had Naloxone on hand to treat overdoses. NP A said the expectation is that nurses call 911 and then administer Naloxone and failure to do could cause the resident worsening of condition and potential harm. In an interview on [DATE] at 09:27 AM, the DON said no training was performed on the emergency administration of Glucagon between CR #19's hospitalization on [DATE] and [DATE]. She said she was just focused on CR #19 being sent out to the hospital and not the failure to administer Glucagon. The DON said no training has been performed on opioid overdoses and the administration of Naloxone since Resident #317's overdose on [DATE] and the last training was performed in December of 2022. Record review of the facility in-service record titled 'Opioid Overdose dated [DATE] revealed, patients who are prescribed opioid medication receive the necessary care and services to avoid complications associated with opioid overdose by: ensuring appropriate monitoring and treatment as may be required utilizing opioid reversal agents such as Naloxone. RN C was noted in attendance as indicated by her name and signature. Record review of RN C's Nurse Proficiency Audit dated [DATE] completed by the DON revealed, RN C was assessed as satisfactory for skills which included: administering medication properly (Oral/IM/SQ), and knowledge of emergency procedures (CPR, Crash Cart/AED, Activate EMS). Proficiency in Glucagon and Naloxone administration were not assessed. On [DATE] at 11:00 AM, the Administrator and was notified of the Immediate Jeopardy (IJ) due to the above failures. The IJ template was provided and a plan of removal (POR) was requested at that time. The following plan of removal was approved on [DATE] at 11:34 AM and read: IJ Component: F726 Competent Nursing Staff: Facility failed to administer glucagon to CR#19 as ordered when identified with a BS of 62. Facility failed to send CR#19 out immediately following an acute change of condition. Facility failed to administer Naloxone to Resident #317 after the resident suffered from an overdose. Immediate Actions: CR#19 was transferred to the ER on [DATE] and did not readmit to the facility. Resident #317 was transferred to the ER on [DATE] at approximately 415am and readmitted to the facility on [DATE] at approximately 810am with diagnosis of Opioid Use and Anemia. Resident #317 was discharged home with home health services on [DATE]. Facility Plan to ensure compliance: 1. 100% review of all facility residents prescribed Glucagon completed by DON, ADON, and Regional Compliance Nurse on [DATE] to identify any other residents that did not receive prescriber ordered Glucagon for hypoglycemia. No other resident from audit identified as not receiving ordered Glucagon. 2. 100% assessment of all facility residents prescribed an opioid completed by DON, ADON, and Regional Compliance Nurse on [DATE] to assess for s/s of opioid overdose. No resident currently residing in the facility as of [DATE] identified from audit as having any s/s of opioid overdose. 3. Facility residents with a diagnosis of Diabetes Mellitus (DM) were audited on [DATE] to ensure all prescriptions were documented correctly. Audit revealed all residents with a diagnosis of DM with a prescription for treatment, either by mouth and/or with insulin orders, were transcribed correctly. 4. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on [DATE] regarding a. Abnormal Blood Sugar readings to include process for administering glucagon, when ordered, and process for treating an unresponsive resident. b. Change of Condition: When to Report to MD/NP/PA c. Conditions that require immediate transfer d. Signs and symptoms of Opioid Overdose e. How to use Narcan/Naloxone 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Abnormal Blood Sugar Readings to include the process for administering glucagon, when ordered, and the process for treating an unresponsive resident. Goal for completion of this education to be completed by end of day on [DATE]. 6. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on [DATE]. 7. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Conditions That Require Immediate Transfer. Goal for completion of this education to be completed by end of day on [DATE]. 8. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Signs/Symptoms of Opioid Overdose. Goal for completion of this education to be completed by end of day on [DATE]. 9. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting [DATE] regarding Narcan/Naloxone Administration. Goal for completion of this education to be completed by end of day on [DATE]. 10. Licensed nurses (LVN/RNs) will be tested to evaluate competency of the education/in-services initiated on [DATE]. Competency tests will be initiated on [DATE] upon completion of the education with goal for completion by end of day on [DATE]. 11. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to abnormal blood sugars or signs of opioid overdose in EMR (), the facility's electronic medical record (EMR). 12. All nurses (LVN/RNs) not in service on [DATE] will be in service prior to working their next scheduled shift. 13. The Medical Director, was notified by Administrator on [DATE] at 1:55pm on the immediate jeopardy citation. 14. An Ad-hoc QAPI meeting was held on [DATE] by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: Record review of the facility schedule revelaed, the facility had 2 nursing shifts 06:00 AM to 06:00 PM day shift and 06:00 PM to 06: 00 AM night shift. Monitoring involved interviews with both day shift and night shift staff. Interviews conducted on [DATE] from 11:20 AM to 11:40 AM revealed, LVN A, LVN B, RN B, and the ADON A received in-service training on the treatment of hypoglycemia, opioid overdose and immediate transfer to the hospital. The staff showed competency in the emergent treatment of hypoglycemia and immediate transfer to the hospital but were not competent in the administration of Naloxone. LVN A and LVN B did not know when to repeat Naloxone, RN B did not know the formulation of Naloxone used in the facility and where it could be located. An interview on [DATE] at 12:34 PM revealed, the DON did not know the formulation of naloxone used in the facility and did not know that Naloxone could be administered if a resident became unconscious after a previous dose was administered. An interview on [DATE] at 12:45 PM with the Regional Clinical Nurse revealed, the facility was not trained on the re-administration of Naloxone if a resident became unconscious after a previous dose was administered. He said the facility had just focused on training the staff to administer the first dose of Naloxone and then call 911. The Regional Clinical Nurse said nursing staff was not trained on readministering Naloxone and all staff would be trained appropriately. In an interview on [DATE] at 01:36 PM, the Regional Clinical Nurse said the DON and Administrator were re-trained on the administration of Naloxone and training of the nursing staff was ongoing. He said since the IJ was called the facility: - audited all residents with opioid prescriptions to ensure they had orders for PRN Naloxone - audited all blood sugars to ensure treatments were given for any abnormal values Interviews conducted on [DATE] from 05:28 AM to 06:27 AM revealed the following: - LVN B was re-trained in the administration of Naloxone showed competency in its administration. - RN A, RN C, LVN D, LVN G, LVN H, received training on treatment of hypoglycemia, immediate transfer to the hospital and opioid overdose. The staffed interviewed showed competency in the use of Glucagon for the treatment of hypoglycemia, resident symptoms that require immediate hospital transfer and the treatment of an opioid overdose using Naloxone. Record review completed on [DATE] revealed: - on [DATE] the [NAME] Clinical Nurse audited all resident's receiving opioids and reassessed them for s/s of opioid overdose and residents displayed any signs or symptoms - on [DATE] the DON reviewed all resident orders for Glucagon administration. - on [DATE] the DON completed a Nurse Proficiency Audit on RN C, she was found to be satisfactory. - on [DATE] a QAPI meeting was held regarding the IJ- the DON, Regional Clinical Nurse, Administrator were in attendance. - on [DATE] the facility trained the ADON, Administrator and DON were trained on change in conditions, conditions that require immediate transfer, signs and symptoms of opioid overdose and responding to an overdose - on [DATE] the facility completed training with nursing staff on: responding to an overdose how to give naloxone, signs/symptoms of opioid overdose, conditions that require immediate transfer, blood sugars: abnormal readings, change in conditions: when to report to the provider. The Nurses were assessed with a competency test and found satisfactory. - on [DATE] the Regional Clinical Nurse reviewed residents with Glucagon ordered and discontinued glucose gel if Glucagon was on order. - on [DATE] the Regional Clinical Nurse audited all residents with a diagnosis of diabetes to ensure they received appropriate treatment and all mediations were appropriate - on [DATE] at 1:00 PM ADON A, the DON and the Administrator were retrained on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose. - On [DATE] the facility retrained the following staff on the administration of Naloxone with emphasis of subsequent administration after a resident becomes unconscious or declines after an effective first dose: MDS Nurse A, RN A, LVN B, LVN A, RN C, LVN D The Administrator was informed the IJ was removed on [DATE] at 06:37 PM. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.