**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for five (LVN A, Medical Records Staff B, OTA C, OTA D, and OT E) out of ten staff reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure LVN A wore an N95, or equivalent, mask over her mouth and nose at all times when in quarantined rooms with residents positive for COVID-19, including while suctioning a COVID-19 positive resident, according to the facility's policy. 2. The facility failed to ensure LVN A and Medical Records Staff B utilized PPE appropriately to prevent cross contamination at all times when in quarantined rooms with residents positive for COVID-19, according to the facility's policy. 3. The facility failed to ensure OTA C, OTA D and OT E wore a mask over their noses and mouths at all times when they were around residents, according to the facility's policy. An IJ was identified on 11/29/23. The IJ template was provided to the facility on [DATE] at 2:50 PM. While the IJ was removed on 11/29/23, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on infection control and prevention. These failures placed residents at risk of exposure of COVID-19 virus which could result in serious illness, hospitalization, and/or death. Findings included: Observation of the facility's posted sign at the receptionist desk, dated 11/29/23, advised that masks were mandatory in the building. Record review of the facility's undated, untitled document stated Resident #1, Resident #2, Resident #3, and Resident #4 all tested positive for COVID-19 on 11/29/23. It also revealed Receptionist tested positive for COVID-19 on 11/2923. Record review of Resident #1's face sheet, dated 11/29/23, revealed a [AGE] year-old female, with a diagnoses of Schizophrenia (delusions and hallucinations), Asthma (chest tightness and breathing issues), Type 2 Diabetes (condition that affects the way the body processes sugar), Dementia (impaired ability to remember), and hyperlipidemia (high levels of fat in the blood). Record review of Resident #2's face sheet, dated 11/29/23, revealed an [AGE] year-old female, with a diagnoses of Asthma (chest tightness and breathing issues), Constipation (less frequent or no bowel movements), Heart Failure, Hypertension (high blood pressure), Dysphagia (difficulty swallowing), Metabolic Encephalopathy (brain issues caused by chemical imbalance), Type 2 Diabetes (condition that affects the way the body processes sugar), and Hyperlipidemia (high levels of fat in the blood). Observation and interview on 11/29/23 at 12:19 PM, revealed LVN A prepared to go into a quarantined room with Resident #1 and Resident #2, who were both positive for COVID-19. LVN A put on a gown and gloves. LVN A did not tie the gown around her body, and she did not put on a face shield. LVN A was observed as she entered the quarantined room with a surgical mask, which did not cover her nose. LVN A's nose was exposed while she was in the quarantined room with Resident #1 and Resident #2. LVN A was observed as she took Resident #2's vital signs. LVN A stated that Resident #2 needed oxygen, so LVN A disposed of her gown and gloves in the bathroom area of the quarantined room, washed her hands, then walked out of the room still wearing her surgical mask below her nose. LVN A was observed as she left the hot area (area where COVID-19 positive residents are housed) and into the main area near the main nurse's station and past a resident in a wheelchair. LVN A retrieved an oxygen tank and walked back passed the resident in the wheelchair and staff members at the nurse's station, back to the hot area. LVN A was observed as she put on a gown and gloves and returned to the quarantined room with her nose exposed from the surgical mask. Medical Records Staff B came to assist LVN A. Medical Records Staff B stated she was not a nurse, but she helped staff when they needed assistance. LVN A was observed as she walked toward the door of the quarantined room and passed a blood pressure wrist cuff to Medical Records Staff B. LVN A asked Medical Records Staff B to record the vitals that were on the blood pressure cuff. Medical Records Staff B took the blood pressure wrist cuff with no gloves on, sanitized the blood pressure cuff with a germicidal wipe, and did not sanitize her hands. Medical Records Staff B was later observed going into the quarantined room to assist LVN A. Medical Records Staff B was observed putting on a gown, gloves, as she entered the quarantined room. Medical Records Staff B had on an N95 mask, but the bottom strap was hanging below her chin. Medical Records Staff B was then observed she discarded her gown and gloves into the trash in the bathroom, which is where the staff stated they washed their hands, and left the quarantined room as she still wore the same N95 mask. Medical Records Staff B was observed as she walked back into the general area near the main nurse's station. LVN A was then observed stood in the doorway of the quarantined room. She spoke with Medical Records Staff B and DON. LVN A advised that she thought Resident #2 needed to go to the hospital. LVN A was observed as she went back into the quarantined room with the surgical mask pulled below her chin, not covering her nose or mouth. LVN A was observed as she pulled her cellphone out to call 911, while standing next to the COVID-19 positive resident. LVN A was also observed suctioning the mouth of the COVID-19 positive resident while wearing her surgical mask inappropriately. LVN A was observed discarding her gown and gloves into the bathroom, and as she came out the room. LVN A did not wash her hands or sanitize, before returning to her cart to put on lotion. LVN A was then observed as she returned to the quarantined room, to the bathroom, to wash her hands, with no PPE on. LVN A stated she was not only working in the 400, hot hall, but also working in the 200 hall during her shift. She stated she had been trained on how to properly wear her surgical mask to cover her nose and mouth. She stated she knew she should have had on the N95 mask when providing care to the COVID-19 positive residents. LVN A stated she felt it was an emergency and stated she knew the risks. She stated the risks of not wearing full PPE or her PPE correctly was passing COVID-19. In an interview on 11/29/23 at 12:51 PM, DON stated Resident #2 was not feeling well this morning, so that prompted them to test her for COVID-19. DON stated Resident #2 was normally up and in the dining hall, went to therapy, was in the resident council, and was usually all over the building. She stated they tested all residents and all staff. She stated there were four positive residents, and Receptionist was positive for COVID-19. She stated Receptionist was sent home to quarantine. Operations Manager stated the current policy was surgical masks in the general facility and with residents not positive with COVID-19, and N95 masks in the quarantined areas, around the positive residents. Operations Manager stated they notified their medical director and the local ombudsman this morning after the testing was completed. She stated they were in the process of doing a self-report to the state. DON stated they stated in-servicing the staff on PPE donning and doffing, current mask requirements, hand-washing, and overall infection control. DON stated LVN A and Medical Records Staff B should have worn all PPE or should have worn it correctly. In an interview on 11/29/23 at 1:20 PM, Medical Records Staff B stated a majority of the time she would assist the nurses, because she knew were all the supplies were in the building. She stated she was trained on how to properly wear a mask. She stated usually she would ensure she wore gloves, gown, mask, face shield, and shoe covers if they had shoe covers out in the quarantined areas. She stated she knew to discard the PPE before she left the quarantined area, and to wash her hands as well before she left the area. Medical Records Staff B stated she did not realize the bottom strap of her N95 mask was hanging under her chin. She stated she did not have a particular reason why she wore her mask with the strap hanging under her chin. Medical Records Staff B stated she did recall that she stepped into the quarantined room at one point with no gown on and stated she knew better. She stated she had not helped any other staff or residents prior to when she assisted LVN A. She stated the facility has plenty of PPE, and she had masks on her desk. She stated she did not think about moving her mask from her face when she left the quarantined area. Medical Records Staff B stated the Operations Manager had just mentioned to her that she should remove her N95 mask when she left the quarantined area. She stated she just took more N95 masks to the quarantined area. She stated the facility has a supply of face shields too, but she doe does not know why they were not available in the quarantined bins, or why she or LVN A did not wear a face shield. She stated the nurses were usually responsible for filling the quarantined bins, but the med techs and caregivers could do it as well. Medical Records Staff B stated the risk of her not wearing her N95 properly and not removing it when she left the quarantined area was a risk of passing COVID-19 to others or getting COVID-19 herself. Observation on 11/29/23 at 11:40 AM, revealed OTA C, OTA D, and OT E in the therapy gym, all not wearing a mask that covered their nose or mouths. There were 11 residents observed in the gym, and at least three within six feet of the three staff members. In an interview on 11/29/23 at 1:36 PM, OTA C stated she was finishing a shake at the time, and knew she was in close proximity to residents. She stated she was not sure if the staff were permitted to eat or drink around residents when COVID-19 was present in the building. She stated in the past she usually would not eat or drink in the room with residents when COVID-19 was in the building. OTA C stated the staff were informed at the beginning of their shift, around 8AM, that residents had tested positive for COVID-19, and the staff were told to wear masks. She stated the facility trained the staff on how to properly wear a mask, which was to go over your nose and to properly fit around your face. OTA C stated she knew the risk of not wearing a mask or wearing it properly was exposure to COVID-19. In an interview on 11/29/23 at 2:00 PM, OTA D stated he took his mask off in the gym, because he had trouble breathing. He stated he was aware there were residents in the room and behind him. He stated he was told today to start wearing masks again. He stated he was informed that if he was working with a COVID-19 positive residents, to wear an N95 mask, and if he was in the general area with residents, to wear a surgical mask. He stated he was told he had to wear full PPE if he went on the COVID-19 hall. OTA D stated he had COVID-19 at the beginning of this month, November 2023. He stated the proper way to wear a mask is to cover your nose and mouth and press it down to ensure it's sealed. He stated the risk of not wearing a mask or wearing it properly was he could get COVID-19 or give it to a patient. In an interview on 11/29/23 at 2:25 PM, OT E stated the facility trained her on the proper way to wear PPE. She stated the proper way to wear a mask was to ensure it covered your nose, ensure you could not feel any air around it, and to ensure it was properly fitted around your ears. She stated today the staff were advised to wear masks. OT E stated she was claustrophobic, so if she was not in direct contact with a resident, she did not wear her mask. She stated if she was around a resident that is positive for COVID-19, she would wear an N95, but if the resident was not positive, she would wear a surgical mask. She stated she was aware her nose was exposed. OT E stated the risk of not wearing your mask or not wearing it properly was to catch COVID-19 or give it to the next person. Record review of the facility's undated policy titled, Emerging Infectious Disease: Coronavirus Disease 2019 (COVID-19), revealed the following: It is the policy of this facility implement recommended appropriate infection control strategies, guidance and standards from the local, state and federal agencies, for an EID event. It is further the policy to include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. Infection Prevention and Control for EID: Personal Protective Equipment and Supply: PPE may include facemasks, N-95 or higher-level respirators, gowns, gloves, and eye protection (i.e. face shield or goggles) Managing Residents with Suspected or Confirmed SARS-CoV-2 Infection Residents with suspected or confirmed SARS-CoV-2 do not need to be placed in an airborne infection isolation room but should be cared for using an N95 or higher-level respirator, eye protection (i.e. goggles or a face shield that covers the front and sides of the face.), gloves, and gown. Record review of the facilities posted sign, dated 11/29/23, advised that masks were mandatory in the building. The same sign was posted at the receptionist desk. Record review of the facilities In-Service, dated 11/29/23, and titled In-service Training Report, revealed the following: Department: Therapy Topic: Masks, Infection Control, Hand-washing Contents or summary of training: Masks need to be worn at all times over nose and mouth. Handwashing between residents must be performed. Staff cannot eat/drink with residents in the gym. Staff must utilize breakroom on 300 hall. The Administrator was notified on 11/29/23 at 2:35 PM that an Immediate Jeopardy was identified due to the above failures. The Administrator was provided the IJ template on 11/29/23 at 2:50 PM. The facility's plan of removal was accepted on 11/29/23 at 5:19 PM and included the following: [Facility Name] Plan of Removal Version 2 F880 Infection Control Per the information provided in the IJ Template given on 11/29/23, the facility failed to ensure all staff properly donned and doffed PPE when leaving and entering the COVID rooms. Currently there are 3 COVID rooms. Immediate Action 1. The Medical Director was notified of IJ on 11/29/23 at 3:00pm. 2. LVN, Medical Records Clerk, and Therapy Staff observed by surveyor were in-serviced immediately. The DON and Cluster Partner in-serviced these staff on masking, donning/doffing PPE, outbreak procedures, and handwashing. 3. Training and competency on donning and doffing PPE, handwashing, and outbreak procedures will be completed with all staff. This training was initiated on 11/29/2023 and will be completed by 11 / 30/ 2023. The training includes masking, donning/doffing PPE, procedures for outbreak and hand washing and will be provided by the DON, ADON, Clinical Resources, Cluster Partners, Rehab Director, and Operations Manager. Train the trainer in-service was given by the Clinical Resource and was completed with DON, ADONs, Cluster Partner, Rehab Director and Operations Manager. 4. This training will be completed in-person with all staff prior to the start of their next shift. A member of management will be at the facility at each change of shift to ensure all get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency/PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received their training and competency. 5. An ad hoc meeting regarding items in the IJ template will be completed on 11/29/2023. Attendees will include the DON, Medical Director, Infection Preventionist/ADON, Clinical Resource, Ops Manager, Clinical Resources and will include the plan of removal items and interventions. 6. The DON, ADON or Clinical Resource will verify staff competency with 10 staff weekly using the PPE and handwashing competency checklists. This will be completed weekly after the initial training and competency began on 11/29/23 and are completed by 11/30/2023. 7. COVID positive residents will be reviewed during the weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to the DON, ADON, Rehab Director and Ops Manager. The DON and Ops Manager will be responsible for ensuring this meeting is held weekly and COVID positive residents are reviewed. This meeting will begin 11/29/2023. 8. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring: In an interview on 11/29/23 at 5:24 PM, Med Tech F stated she was told there was positive COVID-19 residents when she entered the facility for her shift this morning. She stated the receptionist told her to wear a mask. Med Tech F stated she was provided an N95 mask and was told to wear it for the entire shift. She stated she received an in-service over COVID-19, infection control, how to properly wear a mask, and received a COVID-19 test when she arrived. She stated the facility had enough PPE supplies. In an interview on 11/29/23 at 5:31 PM, Nurse G stated the facility had a good supply of PPE. Nurse G stated she was in-serviced today, when she arrived at 2 PM. She stated the in-service was over PPE, how to properly wear masks, handwashing, infection control, and COVID-19. In an observation on 11/29/23 at 5: 45 PM, Nurse G was observed as she donned gloves, gown, N95 mask, and face shield before she entered the quarantined room. She was observed as she assisted Resident #3. She was observed as she doffed all PPE, washed her hands, and exited the quarantined room. Nurse G was observed as she sanitized her hands after leaving the quarantined room and observed as she put on another mask. In an interview on 11/29/23 at 5:54 PM, Med Tech H stated the facility had plenty of PPE supplies. She stated the facility informed her today some residents tested positive for COVID-19, early this morning before or around 8 AM. She stated the staff were told to wear N95 masks. She stated they were told to wear N95 masks if they went into the COVID-19 rooms, and they could wear surgical masks if they were not in that area or around positive residents. She stated she received a COVID-19 test this morning, and it was negative. She stated she was in-serviced today on infection control, COVID-19, PPE donning and doffing, which PPE to wear around COVID-19 positive residents, which was masks, gloves, gown, face shield, and shoe covers if they had them. She stated she was trained on how to properly wear a mask, which was the mask was supposed to cover your nose and mouth. In an interview on 11/29/23 at 6:01 PM, ADON stated she had been the ADON and facility preventionist for 13 days. She stated she was one of the facilitators for the in-services completed today. She stated DON in-serviced her on infection control, donning and doffing PPE, COVID-19, handwashing, and how to properly wear a mask. She stated all positive residents would be moved to the COVID-19 hall. She stated they did not have dedicated staff for the COVID-19 positive residents, because there was a small amount of positive residents. She stated the staff cared for non-positive residents as well. ADON stated the facility will do follow-up COVID-19 tests on residents and staff on day 3 and day 5. She stated if people still tested positive for COVID-19, then the cycle would start over again. ADON stated the risk of not wearing the PPE appropriately would be infection control, staff could he get COVID-19, then the residents, or vice versa. She stated different residents had different health issues and catching COVID-19 could make those residents worse. In an interview on 11/29/23 at 6:15 PM, DON stated she had been DON since September 2023. She stated the facility in-serviced the staff that were present today. She stated she was in-serviced by the Clinical Resources Director. She stated the in-service went over donning and doffing PPE, masks, handwashing, N95 masks which should be worn around positive residents/surgical masks for the other residents, and infection control in general. DON stated the residents and one staff member just tested positive for COVID-19 today. She stated they did not have dedicated staff for the COVID-19 hall. DON stated the facility went over the risks during the in-service, and the main risk was getting COVID-19. DON stated you do not want to get infected or infect someone else. In an interview on 11/29/23 at 6:19 PM, Operations Manager stated she had been the Operations Manager since July 2023. She stated the facility's Administrator, was out on leave, and she covered his position. She stated in-services were completed on staff today, and she was in-serviced by DON. She stated the in-service covered donning and doffing PPE, how to properly wear a mask, hand hygiene, COVID-19, and infection control and prevention. She stated the facility's policy is to test staff and residents on day 1, 3, and 5. She stated all staff should keep masks on for 14 days. She stated if the facility had no positive cases on day 14, then on day 15 the mask requirement would be removed. Operations Manager stated if there were still positive cases on day 14, then the mask requirement would be extended another 14 days. She stated the risk of not wearing PPE appropriately was exposure to COVID-19. Record review on 11/29/23 of the following: In-Service dated 11/29/23, titled, In-service Training Report, and Subject was Infection Control, PPE, Masking, Outbreak, Testing. In-Service dated 11/29/23, titled, In-service Training Report, and Subject was, Donning/Doffing PPE. In-Service dated 11/29/23, titled, In-service Training Report, and Subject was, COVID-19 Positive/Symptoms, Resident and Staff Handwashing. Record review of COVID-19 Vaccination verification for Receptionist, LVN A, Medical Records Staff B, Resident #3, Resident #1, Resident #2, and Resident #4. All had received two COVID-19 vaccinations. Record review of Suspension document and in-service for LVN A, dated 11/29/23 On 11/29/23, Operations Manager was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for one (Resident #1) of 5 resident reviewed for changes in condition. The facility failed to notify the physician when the resident began having seizures and required hospitalizations on 12/03/22, 12/04/22 through 12/08/22, and 12/12/22 through 12/23/22 as evidence of the failure to monitor diagnostic lab work and to follow the pharmacy's recommendation to obtain orders for lab levels. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/20/2023 at 4:40 p.m. The IJ was removed on 1/21/2023 at 3:50 P.M. While the IJ was removed on 01/21/23, the facility remained out of compliance at a scope of a pattern and actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving adequate care and treatment, hospitalizations, and possible death. Findings included: Record review of Resident #1's Face Sheet dated 1/19/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 12/23/2022. Resident #1's diagnoses included, unspecified convulsions, status epilepticus (seizure that lasts too long or when seizures occur close together and the person doesn't recover between seizures), diabetes, muscle weakness, reduced mobility, high blood pressure, heart disease, arthritis, and anemia (lack of enough healthy red blood cells to carry adequate oxygen to body's tissues). Record review of Resident #1's MDS dated [DATE] reflected a reentry date of 12/23/2022 from an acute (sudden) hospital stay. The MDS noted the date the episode for transfer to hospital began was on 12/08/2022. Resident #1's BIMS score was an 11 , which indicated moderate cognitive impairment per brief interview for mental status. Resident #1 required extensive physical assist with bed mobility, transfer between surfaces, dressing, toilet use, personal hygiene, locomotion on and off the unit using a wheelchair as a mobility device and only able to stabilize with staff assistance. Resident #1 had no behavioral symptoms during the MDS review period. Record review of Resident #1's Care Plan dated 12/28/2022 indicated she had a seizure disorder, and the goal was to help her remain free from injury related to seizure activity and reflected an additional goal to maintain lab values within a therapeutic range. Resident #1's care planned interventions indicated the following: -give the medications as ordered. Monitor and document for effectiveness and side effects. -monitor labs and report any sub therapeutic or toxic results to the MD. -obtain and monitor lab/diagnostic work as ordered. Report results to the MD as follow up as indicated. Interview on 1/19/23 at 10:00 am with Resident #1's family member, she said Resident #1 had not had any seizures for many years, and said she recently had three visits to the hospital in December 2022 after having seizures. She thinks the cause for the re occurrences of the seizures is due to facility nurses not giving Resident #1's antiseizure medications correctly and the resident told her the nurses were not giving her the medications as prescribed and skipping giving her doses. Resident #1's family member said that she was told by MDs at the hospital that the cause for the new onset seizure activity may have been due to labs not being drawn in a constant manner, and the medication not being provided as prescribed. Resident #1's family member said she was also told by the hospital MD's Resident #1's antiseizure medication levels were low and that is why she was having seizure, and that is the reason Resident #1's family member called the State Health and Human services to complain about the resident's care, and to have someone come out and investigate the facility. Interview on 1/19/23 at 10:15 am with Resident #1, the resident was in bed and revealed she was upset for the last three visits to the hospital emergency room because she started having seizure again. Resident #1 was teary and gloomy, saying she had lived in the facility for about 13 years and for many of those years she had not experienced seizures. Resident #1 said that maybe the seizures began because the nursing staff would take long bringing her morning and evening medications, and said she thought they did not give her some of the doses. Review of Resident #1's Clinical Physician's Orders, dated 12/01/2022 reflected the resident had orders for antiseizure medications as follows: -Carbamazepine tablet 200 mg, give 1 tablet by mouth before meals for seizures, order date was 6/29/2022 -Dilantin capsule, five 200 mg, give by mouth two times as day related to epilepsy, order date was 6/29/2022 -Levetiracetam tablet 1000 mg, give 1 tablet by mouth two times a day for seizures related to epilepsy, order date was 7/06/2022. -Resident #1's Clinical Physician Orders did not include instructions for antiseizure medication lab draws. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 7/01/2022 through 7/18/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON, she signed off by adding a notation completed. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 10/01/2022 through 10/17/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 12/01/2022 through 12/12/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON and she added the labs were ordered but Resident #1 had been sent to the hospital. Record review of Resident #1s Progress Note written by ADON I dated 12/03/2022 at reflected Resident #1 was in bed and ADON I documented an observation of the resident having some confusion, complaining of headache, and did not note the resident having a seizure. ADON I documented Resident #1 stated she felt like she was going to have a seizure and called 911 per Resident #1's request. The note reflected the resident was transferred to the emergency room, and ADON I called and notified the NP. Record review of Resident #1's emergency room stay on 12/03/2022 reflected she was discharged back to the nursing facility on 12/03/22with seizure discharge instructions and to follow up with the hospital in 3 days if symptoms worsened. The record reflected for Resident #1 to follow up with a neurologist in 1 week, the name, phone number and address were provided on the discharge paperwork, and according to DON the neurologist appointment was not made because of Resident #1 until 12/27/22 due to Resident #1's numerous hospitalizations. The record reflected the reason for the emergency department visit was due to seizures. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Tests Completed reflected in part some of the lab's levels that were during the visit included, Carbamazepine and Phenytoin. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Results reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *) and Phenytoin level at 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Medications given reflected the resident received AED medications and none of the doses had been changed. Record review of Resident #1's emergency room discharge instructions dated 12/03/2022 reflected there were no upcoming doctor appointments scheduled, and to continue with the same medication regimen she was currently taking at the NH. During an interview on 1/19/2023 at 12:48 p.m. with ADON I, she said Resident #1 came back after midnight on 12/4/2022. ADON I stated the NP had ordered AED labs to be drawn on 12/04/22 but had not been drawn due to Resident #1's request to be sent back to the emergency department on 12/04/22. ADON I denied knowing the recommendations by the pharmacy consultant for therapeutic lab values were drawn prior to the emergency room visit and said and said she had not reviewed the hospital discharge instructions and when a resident was readmitted to the facility after a hospital stay it was the nursing administration teams responsibility to go over the records and implement any appointments or new orders. Record review of Resident #1s Progress Note written by ADON I and dated 12/04/2022 reflected Resident #1's family member told her she wanted Resident #1 to be sent out to the hospital be reassessed for seizures. ADON I wrote she observed Resident #1 in her room having a seizure lasting about 60 seconds, and when the seizure became less intense and ended, the patient returned to normal. ADON I called EMS who came to transfer Resident #1 to the hospital, and ADON I documented that the resident was observed to continue being disoriented on exit. During an interview on 1/19/2023 at 1:35 p.m. with ADON I, she said Resident #1's family member was in the room dressing her on 12/03/22 when the family member called out to say Resident #1 got hot and began perspiring,, the ADON I came into the room, and Resident #1 had calmed down, but the resident was looking at the ADON with a blank stare and not moving. ADON I said she thought Resident #1 was having a seizure, and she said, Once she came out of it, she was confused and called 911 for transport to the hospital. ADON I said Resident #1's family member told her Resident #1 had not had a seizure for 30 years. The ADON stated the recent seizure activity was out of the norm for Resident #1. ADON I said she notified the resident's NP regarding the hospital transfer. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on [DATE] for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on [DATE] for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled Physical Exam Review of Systems (review of systems is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing) referenced Resident #1 was unable to be reviewed because she had a mental status change that prevented her from answering medical questions. Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.7 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Final Diagnoses reflected an admission diagnose of altered mental status, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Hospital Medicine admission History and Physical: Resident #1 reflected a chief complaint of altered mental status and weakness symptoms, and review of systems were noted to have lack of energy, headache, and confusion. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Assessment & Plan Active Problems: # Seizure disorder, Continue Keppra 1000 mg BID, Phenytoin 200 mg BID, Carbamazepine 200 mg TID, Neurology referral on discharge. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Neurology Inpatient Consult, Reason for Consult: seizure an assessment note reflected the neurologist thoughts of Resident #1's seizure activity saying it was odd that she began having seizure lately after 37 years without having any and said he would adjust the carbamazepine medication dosage. Record review of Resident #1's hospital admission record dated 12/06/2022 titled HMD attending attestation #AMS #Breakthrough Seizure reflected the doctor said the resident was seen by a neurologist who attested that her primary diagnosis was refractory seizure (medications are not controlling seizure activity), and AEDs were adjusted. Record review of Resident #1's hospital admission record dated 12/06/2023 titled Labs reflected a lab value reading for Phenytoin Free level (the measurement of free phenytoin level is necessary to properly evaluate the phenytoin level than that calculated from total phenytoin level) was 0.6 ug/mL (*normal reference range is 1.0 - 2.5 ug/mL). Record review of Resident #1's hospital admission record dated 12/07/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation reflected the hospital doctor wrote the resident was stable enough for discharge and stated Resident #1's AEDs had been adjusted. Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Reason for hospitalization reflected the hospital doctor wrote the resident had a seizure in route to the hospital on [DATE] that lasted 1 minute and was administered 5 g of versed (relaxant). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Hospital Course / Summary reflected the hospital doctor stated neurology had adjusted the resident's carbamazepine to carbamazepine extended release and would now be taking the medication twice a day instead of three times a day and increased the dose to 400 mg BID from the previous dose which was 200 mg TID. The doctor stated Resident #1 had expressed concerns about her medical care in the NH, she wrote in part, she does not feel she is being taken care of properly there and Patient is agreeable to return to it for now and give her daughter and son time to pick out an alternative option. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Discharge Medications: Medication list, STOP taking these medications, reflected Carbamazepine 200 mg tablet, commonly known as: Tegretol, Replaced by: Carbamazepine 400 mg 12 hr tablet. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Patient Instructions reflected the resident had been evaluated at the hospital for breakthrough seizure activity and listed instructions noting the change in carbamazepine dosage and to take as prescribed to prevent future seizure activity. Record review of Resident #1's progress note written by ADON I on 12/12/2022 at 1:53 p.m., reflected the resident was disoriented and not responding to questions, just mumbling, the NP was notified, and Resident #1's family member was also contacted. Record review of Resident #1's progress note dated 12/12/2022 at 3:10 p.m. described Resident #1's family member's concerns and requested for Resident #1's transfer to the emergency department for further evaluation and treatment. ADON I called 911, she described Resident #1 was talking incoherently and not answering questions appropriately and noted notifying the NP and DON. Record review of Resident #1's emergency room admission record dated 12/12/2022 titled ED Provider Note, Date of Service 12/12/22, Chief Complaint reflected the patient presented with seizures. The record states the resident had a recent admission to the hospital earlier this month, no date was given, for altered mental status, she was seen by Neurology who adjusted her antiepileptic drugs. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022titled Medical Decision Making, Mon [DATE] stated, Patient here with seizure today, phenytoin level subtherapeutic. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Final Diagnoses reflected Seizure, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure noted AED levels for Phenytoin(7.7), Carbamazepine(3.2), and Levetiracetam(43.4). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.7 (*normal reference range is 10.2 - 20.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Hospital Medicine admission History and Physical: Resident #1 reflected a chief complaint of seizure- like activity. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure and reflected admitted here 12/04-12/08 after breakthrough seizure on 12/03 due to medication non-compliance as patient lives in a NH and reports her medications are often not given as scheduled. The record states neurology increased carbamazepine dosing from 200 mg TID to ER 400 mg BID and added, Please consult neurology in AM. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/15/2022 titled Neurology Inpatient Consult, Reason for Consult: Recommendations for AED selection/dosing reflected Phenytoin level on 12/12/2022 was 7.7, Carbamazepine level on 12/12/2022 was 3.2, and Levetiracetam level on 12/12/2022 was 43.4. The document stated Resident #1's Home AEDs were Keppra 1000 mg BID, Carbamazepine XR, 400 mg BID, and Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/15/2022 under the Neurology Inpatient Consult titled Assessment & Plan, Impression reflected the neurologist concern for the recent presentation of Resident #1's breakthrough seizure activity, writing the likely cause for the occurrences could be due to medication non-adherence and recent check of AED levels that were low. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.4 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/23/2022 titled Hospital Medicine Discharge Summary reflected a discharge diagnosis of active problems were seizures. The neurologist recommended continuation of Keppra 1000 mg BID, switched Carbamazepine XR 400 mg BID back to 200 mg TID, and said to continue Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/23/2022 titled Discharge Medications: CHANGE how you take these medications reflected the antiseizure medication Keppra's dosage had been changed from 1000 mg BID to 1500 mg BID. During an interview on 1/19/2023 at 2:00 p.m. with the DON, stated she contacted Resident #1's NP for the change in condition instead of her PCP because at times it was hard to get a hold of the PCP. She said the documentation entered by her on 12/0 The DON she was aware of Resident #1's altered mental state and was told by ADON I, Resident #1 was transferred to the hospital. The DON said she did not speak to Resident #1's PCP because the NP was providing the care. The DON said she did not consider consulting with the Medical Director because she felt the NP was caring for Resident #1's correctly, saying the situation did not warrant a consult for additional interventions for the care of the current significant change in Resident #1's condition. The DON stated it was not normal for Resident #1 to be sent out to the hospital 3 times in December 2022, and said the resident was sent out the first time was the only time it was for seizure activity. The DON said the other 2 hospital visits were not for epileptic seizures, and that Resident #1 was sent out due to satisfy Resident #1's family wishes. The DON said she did review all 3 hospital records but did not pursue trying to get Resident #1's lab values taken during the stays. The DON said the NP reviewed the hospital discharge instructions on 1/10/22, after a visit with Resident #1, and was told by the NP that there were no new orders, and to was told by the NP to continue observe the resident for seizure activity. During an interview on 1/19/2023 at 6:22 pm with Resident #1's NP revealed she was aware of the hospitalizations that occurred during December 2022 and stated she did not inform the PCP regarding the seizures, because she was an independent practitioner and could order treatments and medications for Resident #1 medical care. The NP said she was not aware there weren't any AES labs ordered to verify antiseizure medication levels for Resident #1, saying that she had cared for the resident for many years and knew there used to be an order for the lab draws in the past and admitted not checking the orders lately. She said the orders that were once place in paper health records could have been missed, dropped off and not carried over into the new electronic system currently in use. The NP said it was a team effort by nursing staff and practitioners to catch those types of mistakes, she relied on the nursing staff to keep her informed and ask for orders. The NP said the antiseizure medication levels should be monitored for therapeutic levels in the body to rule out toxicity side effects and could say why she had not reentered lab orders. She denied being informed of any abnormal antiseizure medication levels in the past, and said she ordered some labs to be drawn on 1/08/2022, checking the results when she came into the facility on 1/10/2022 for a visit with Resident #1, and reported the decision to nursing staff to continue with the current antiseizure medication regimen and not add any new orders. The NP stated she no longer would be in charge of Resident #1's health care and had stopped last week and could not say when the last day was before signing off as Resident #1's NP. The NP said the decision to sign off on the care was due to Resident #1's newly assigned PCP who had their own NP on board. Record review of Resident #1's clinical results electronic documentation dated from 7/11/2022 through 1/19/2023, reflected only one lab draw was ordered on 1/06/23 for therapeutic levels for Resident #1's antiseizure medications. Record review of Resident #1's laboratory results dated [DATE], reflected an abnormal level for antiseizure medication Carbamazepine, result read <2.0 L ug/mL, and a normal reference range of 4.0- 12.0. Another antiseizure medication laboratory report for Dilantin medication resulted at 4.0 ug/mL with a normal reference range of 10.0 -20.0 flagged as low. During an interview on 1/19/2022 at 6:30 p.m. with the DON, she was asked who was currently in charge of Resident #1's care, she said the NP, and was not aware the NP had discharged herself from taking care of Resident #1's health care. The DON said she was not aware of the change. She could not say who was currently overseeing Resident #1's health care. During an interview on 1/19/2022 at 7 p.m. with the Facility Medical Director, he said Resident #1's former PCP had been terminated from the care for the resident on 12/31/22, and he believed it was because the PCP was not coming to the facility to care for her patients. The Medical Director claimed he was unaware of Resident #1's December 2022 hospitalizations, and stated he was not familiar with the resident at all, saying that she was not his patient and therefore would not know of her or her recent seizure activity. He was asked what the protocol was for the care of residents who had a diagnosis of epilepsy that were admitted to the facility, and he said, initial labs need to be ordered to assess whether the residents are experiencing therapeutic levels of ordered antiseizure medications. Then he said, for normal levels, he stated ordering labs should be paced and drawn every 3 months. The Medical Director explained if the antiseizure medication level are abnormal, the practice is to order the labs to be drawn every week until the levels are therapeutic and then they are ordered once a month for 6 months, with instructions for close monitoring of seizure activity symptoms. The Medical Director stated he expects the nursing staff to observe for toxicity signs and symptoms, confusion, body jerking movements, and fainting, the nursing staff should alert the MD immediately for intervention orders. He said if a resident goes on having seizures and there are no interventions ordered, the residents could be affected with status epilepticus which is a common form of emergency situation that can occur with prolonged or repeated seizure activity, causing convulsions and possibly death. During an interview on 1/19/2022 at 7:15 p.m. with Resident #1's new PCP, she denied knowing Resident #1'shad been recently hospitalized three different times in December 2022 for new onset seizure activity. The new PCP mentioned t she had just been given the assignment to take over Resident #1 's care the week of 1/09/22and had not been to the facility to assess Resident #1 , adding she would be coming next week to perform a thorough history and physical. The new PCP said her process for care of an admitted epileptic resident taking antiseizure medications was to order the nursing staff to monitor for symptoms of seizures including toxicity, and notifying the MD with concerns, and abnormal lab values. She stated when she takes over the care of a new resident, she will order labs to find out the current base line of the medication levels. She stated if they are abnormal, she will change dosages to antiseizure medications and check blood levels in one week until the drugs reached the proper therapeutic level in a person. She stated after reaching the normal level she will order antiseizure medication levels once a month until she was assured the person medication blood levers were safe. The new PCP stated after that she orders the labs to be drawn every 6 months. The newly assigned PCP said she checks the labs each time she comes to visit the resident, once a week, and expects the nurses to call her any time with any changes. The new PCP said the outcome for residents not being properly monitored after having a new onset of seizures is that they can end up in unnecessarily the hospital with longer and stronger seizure activity. During an interview on 1/20/2022 at 1:20 p.m. with the Administrator revealed Resident #1's PCP had been, pulling away from the facility, and he was asked to clarify pulling away. He stated the PCP was not rounding with her residents as much as needed. The Administrator was asked if the PCP had been fired from caring for Resident #1, and he stated that was not true, and that he had not fired her. The Administrator was told the Medical Director had mentioned the facility had fired the PCP, and he said he did not know Resident #1, her situation of rehospitalizations because he said, she is not my patient. The Administrator stated that indeed the Medical Director knew Resident #1, and that he would advise the Medical Director the PCP had not been fired from Resident #1's care, he added that the reason the Medical Director had said he did not know the resident may have happened because The Medical Director did not directly provide care for Resident #1. The Administrator said, due to the prior PCP, pulling away from her residents, he decided to approach the PCP in November 2022 to ask her if she accepted help to lessen her resident load, by asking some of her current residents if they wanted a new MD, and said she agreed to release whoever requested another practitioner. The Administrator said a total of 5 residents agreed with the suggestion to receive care from a new MD. He said the last time the PCP saw Resident #1 was on 1/06/2023. The Administrator was asked if he was aware of the NP's allegation that she was no longer caring for Resident #1, stating she had resigned from Resident #1's care earlier that week, and denied knowing the NP had stopped care. He was asked who was currently in charge of Resident #1's care and he said, That is a good question and added, I will need to find out. The Administrator was asked whether nursing had notified him of a change of condition for Resident #1's health status and he said the DON did the first time the resident went out the hospital in December 2022. He stated that Resident #1's change in condition was brought up several times in December 2022, discussed by an interdisciplinary weekly resident meeting, and during the meeting it was deemed she had a significant change in condition from her normal state, stating he was informed the resident became confused, and had a seizure on 12/03/22. The Administrator said he leads the meetings, and he expects nursing staff to follow up with physicians to discuss health interventions, such as new orders, treatments, or labs to determine the cause for the [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and included adequate monitoring for high-risk medications for 1 (Resident #1) of 5 residents reviewed for antiseizure medications. The facility failed to Monitor Resident #1 antiseizure medications therapeutic blood levels. -Resident #1 was transferred to the hospital three different times in the month of December 2022 because the DON deemed the transfer to the emergency room was necessary due to unstable symptoms of altered mental status. The facility failed to follow up on the pharmacist consult recommended antiseizure medication interaction to ensure therapeutic medication labs were ordered and uploaded to Resident #1's medical record. The facility failed to inform the attending physician of antiseizure medication interventions recommended by the pharmacist to safely manage Resident #1's epileptic diagnosis. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/20/2023 at 4:40 p.m. The IJ was removed on 1/21/2023 at 3:50 P.M. The facility remained out of compliance at a scope of a pattern and actual harm with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents receiving psychotropic medications at risk for adverse side effects and consequences, including altered mental status, a decreased quality of life, a change in condition, and death. Findings included: Record review of Resident #1's Face Sheet dated 1/19/2023 indicated she was a [AGE] year-old female admitted to the facility on [DATE], with a recent readmission date of 12/23/2022. Resident #1's diagnoses included, unspecified convulsions, status epilepticus (seizure that lasts too long or when seizures occur close together and the person doesn't recover between seizures), diabetes, muscle weakness, reduced mobility, high blood pressure, heart disease, arthritis, and anemia (lack of enough healthy red blood cells to carry adequate oxygen to body's tissues). Record review of Resident #1's MDS dated [DATE] reflected a reentry date of 12/23/2022 from an acute (sudden) hospital stay. The MDS noted the date the episode for transfer to hospital began was on 12/08/2022. Resident #1's BIMS score was an 11 , which indicated moderate cognitive impairment per brief interview for mental status. Resident #1 required extensive physical assist with bed mobility, transfer between surfaces, dressing, toilet use, personal hygiene, locomotion on and off the unit using a wheelchair as a mobility device and only able to stabilize with staff assistance. Resident #1 had no behavioral symptoms during the MDS review period. Record review of Resident #1's Care Plan dated 12/28/2022 indicated she had a seizure disorder, and the goal was to help her remain free from injury related to seizure activity and reflected an additional goal to maintain lab values within a therapeutic range. Resident #1's care planned interventions indicated the following: -give the medications as ordered. Monitor and document for effectiveness and side effects. -monitor labs and report any sub therapeutic or toxic results to the MD. -obtain and monitor lab/diagnostic work as ordered. Report results to the MD as follow up as indicated. Interview on 1/19/23 at 10:00 am with Resident #1's family member, she said Resident #1 had not had any seizures for many years, and said she recently had three visits to the hospital in December 2022 after having seizures. She thinks the cause for the re occurrences of the seizures is due to facility nurses not giving Resident #1's antiseizure medications correctly and the resident told her the nurses were not giving her the medications as prescribed and skipping giving her doses. Resident #1's family member said that she was told by MDs at the hospital that the cause for the new onset seizure activity may have been due to labs not being drawn in a constant manner, and the medication not being provided as prescribed. Resident #1's family member said she was also told by the hospital MD's Resident #1's antiseizure medication levels were low and that is why she was having seizure, and that is the reason Resident #1's family member called the State Health and Human services to complain about the resident's care, and to have someone come out and investigate the facility. Interview on 1/19/23 at 10:15 am with Resident #1, the resident was in bed and revealed she was upset for the last three visits to the hospital emergency room because she started having seizure again. Resident #1 was teary and gloomy, saying she had lived in the facility for about 13 years and for many of those years she had not experienced seizures. Resident #1 said that maybe the seizures began because the nursing staff would take long bringing her morning and evening medications, and said she thought they did not give her some of the doses. Review of Resident #1's Clinical Physician's Orders, dated 12/01/2022 reflected the resident had orders for antiseizure medications as follows: -Carbamazepine tablet 200 mg, give 1 tablet by mouth before meals for seizures, order date was 6/29/2022 -Dilantin capsule, five 200 mg, give by mouth two times as day related to epilepsy, order date was 6/29/2022 -Levetiracetam tablet 1000 mg, give 1 tablet by mouth two times a day for seizures related to epilepsy, order date was 7/06/2022. -Resident #1's Clinical Physician Orders did not include instructions for antiseizure medication lab draws. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 7/01/2022 through 7/18/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON, she signed off by adding a notation completed. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 10/01/2022 through 10/17/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON. Record review of Resident #1's Consultant Pharmacist's Medication Regimen Review document dated 12/01/2022 through 12/12/2022 reflected a pharmacist's recommendation to check Dilantin and Carbamazepine blood levels, suggested to ensure lab result levels were current in Resident #1's electronic medical record for review for AED medications Dilantin and Carbamazepine, the suggestion was signed off by the DON and she added the labs were ordered but Resident #1 had been sent to the hospital. Record review of Resident #1s Progress Note written by ADON I dated 12/03/2022 at reflected Resident #1 was in bed and ADON I documented an observation of the resident having some confusion, complaining of headache, and did not note the resident having a seizure. ADON I documented Resident #1 stated she felt like she was going to have a seizure and called 911 per Resident #1's request. The note reflected the resident was transferred to the emergency room, and ADON I called and notified the NP. Record review of Resident #1's emergency room stay on 12/03/2022 reflected she was discharged back to the nursing facility on 12/03/22with seizure discharge instructions and to follow up with the hospital in 3 days if symptoms worsened. The record reflected for Resident #1 to follow up with a neurologist in 1 week, the name, phone number and address were provided on the discharge paperwork, and according to DON the neurologist appointment was not made because of Resident #1 until 12/27/22 due to Resident #1's numerous hospitalizations. The record reflected the reason for the emergency department visit was due to seizures. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Tests Completed reflected in part some of the lab's levels that were during the visit included, Carbamazepine and Phenytoin. Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Lab Results reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *) and Phenytoin level at 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency room admission record dated 12/03/2022 titled Medications given reflected the resident received AED medications and none of the doses had been changed. Record review of Resident #1's emergency room discharge instructions dated 12/03/2022 reflected there were no upcoming doctor appointments scheduled, and to continue with the same medication regimen she was currently taking at the NH. During an interview on 1/19/2023 at 12:48 p.m. with ADON I, she said Resident #1 came back after midnight on 12/4/2022. ADON I stated the NP had ordered AED labs to be drawn on 12/04/22 but had not been drawn due to Resident #1's request to be sent back to the emergency department on 12/04/22. ADON I denied knowing the recommendations by the pharmacy consultant for therapeutic lab values were drawn prior to the emergency room visit and said and said she had not reviewed the hospital discharge instructions and when a resident was readmitted to the facility after a hospital stay it was the nursing administration teams responsibility to go over the records and implement any appointments or new orders. Record review of Resident #1s Progress Note written by ADON I and dated 12/04/2022 reflected Resident #1's family member told her she wanted Resident #1 to be sent out to the hospital be reassessed for seizures. ADON I wrote she observed Resident #1 in her room having a seizure lasting about 60 seconds, and when the seizure became less intense and ended, the patient returned to normal. ADON I called EMS who came to transfer Resident #1 to the hospital, and ADON I documented that the resident was observed to continue being disoriented on exit. During an interview on 1/19/2023 at 1:35 p.m. with ADON I, she said Resident #1's family member was in the room dressing her on 12/03/22 when the family member called out to say Resident #1 got hot and began perspiring,, the ADON I came into the room, and Resident #1 had calmed down, but the resident was looking at the ADON with a blank stare and not moving. ADON I said she thought Resident #1 was having a seizure, and she said, Once she came out of it, she was confused and called 911 for transport to the hospital. ADON I said Resident #1's family member told her Resident #1 had not had a seizure for 30 years. The ADON stated the recent seizure activity was out of the norm for Resident #1. ADON I said she notified the resident's NP regarding the hospital transfer. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on [DATE] for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled ED Provider Note, Date of Service 12/04/2022, Chief Complaint reflected the patient presented to the emergency room with altered mental status problems and weakness. The physician stated Resident #1 had symptoms of altered mental status and questioned whether it was related to a seizure, noted the resident was taking Keppra, Dilantin, Tegretol, and stated an emergency medical clinician had witnessed the resident had a seizure while in route to the hospital from the nursing home and had been given versed (an anticonvulsant medication) which helped to stop the seizures. The ED physician also noted Resident #1 had been seen at another hospital on [DATE] for a seizure. Record review of Resident #1's emergency room admission record dated 12/04/2022 titled Physical Exam Review of Systems (review of systems is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing) referenced Resident #1 was unable to be reviewed because she had a mental status change that prevented her from answering medical questions. Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.7 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's emergency department to hospital admission record dated 12/04/2022 titled Final Diagnoses reflected an admission diagnose of altered mental status, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Hospital Medicine admission History and Physical: Resident #1 reflected a chief complaint of altered mental status and weakness symptoms, and review of systems were noted to have lack of energy, headache, and confusion. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Assessment & Plan Active Problems: # Seizure disorder, Continue Keppra 1000 mg BID, Phenytoin 200 mg BID, Carbamazepine 200 mg TID, Neurology referral on discharge. Record review of Resident #1's hospital admission record dated 12/05/2022 titled Neurology Inpatient Consult, Reason for Consult: seizure an assessment note reflected the neurologist thoughts of Resident #1's seizure activity saying it was odd that she began having seizure lately after 37 years without having any and said he would adjust the carbamazepine medication dosage. Record review of Resident #1's hospital admission record dated 12/06/2022 titled HMD attending attestation #AMS #Breakthrough Seizure reflected the doctor said the resident was seen by a neurologist who attested that her primary diagnosis was refractory seizure (medications are not controlling seizure activity), and AEDs were adjusted. Record review of Resident #1's hospital admission record dated 12/06/2023 titled Labs reflected a lab value reading for Phenytoin Free level (the measurement of free phenytoin level is necessary to properly evaluate the phenytoin level than that calculated from total phenytoin level) was 0.6 ug/mL (*normal reference range is 1.0 - 2.5 ug/mL). Record review of Resident #1's hospital admission record dated 12/07/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 6.0 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation reflected the hospital doctor wrote the resident was stable enough for discharge and stated Resident #1's AEDs had been adjusted. Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Reason for hospitalization reflected the hospital doctor wrote the resident had a seizure in route to the hospital on [DATE] that lasted 1 minute and was administered 5 g of versed (relaxant). Record review of Resident #1's hospital admission record dated 12/08/2022 titled HMD attending attestation, Hospital Course / Summary reflected the hospital doctor stated neurology had adjusted the resident's carbamazepine to carbamazepine extended release and would now be taking the medication twice a day instead of three times a day and increased the dose to 400 mg BID from the previous dose which was 200 mg TID. The doctor stated Resident #1 had expressed concerns about her medical care in the NH, she wrote in part, she does not feel she is being taken care of properly there and Patient is agreeable to return to it for now and give her daughter and son time to pick out an alternative option. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Discharge Medications: Medication list, STOP taking these medications, reflected Carbamazepine 200 mg tablet, commonly known as: Tegretol, Replaced by: Carbamazepine 400 mg 12 hr tablet. Record review of Resident #1's hospital admission record dated 12/08/2022 titled Patient Instructions reflected the resident had been evaluated at the hospital for breakthrough seizure activity and listed instructions noting the change in carbamazepine dosage and to take as prescribed to prevent future seizure activity. Record review of Resident #1's progress note written by ADON I on 12/12/2022 at 1:53 p.m., reflected the resident was disoriented and not responding to questions, just mumbling, the NP was notified, and Resident #1's family member was also contacted. Record review of Resident #1's progress note dated 12/12/2022 at 3:10 p.m. described Resident #1's family member's concerns and requested for Resident #1's transfer to the emergency department for further evaluation and treatment. ADON I called 911, she described Resident #1 was talking incoherently and not answering questions appropriately and noted notifying the NP and DON. Record review of Resident #1's emergency room admission record dated 12/12/2022 titled ED Provider Note, Date of Service 12/12/22, Chief Complaint reflected the patient presented with seizures. The record states the resident had a recent admission to the hospital earlier this month, no date was given, for altered mental status, she was seen by Neurology who adjusted her antiepileptic drugs. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022titled Medical Decision Making, Mon [DATE] stated, Patient here with seizure today, phenytoin level subtherapeutic. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Final Diagnoses reflected Seizure, and stated, Patient left with a disposition of Admit. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure noted AED levels for Phenytoin(7.7), Carbamazepine(3.2), and Levetiracetam(43.4). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.7 (*normal reference range is 10.2 - 20.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/12/2022 titled Hospital Medicine admission History and Physical: Resident #1 reflected a chief complaint of seizure- like activity. Record review of Resident #1's hospital admission record dated 12/12/2022 titled Assessment & Plan, Active Problems; Seizure and reflected admitted here 12/04-12/08 after breakthrough seizure on 12/03 due to medication non-compliance as patient lives in a NH and reports her medications are often not given as scheduled. The record states neurology increased carbamazepine dosing from 200 mg TID to ER 400 mg BID and added, Please consult neurology in AM. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Carbamazepine blood level final result was abnormal, it was 3.2, (*normal reference range is 4.0 - 12.0 ug/mL *). Record review of Resident #1's hospital admission record dated 12/15/2022 titled Neurology Inpatient Consult, Reason for Consult: Recommendations for AED selection/dosing reflected Phenytoin level on 12/12/2022 was 7.7, Carbamazepine level on 12/12/2022 was 3.2, and Levetiracetam level on 12/12/2022 was 43.4. The document stated Resident #1's Home AEDs were Keppra 1000 mg BID, Carbamazepine XR, 400 mg BID, and Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/15/2022 under the Neurology Inpatient Consult titled Assessment & Plan, Impression reflected the neurologist concern for the recent presentation of Resident #1's breakthrough seizure activity, writing the likely cause for the occurrences could be due to medication non-adherence and recent check of AED levels that were low. Record review of Resident #1's emergency department to hospital admission record dated 12/12/2022 titled Labs (list of abnormal value): ordered & reviewed reflected Phenytoin Level, Total - Abnormal; Notable for the following components: Phenytoin 7.4 (*normal reference range is 10.2 - 20.0 ug/mL). Record review of Resident #1's hospital admission record dated 12/23/2022 titled Hospital Medicine Discharge Summary reflected a discharge diagnosis of active problems were seizures. The neurologist recommended continuation of Keppra 1000 mg BID, switched Carbamazepine XR 400 mg BID back to 200 mg TID, and said to continue Phenytoin ER 200 mg BID. Record review of Resident #1's hospital admission record dated 12/23/2022 titled Discharge Medications: CHANGE how you take these medications reflected the antiseizure medication Keppra's dosage had been changed from 1000 mg BID to 1500 mg BID. During an interview on 1/19/2023 at 2:00 p.m. with the DON, stated she contacted Resident #1's NP for the change in condition instead of her PCP because at times it was hard to get a hold of the PCP. She said the documentation entered by her on 12/0 The DON she was aware of Resident #1's altered mental state and was told by ADON I, Resident #1 was transferred to the hospital. The DON said she did not speak to Resident #1's PCP because the NP was providing the care. The DON said she did not consider consulting with the Medical Director because she felt the NP was caring for Resident #1's correctly, saying the situation did not warrant a consult for additional interventions for the care of the current significant change in Resident #1's condition. The DON stated it was not normal for Resident #1 to be sent out to the hospital 3 times in December 2022, and said the resident was sent out the first time was the only time it was for seizure activity. The DON said the other 2 hospital visits were not for epileptic seizures, and that Resident #1 was sent out due to satisfy Resident #1's family wishes. The DON said she did review all 3 hospital records but did not pursue trying to get Resident #1's lab values taken during the stays. The DON said the NP reviewed the hospital discharge instructions on 1/10/22, after a visit with Resident #1, and was told by the NP that there were no new orders, and to was told by the NP to continue observe the resident for seizure activity. During an interview on 1/19/2023 at 6:22 pm with Resident #1's NP revealed she was aware of the hospitalizations that occurred during December 2022 and stated she did not inform the PCP regarding the seizures, because she was an independent practitioner and could order treatments and medications for Resident #1 medical care. The NP said she was not aware there weren't any AES labs ordered to verify antiseizure medication levels for Resident #1, saying that she had cared for the resident for many years and knew there used to be an order for the lab draws in the past and admitted not checking the orders lately. She said the orders that were once place in paper health records could have been missed, dropped off and not carried over into the new electronic system currently in use. The NP said it was a team effort by nursing staff and practitioners to catch those types of mistakes, she relied on the nursing staff to keep her informed and ask for orders. The NP said the antiseizure medication levels should be monitored for therapeutic levels in the body to rule out toxicity side effects and could say why she had not reentered lab orders. She denied being informed of any abnormal antiseizure medication levels in the past, and said she ordered some labs to be drawn on 1/08/2022, checking the results when she came into the facility on 1/10/2022 for a visit with Resident #1, and reported the decision to nursing staff to continue with the current antiseizure medication regimen and not add any new orders. The NP stated she no longer would be in charge of Resident #1's health care and had stopped last week and could not say when the last day was before signing off as Resident #1's NP. The NP said the decision to sign off on the care was due to Resident #1's newly assigned PCP who had their own NP on board. Record review of Resident #1's clinical results electronic documentation dated from 7/11/2022 through 1/19/2023, reflected only one lab draw was ordered on 1/06/23 for therapeutic levels for Resident #1's antiseizure medications. Record review of Resident #1's laboratory results dated [DATE], reflected an abnormal level for antiseizure medication Carbamazepine, result read <2.0 L ug/mL, and a normal reference range of 4.0- 12.0. Another antiseizure medication laboratory report for Dilantin medication resulted at 4.0 ug/mL with a normal reference range of 10.0 -20.0 flagged as low. During an interview on 1/19/2022 at 6:30 p.m. with the DON, she was asked who was currently in charge of Resident #1's care, she said the NP, and was not aware the NP had discharged herself from taking care of Resident #1's health care. The DON said she was not aware of the change. She could not say who was currently overseeing Resident #1's health care. During an interview on 1/19/2022 at 7 p.m. with the Facility Medical Director, he said Resident #1's former PCP had been terminated from the care for the resident on 12/31/22, and he believed it was because the PCP was not coming to the facility to care for her patients. The Medical Director claimed he was unaware of Resident #1's December 2022 hospitalizations, and stated he was not familiar with the resident at all, saying that she was not his patient and therefore would not know of her or her recent seizure activity. He was asked what the protocol was for the care of residents who had a diagnosis of epilepsy that were admitted to the facility, and he said, initial labs need to be ordered to assess whether the residents are experiencing therapeutic levels of ordered antiseizure medications. Then he said, for normal levels, he stated ordering labs should be paced and drawn every 3 months. The Medical Director explained if the antiseizure medication level are abnormal, the practice is to order the labs to be drawn every week until the levels are therapeutic and then they are ordered once a month for 6 months, with instructions for close monitoring of seizure activity symptoms. The Medical Director stated he expects the nursing staff to observe for toxicity signs and symptoms, confusion, body jerking movements, and fainting, the nursing staff should alert the MD immediately for intervention orders. He said if a resident goes on having seizures and there are no interventions ordered, the residents could be affected with status epilepticus which is a common form of emergency situation that can occur with prolonged or repeated seizure activity, causing convulsions and possibly death. During an interview on 1/19/2022 at 7:15 p.m. with Resident #1's new PCP, she denied knowing Resident #1'shad been recently hospitalized three different times in December 2022 for new onset seizure activity. The new PCP mentioned t she had just been given the assignment to take over Resident #1 's care the week of 1/09/22and had not been to the facility to assess Resident #1 , adding she would be coming next week to perform a thorough history and physical. The new PCP said her process for care of an admitted epileptic resident taking antiseizure medications was to order the nursing staff to monitor for symptoms of seizures including toxicity, and notifying the MD with concerns, and abnormal lab values. She stated when she takes over the care of a new resident, she will order labs to find out the current base line of the medication levels. She stated if they are abnormal, she will change dosages to antiseizure medications and check blood levels in one week until the drugs reached the proper therapeutic level in a person. She stated after reaching the normal level she will order antiseizure medication levels once a month until she was assured the person medication blood levers were safe. The new PCP stated after that she orders the labs to be drawn every 6 months. The newly assigned PCP said she checks the labs each time she comes to visit the resident, once a week, and expects the nurses to call her any time with any changes. The new PCP said the outcome for residents not being properly monitored after having a new onset of seizures is that they can end up in unnecessarily the hospital with longer and stronger seizure activity. During an interview on 1/20/2022 at 1:20 p.m. with the Administrator revealed Resident #1's PCP had been, pulling away from the facility, and he was asked to clarify pulling away. He stated the PCP was not rounding with her residents as much as needed. The Administrator was asked if the PCP had been fired from caring for Resident #1, and he stated that was not true, and that he had not fired her. The Administrator was told the Medical Director had mentioned the facility had fired the PCP, and he said he did not know Resident #1, her situation of rehospitalizations because he said, she is not my patient. The Administrator stated that indeed the Medical Director knew Resident #1, and that he would advise the Medical Director the PCP had not been fired from Resident #1's care, he added that the reason the Medical Director had said he did not know the resident may have happened because The Medical Director did not directly provide care for Resident #1. The Administrator said, due to the prior PCP, pulling away from her residents, he decided to approach the PCP in November 2022 to ask her if she accepted help to lessen her resident load, by asking some of her current residents if they wanted a new MD, and said she agreed to release whoever requested another practitioner. The Administrator said a total of 5 residents agreed with the suggestion to receive care from a new MD. He said the last time the PCP saw Resident #1 was on 1/06/2023. The Administrator was asked if he was aware of the NP's allegation that she was no longer caring for Resident #1, stating she had resigned from Resident #1's care earlier that week, and denied knowing the NP had stopped care. He was asked who was currently in charge of Resident #1's care and he said, That is a good question and added, I will need to find out. The Administrator was asked whether nursing had notified him of a change of condition for Resident #1's health status and he said the DON did the first time the resident went out the hospital in December 2022. He stated that Resident #1's change in condition was brought up several times in December 2022, discussed by an interdisciplinary [TRUNCATED]