**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents reviewed for medications. (Resident #1) The facility failed to ensure: 1. Resident #1 was administered his regular evening medication as ordered along with Resident #2's evening medication on the evening of 5/5/2025. Resident #1's medication included Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. 2. Resident #2's medications was administered to Resident #1 on 5/5/2025 which included clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). 3. Resident #1's orders indicated he had an allergy to Trazodone with documented reaction indicating an intolerance and reaction manifestation of altered mental status. An Immediate Jeopardy (IJ) was identified on 5/15/2025 at 9:30 AM. The IJ template was provided to the facility on 5/15/2025 at 10:03 AM. While the IJ was removed on 5/16/2025 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of physical complications, hospitalization, and possible death. Findings included: Record of Resident #1's face sheet dated 5/14/2025 indicated he was an [AGE] year-old male readmitted to the facility on [DATE]. Resident #1's diagnosis included COPD (a group of lung diseases that block airflow and make it difficult to breathe), transient cerebral ischemic attack (a brief stroke-like attack that despite resolving within minutes to hours, requires immediate medical attention), acute and chronic respiratory failure (a condition where the lungs are unable to adequately transfer oxygen into the blood, leading to low oxygen levels in the body), benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate gland which can put pressure on the urethra and cause urinary symptoms), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of an annual MDS assessment, dated 1/14/2025, indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had a BIMS score of 13 which indicated he was cognitively intact, and he required partial assistance with oral hygiene, dressing upper body, and dressing lower body. Resident #1 required maximal assistance with bathing and was dependent with toileting and putting on and taking off footwear. Record review of Resident #1's care plan revised on 1/29/2025 indicated ADL self-care performance deficits related to fatigue, COPD and recurrent pneumonia. Some of the interventions included level of assistance may vary slightly from day to day. OT started on 4/3/2025 and completed on 4/18/2025 related to muscle wasting and pain to right hand. The resident required assistance from staff for bathing and required extensive assistance for bed mobility. Resident #1 had a decreased cognitive function/memory impairment related to his diagnosis of Dementia. Some interventions included to administer medications as ordered. Monitor and document for side effects and effectiveness, ask yes/no questions to determine the resident's needs, cue, reorient and supervise as needed, and keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. Record review of Resident #1's order summary report dated 5/13/2025 indicated Resident #1 was prescribed the following evening medications: Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. Resident #1 had orders for side effect monitoring for antidepressants. Resident #1 did not have any new orders for vital signs or neuro checks ordered. Record review of Resident #1's TAR dated 5/1/2025-5/31/2025 indicated Resident #1's behavioral monitoring for side effects of antidepressants did not indicate by O- None that Resident was experiencing any side effects of his medications. Record review of Resident #1's MAR dated 5/1/2025-5/31/2025 indicated Resident #1 was administered his evening medication which included Gabapentin 200 mg at bedtime ( a medication used to treat peripheral neuropathy, chronic pain) Hemp gummies 20,000 2 gummies at bedtime ( a supplement used to treat anxiety, depression, pain, inflammation and improve sleep), Melatonin 9 mg at bedtime (a supplement to assist in sleep), Tamsulosin 0.4 mg at bedtime ( a medication used to treat an enlarged prostate), Docusate Sodium 100 mg twice daily (a stool softener), Eliquis 5 mg every 12 hours (a blood thinner), Furosemide 40 mg twice daily ( a medication used to treat fluid), Metoprolol 50 mg twice daily and acetaminophen-codeine 300-60 mg three times daily. Record review of Resident #1's progress note dated 5/5/2025 at 8:45 PM, LVN A noted Resident #1 was inadvertently given the wrong medications. LVN A noted vital signs were taken, resident was alert and answering appropriate questions at this time. LVN A documented the NP was notified and orders were received to check neuros every 30 minutes for 4 hours and then every hour throughout the shift. The progress note indicated to refer to neuro notes and oxygen saturation notes and the DON was notified. Record review of Resident #2's order summary report dated 5/16/2025 indicated Resident #2's evening medications were clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). These medications were administered to Resident #1 on 5/5/2025. Record Review of an allergy alert dated 6/24/2024, indicated Resident #1 had an allergy to Trazodone with a reaction manifestation noted altered mental status. Record review of neurological assessment dated [DATE] at 8:45 PM, LVN A noted Resident #1 did not refuse neuro checks. She indicated his blood pressure was 109/50, pulse 96, respirations 18 and temperature 97.9. The neurological assessment indicated Resident #1 was alert, hand grasp was equal, he moved all extremities, his pupils were equal and reactive to light. LVN A documented Resident # 1's right and left pupils were dilated and responded appropriately to pain. Record review of neurological assessment dated [DATE] at 9:15 PM, LVN A noted Resident #1 did not refuse neuro checks. She documented NA for the blood pressure, pulse, respirations, and temperature indicating the vital signs were not assessed. The neurological assessment indicated Resident #1 was alert, hand grasp was equal, he moved all extremities, his pupils were equal and reactive to light. LVN A documented Resident # 1's right and left pupils were dilated and there was no response to pain. Record review of neurological assessment dated [DATE] at 10:45 PM, LVN A noted Resident #1 did not refuse neuro checks. She documented NA for the blood pressure, pulse, respirations, and temperature indicating the vital signs were not assessed. The neurological assessment indicated Resident #1 was lethargic/drowsy, hand grasp was equal, he moved all extremities, his pupils were not equal and reactive to light. LVN A documented Resident # 1's right and left pupils were sluggish and Resident #1 response to pain was appropriate. Record review of Resident #1's progress note dated 5/5/2025 at 11:00 PM, Resident #1 was awake and trying to get out of bed, wanted something to eat. He wanted a can of Vienna [NAME] and ate them all. Resident #1 then wanted pizza he had left and ate it all. LVN A indicated Resident #1 continues to be drowsy but alert and appeared too sleepy to open eyes. Record review of neurological assessment dated [DATE] at 11:45 PM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated his blood pressure was 124/75, pulse 113, respirations 18 and no temperature was taken. The neurological assessment indicated Resident #1's level of consciousness was lethargic/drowsy, hand grasp was equal, moved all extremities, pupils were not equal or reactive to light, right and left pupil were sluggish, and Resident #1 responded appropriately to pain. Record review of neurological assessment dated [DATE] at 12:15 AM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated NA on his blood pressure, pulse, respirations, and temperature indicating vital signs were not obtained. LVN A noted Resident #1's level of consciousness was lethargic/drowsy, hand grasp was equal, moved all extremities, pupils were not equal or reactive to light, right and left pupils were sluggish, and Resident #1 responded appropriately to pain. Record review of neurological assessment dated [DATE] at 12:45 AM, LVN A indicated Resident #1 did not refuse neuro checks. She indicated NA on his blood pressure, pulse, respirations, and temperature indicating vital signs were not obtained. LVN A noted Resident #1's level of consciousness was alert, hand grasp was equal, he moved all extremities, pupils were not equal and reactive to light, right and left pupil were sluggish, and Resident #1 responded appropriately to pain. Record review of a neurological assessment dated [DATE] at 1:45 AM indicated Resident #1 refused neuro checks. Record review of Resident #1's progress note dated 5/6/2025 at 1:45 AM, LVN A indicated Resident #1 would not open his eyes when nurse asked him to open his eyes but did shake his head no. LVN A noted she had been able to obtain oxygen saturations and the readings were in the high 90's. Record review of a neurological assessment dated [DATE] at 2:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 3:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 4:45 AM indicated Resident #1 refused neuro checks. Record review of a neurological assessment dated [DATE] at 5:45 AM indicated Resident #1 refused neuro checks. Record review of a Physician Progress note dated 5/7/2025 at 11:15 AM indicated Resident #1 was out of room in his wheelchair. The Pain Management NP documented Resident #1 required full assist with transfers and ADL's. The progress note indicated Resident #1 was prescribed Tylenol #4 every 4 to 6 hours as needed but because of increased pain on April 13, the dose was changed to Tylenol #4 scheduled 3 times a day and every 6 hours as needed for rescue pain treatment. The progress note indicated Resident #1 had no adverse effects from medications and was pleasant. He indicated Resident #1 had an allergy to Trazodone. The Pain Management NP's progress note indicated Resident #1 reported fatigue and arthralgia/joint pain. The progress note indicated Resident #1 was oriented to self, place, and time and his affect was appropriate. During an interview on 5/14/2025 at 1:33 PM, LVN A said she worked at the facility part-time. LVN A said she had gone into Resident #1 and Resident #2's room while holding Resident #2's evening medications. She said Resident #1 was wanting a breathing treatment and she handed him Resident #2's medications and he took them. She said she realized what she had done and call the NP. LVN A said Resident #1 acted drunk and was slurring his words after taking the medications. She said Resident #1 was fine when she left. LVN A said she had notified Interim DON T and the Physician. LVN A said the NP instructed her to check Resident #1's vital signs every 30 minutes for 4 hours and then hourly. She said she was also instructed to complete neuro checks and oxygen saturations. LVN A said Resident #1 was getting upset and not letting her check his vital signs. LVN A said she could not recall the medications that were administered to Resident #1. LVN A said she completed a risk management form and completed the medication error form that populates in the EMR. LVN A said she did not recall completing an incident report. LVN A said Resident #1 received all of Resident #2's evening medications. LVN A said she could not recall if she checked to see if Resident #1 had any allergies to Resident #2's medications. LVN A said Resident #1 could have an adverse reaction and she could not recall if Trazadone was one of the medications she administered. LVN A said whatever was on Resident #2's MAR for the evening was what Resident #1 had received. During an interview on 5/14/2025 at 2:05 PM, LVN B said Resident #1 was transported to the hospital on 5/13/2025. LVN B said Resident #1 was bedbound and navigated the facility in his electric scooter. LVN B said Resident #1 was normally awake, alert, and oriented to person, place, time, and situation. LVN B said Resident #1 was sometimes confused. LVN B said the normal process to reporting an incident such as falls, or medication errors required the nurse to complete a form under risk management on the EMR. She said the first thing she would need to do would be to contact the Physician, DON, Supervisor, and family. She said then the nurse would need to write up an incident and document when it occurred. LVN B said the DON and ADM should investigate the issue and follow up. During an interview on 5/14/2025 at 2:33 PM, the RP said Resident #1 was currently in the hospital. He stated Resident #1 had not been the same since he was administered the wrong medication and stated he had gone downhill. RP said the medication that he took caused a reaction. RP said Resident #1 was taken by ambulance and he stayed in the ER for a while until he was stable. RP said Resident #1 was currently on oxygen and was in and out mentally. RP said he could hardly hear him when he talked, and Resident #1 does not know who he is. RP said it was from his understanding the medication was administered to him on Monday night. He said when the facility called, they told him Resident #1 was having an episode. Rp said he did not find out about the nurse administering the wrong medication until the next day. RP said the NP did not send Resident #1 out the day the medication was administered. RP said Resident #1 was currently in ICU. RP said the facility would not tell him what medications were administered. RP said Resident #1 had COPD and it had been controlled. RP said he was not sure if Resident #1 had any allergies. During a phone interview on 5/14/2025 at 3:02 PM, the NP said he was called about the medication error last week. He said the nurse had informed him she had administered Resident #1 the wrong medications. He said he was told the medications were Tegretol, Keppra and Metformin. He said he had asked her if she had administered the 5 rights of medication administration and she said no. He advised her to monitor the resident and he called the Physician to consult. NP said he was going to instruct the nurse to monitor Resident #1 every hour but changed it to every 30 minutes after discussing with the DON. NP said he did not assess Resident #1 on Thursday when he was at the facility because he saw him up and about. The NP said the main side effect could be sedation. The NP said with all the medications administered, it could affect the residents breathing. The NP said he did not feel the medication error could have caused Resident #1 to have pneumonia. During an interview on 5/14/2025 at 3:14 PM, the Interim DON U said Resident #1 was sent to the hospital because his eyes rolled back. Interim DON U said if there was a medication error, it would be entered by the nurse and brought to the charge nurse, ADON, DON and ADM. He said the physician and family would have been made aware. Interim DON U said there was an incident report in the computer, but it did not list the medications that were administered. Interim DON U said he would have listed the medications administered. Interim DON U said he would expect the orders to be in the computer but could not locate the neurological assessment orders or the vital sign orders. Interim DON U said medications administered to Resident #1 could cause an allergic reaction or adverse effect depending on the medication. He said Resident #1 could have respiratory issues or become too sleepy. Interim DON U said a resident with COPD can increase the risk with many medications. He said Resident #1 remained in the hospital. During an interview on 5/15/2025 at 7:35 AM, the ADON said the Interim DON T at the time was notified and the NP had called her. The ADON said the NP was upset. The ADON said the NP instructed staff to monitor Resident #1 until the next day. The ADON said the pain management provider came in and noticed Resident #1 was drowsy and wanted to adjust his pain medications. The ADON said she explained to the NP what had happened, and Resident #1 was not sedated from the pain medication but was administered the wrong medications. The ADON said Resident #1 was up in his wheelchair the next day and was doing fine. She said Resident #1 was ordered to have every 4-hour vital sign and neuro checks, but Interim DON T had advised vital signs to be checked more frequently. The ADON said there would not need to be an order written. The ADON said she would expect the nurse to have documented the vital signs in the computer. The ADON said the Interim DON T did not complete an investigation. The ADON said if the resident did not have a good renal function, it could have been bad. She said the medications administered to Resident #1 could have suppressed his respirations. The ADON said she was not aware Resident #1 had his evening medications as scheduled and the nurse did not tell the resident had any allergies. The ADON said she had provided the nurse a verbal in-service on the 7 Rights of Medication Administration. During an interview on 5/15/2025 at 9:01 AM, the NP said he had spoken with the Interim DON T and discussed she wanted the vital signs and neuro checks to be completed every 30 minutes. He said he would not have done anything differently if he had known Resident #1 was allergic to Trazadone. He said if Resident #1 was to have an allergic reaction, he would have advised the nurse to administer the resident a Benadryl and to call 911. He said it would have been nice to know the resident had slurred speech and was drowsy but that would be expected with the medications he was administered. The NP said it did not surprise him that the vital signs were not taken as he had ordered . He said the pain management NP came in the next day and assessed the resident and said he was fine. During an interview on 5/15/2025 at 1:30 PM, the Regional [NAME] President provided additional information. He said he provided the neurological assessment with vital signs that were documented on 5/5/2025. He said the vital signs were documented on the neurological assessment form and not in the computer. He said LVN A did not document in her charting Resident #1 was slurring his words or acting drunk. He said Resident #1 took CBD gummies and would be lethargic at bedtime. The Regional [NAME] President said one of the progress notes indicated Resident #1 woke up asking for food and it was provided to him. The Regional [NAME] President felt Resident #1 was alert enough to ask for food. He said he spoke with the Corporate Nurse, and she said the orders for neuro checks was fine in the progress note and a written order would not be necessary. The Regional [NAME] President reviewed neuro checks and acknowledged there was only 2 vital sign checks on the neuro check form. During a phone interview on 5/15/2025 at 3:20 PM, the Pain Management NP said he saw Resident #1 the next day. He said Resident #1 was sitting up in his wheelchair, oriented and listening to his podcast. The Pain Management NP said he had spoken with ADON due to reviewing a progress note on Resident #1 indicating he was fatigued. He said he was going to adjust his medications during the visit, but the ADON had informed him of the medication error causing Resident #1's documented fatigue. Pain Management NP said Resident #1 was fully oriented, was not impaired and was in great condition when he saw him, and he had no concerns at the time of his visit. During an interview on 5/15/2025 at 3:29 PM, the Interim DON T said she was there are at the time of medication error. She said she was the Interim DON for the last 2-3 months. Interim DON T said LVN A had called her and told her she had got some medications for Resident #2 and had the new medications in the cup. She said she was heading to administer the medications and stopped to answer the call light and handed the cup of medications to the wrong resident. She said LVN A called and notified the NP and informed him about what had happened. Interim DON T said the NP had asked LVN A if Resident #1 had any changes and she said no. Interim DON T said the NP called her and discussed vital signs checks to be ordered every 30 minutes through the night and arouse resident. Interim DON T said the NP also wanted neuro every hour. She said the staff checked him for 24 hours and family was notified. She said the wife was notified and monitored Resident #1 for 3 days. The Interim DON said the NP came and checked Resident #1 out and he was doing good. Interim DON T said she checked on Resident #1 during the day. Interim DON T said she did not find out what was administered and did not put it on the incident report. She said the nurse said what the medications were, and she said they did check the allergies and the NP visited. Interim DON T said Resident #1 had been doing good. She said the only allergy Resident #1 had been to Motrin. Interim DON T said Resident #1 was not lethargic and the RP had checked on Resident #1 and talked to DON T about it. Interim DON T said she asked the ADON to complete the in-service and she spoke with LVN A about the 7 rights of medication administration. During an interview on 5/15/2025 at 3:48 PM, the ADM said she was made aware of the medication error and what happened. She said she had spoken with the RP. The ADM said from what she knew, was the nurse had medications for another resident and Resident #1 received the medications instead. The ADM said LVN A handed Resident #1 the medications. The ADM said she was not aware of whose medication Resident #1 received and did not know if it was multiple medications. The ADM said in theory, it would be clinical and multiple departments assisting in the investigation. She said in her roll, she has checks and balances. She said she would involve HR to see if this had happened before. She said the investigation would be resident care and involve communication to NP or MD. The ADM said she did not know if each medication should have been listed on the investigation. She said the facility tries to identify and figure out during their investigation. The ADM said from her understanding, there was an investigation. She said she was made aware immediately what was happening. She said a medication error could negatively impact a resident that was not prescribed to him but would not elaborate. During an interview on 5/15/2025 at 4:30 PM, the ADM said she had spoken to the Corporate Nurse, and she was told the incident report was the investigation and there was not a separate investigation. 2. Record review of Resident #2's face sheet dated 5/16/2025 indicated he was readmitted to the facility on [DATE]. Resident #2's diagnosies included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), cognitive communication (difficulties arising from impairments in cognitive function like attention, memory and executive functions, rather than issues with speech or language itself), diabetes mellitus (a group of diseases that result in too much sugar in the blood), mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking) and depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities previously enjoyed). Record review of a quarterly MDS assessment, dated 1/14/2025, indicated Resident #2 was usually understood and usually understood others. The MDS indicated Resident #2 had a BIMS score of 7 which indicated he was severely cognitively impaired, and he required substantial assistance with toileting, bathing, and dressing lower body. Record review of Resident # 2's care plan dated 10/29/2018 indicated Resident #2 uses anti-anxiety medications related to seizures diagnosis. Interventions included to administer anti-anxiety (Ativan, valium) medications as ordered by physician and monitor for side effects and effectiveness every shift. Interventions included to monitor, document, and report any adverse reactions to anti-anxiety therapy such as drowsiness, lack of energy clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double visit. Record review of Resident #2's order summary report dated 5/16/2025 indicated Resident #2's evening medications were clobazam 20 mg 1 tablet twice daily ( a medication used to treat seizures), diazepam 5 mg 1 tablet twice daily (a medication used to treat seizures), Docusate sodium 100 mg 1 capsule twice daily (a stool softener used to treat constipation), Keppra 1000 mg twice daily (a medication used to treat seizures), lamotrigine 200 mg 1 tablet three times daily (a medication used to treat seizures), Metformin 500 mg 1 tablet twice daily ( a medication used to treat diabetes), Mirtazapine 15 mg 1 tablet at bedtime (a medication used to treat depression), Singular 10 mg 1 tablet at bedtime (a medication used to treat allergies), Topamax 200 mg 1 tablet twice daily (a medication used to treat seizures), and Trazadone 50 mg 1 tablet at bedtime (a medication to treat insomnia). Record review of Resident #2's MAR dated 5/1/2025-5/31/2025 indicated Resident #2 received his medications as ordered. The Administrator was notified on 5/15/2025 at 10:03 AM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 5/15/2025 at 10:08 AM and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 05/15/2025 at 2:37 PM and included: Plan of Removal F-760 Action: The Director of Nursing and/or Designee completed medication reconciliations to ensure that medications were given as ordered and documented on the MAR. The Director of Nursing and/or Designee reviewed the last 30 days of medication errors incidents to ensure that vital signs monitoring have been ordered and completed and documented include notification to physician of any allergies and adverse effects related to the medication error. Action/System Change: All licensed nurses and Certified Medication Aides were re-educated on 5/15/2025 by the Director of Nursing or designee on the following: Medication Administration Policy and Seven Rights of medication administration Medication errors to include writing orders as prescribed by Physician and Notification of adverse effects and resident allergies. Documentation and completion of vital signs as prescribed by the physician. Staff not in the facility on 5/15/2025 and/or on PTO/FMLA /Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. Beginning 5/15/2025 and ongoing, newly hired licensed nurses will receive this training during orientation proper to providing care to the residents. The training will include the above-stated educational components. Medication error incidents will be reviewed during the morning clinical meeting to ensure that physicians were notified of any resident allergies related to medications received. Review will also ensure that monitoring of adverse effects to include vital signs were ordered, completed, and documented and physician was notified for abnormal findings. Completion and time was 5/15/2025 at 11:59 PM. Monitoring: Beginning 5/15/2025 and going forward, the Director of Nursing will monitor compliance with medication administration policy and the seven rights of medication administration. Beginning 5/15/2025 and going forward, the Director of Nursing/designee will monitor compliance each weekday morning on review of medication administration report and medication errors incidents to ensure medications are administered as ordered and physician notifications with orders written for monitoring of vital signs and adverse effects, carried out and documented in the record. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the incident report and medication administration report during the clinical meeting.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to consult with the physician when there was a significant change in residents' physical status that was life threatening for 2 of 7 residents (Resident #1 and Resident #2) reviewed for change in condition. The facility failed notify Resident #1's physician on 2/5/25 when his PICC continued to be dislodged and he was unable to receive his IV antibiotics. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to notify Resident #1's physician of his x-ray results that were ordered on 2/7/25 with results that indicated they were sent back to the facility on 2/7/25. Res #1's MD was notified on 2/10/25 that Res #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. Resident #1 was admitted to the hospital on [DATE] with diagnoses of right lobe pneumonia due to ESBL(extended spectrum beta lactamase). The facility failed to notify Res #2's physician that his surgical wound had worsened. Resident #2 was admitted to the hospital on [DATE] with left lower leg pain and fever. He had a diagnosis of sepsis ( a life threatening complication of an infection) left below the knee amputation infection. The facility failed to follow their policy on notification of changes with significant health issues. An Immediate Jeopardy (IJ) situation was identified 2/13/25 at 5:00 p.m. While the IJ was removed on 2/14/25 at 7:35 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate threat with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures caused life threatening consequences for these two residents and put other residents at risk for not receiving timely medical interventions. Findings included: Record review of Resident #1's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was readmitted on [DATE] with diagnoses of Diffused traumatic brain injury, osteomyelitis, pneumonia, covid 19, quadriplegia, contracture of the right and left hand, and presence of left artificial elbow joint. Record review of Resident #1's admission MDS dated [DATE] indicated he was moderately impaired in decision making. He was unable to complete the BIMS. The resident had impaired range of motion on both sides of his upper extremity (shoulder, elbow, wrist, and Hand) and his lower extremity (hip, knee, ankle, and foot.) He required a wheelchair for mobility. He was dependent on staff for all activities of daily living. The MDS indicated the resident had an indwelling catheter and ostomy. Record review of Resident #1's care plan dated 1/28/25 indicated a problem of altered respiratory status/difficulty breathing related to recent hospitalization stay for Covid and pneumonia. The resident will be on IV antibiotics for pneumonia with an initiation date of 1/27/25 and a revision date of 2/7/25. Some of the interventions were to monitor and document changes in orientation. Monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, confusion, and cough. A care plan problem of IV medications related to pneumonia. The care plan interventions were related to complications related to IV therapy such as infiltrated IV, drainage, or inflammation. Record review of Resident #1's prior to facility admission hospital records dated 1/31/25 indicated a diagnosis of pneumonia due to covid dated 1/23/25, ESBL Extended spectrum beta lactamase: producing bacterial infection dated 9/17/24 still present, Acute osteomyelitis of the right elbow dated 12/24/24 still present. His discharge medication included meropenem 1 GM. Record review of Resident #1's nursing notes dated 1/31/25 at 6:17 p.m. indicated the resident was returning to the facility from the hospital. Signed by RN H. Record review of Resident #1's physician order indicated Meropenem Intravenous Solution Reconstituted use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days dated 2/1/25. Record review of Resident #1's MAR indicated Meropenem Intravenous Solution Reconstituted 1 GM use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days. With a start date of 2/1/25. The MAR indicated the medication was to be administered at 7:00 a.m., 3:00 p.m., and 11:00 p.m. The MAR indicated the mediation was given 3 times daily with the last dose 2/5/25 at 11:00 p.m. Record review of Resident #1's nursing notes indicated: On 2/6/25 at 1:27 p.m. meropenem intravenous Solution reconstituted 1GM was not given due to loss of PICC access. The PICC company was notified for replacement. The NP was made aware. Signed by LVN C. On 2/6/25 at 10:13 p.m. indicated the resident refused midline, would not let staff unbend arm to pace midline. Signed by LVN F. On 2/7/25 at 1:40 p.m. the company that replaced PICC lines was called to replace Resident #1's PICC line. Signed by LVN E On 2/7/25 at 2:58 p.m. no PICC line in place for administration of medication. Signed by LVN E On 2/7/25 at 10:12 p.m. no PICC line access. Signed by LVN F On 2/8/25 at 12:17 a.m. resident remained without IV access signed by LVN F. On 2/10/25 at 11:38 a.m. Resident #1's PICC line was dislodged on 2/5/25 and the NP was informed. An outside service provider attempted to replace and insert new PICC line in the facility. The technician was unsuccessful due to contraction of upper extremities of patient. The patient did not complete antibiotic therapy and missed several doses. The nurse contacted NP regarding situation and current symptoms to include cough, abnormal lung sounds, abnormal chest x ray. The nurse received an order to send Resident #1 to the ER. His blood pressure was 116/64, oxygen status on room air was 91 percent, his temperature was 98.8 and his pulse was 80. Signed by LVN E. Record review of a change in condition note dated 2/10/25 at 6:57 p.m. indicated Resident #1 had increased cough, a positive chest x ray, incomplete antibiotic therapy, these things made the condition worse. Signed by LVN E. Record review of Resident #1's x ray report dated 2/7/25 and signed electronically on 2/7/25 at 11:07 a.m. indicated Resident #1 had patch bilateral lung opacities (area of increased density or darkness in the lungs.) This was consistent with bilateral pneumonia. The findings are worse compared with prior. There was no indication the physician was notified. Record review of Resident #1's hospital records dated 2/10/25 indicated Resident #1 was receiving IV antibiotics for pneumonia. He lost his PICC line assess, and the facility attempted to have it replaced but was unsuccessful. The resident had an x ray showing he still had pneumonia and was sent to the hospital for PICC line replacement. He has a history of pneumonia. He is nonverbal and quadriplegic, unable to move upper or lower extremities, with severe contractions noted. The hospital records indicated they spoke with the RN at the facility and was informed the PICC line had been out since 2/5/25. He had a diagnosis of pneumonia of the right lower lobe due to infectious organism ESBL (extended spectrum beta -lactamase) producing bacterial infection. Record review of a nursing note dated 2/10/25 at 9:56 p.m. indicated the nurse called to check on Resident #1's status. He was admitted to the hospital with a diagnosis of right lower lobe pneumonia, acute osteomyelitis, ESBL. Signed by LVN E During an interview and record review on 2/12/25 at 3:21 p.m. LVN C said Resident #1 did not have PICC line access when she came in on 2/6/25. She said she had gotten the ADON/RN D to come in and help her assess the resident. She said the NP was in the building doing rounds. She said the NP told them to contact a company that replaced PICC lines. She said she had contacted that company on 2/6/25 for them to come out and replace Resident #1's PICC line. A review of the nursing notes with LVN C indicted Resident #1 had refused the reinsertion on 2/6/25. LVN C said she was not aware the company had been contacted again on 2/7/25 by LVN E and she did not know what had happened with Resident #1's PICC line. During an interview on 2/12/25 at 3:44 p.m. ADON/RN D said she was not sure if Resident #1's PICC line had been noted as displaced by the prior shift on 2/5/25. She said Resident #1's right arm was contracted, and he held it tightly to his biceps. The ADON/RN said she did not know how the PICC line came out. She said LVN C had asked her to come in and assess Resident #1 on the morning of 2/6/25. She said the NP was in the building and the NP and told them to contact a company that replaced PICC lines. She said she knew LVN C had called the company. She did not know Resident #1 had refused or how many times the company had been called or why the PICC line was not replaced. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he had gotten a text earlier on the morning of 2/6/25 that Resident #1's PICC line had come out. He said he told them to call the PICC line replacement company and have them to come out to replace the PICC line. He said the facility did not inform him they were unable to replace the PICC line. He said he was not informed Resident #1 was not taking the antibiotic. The NP said if they had informed him Resident #1 was not able to finish his antibiotic, he would have told them to send him to the hospital. During a telephone interview on 2/12/25 at 4:31 p.m. the DON said on 2/7/25 LVN E told her that the PICC line company said they would not come back to the facility to try and reinsert Resident #1's PICC line. They said they were unable to do so due to his contractures. She said she told LVN E to call the physician and let him know. The DON said on the morning of Monday, 2/10/25 after the x rays were reviewed, she told LVN E to call the physician and send Resident #1 to the hospital. During a telephone interview on 2/12/25 at 4:32 p.m. LVN E said she had talked to the PICC line company, and their nurse said they were not coming out. She said the nurse said Resident #1 was too contracted and they were not able to place the PICC line. LVN E said she was leaving for the day and told the DON what the company had said. The DON told her to make the physician aware. She told the oncoming nurse LVN F about the situation during report. She said she did not know what happened after then. She said she had not notified the physician. During a telephone interview on 2/12/25 at 4:55 p.m. LVN F said that on Friday 2/7/25 LVN E told her the PICC line company had refused to come out. She said it was mentioned in the conversation about notifying the physician, but she thought LVN E had notified the physician. LVN F said she had not notified the physician because she thought it was already done. During an interview on 2/13/25 at 7:21 a.m. LVN C said she did not know anything about Resident #1's x rays results until Monday, 2/10/25. She said she worked PRN and was under the impression x rays results would be sent by fax. She said that on Monday, 2/10/25 Resident #1 had a cough that was deeper than on 2/7/25 and she was told he had x ray results that indicated pneumonia and to send him out to the hospital. During an interview on 2/13/25 at 10:30 a.m. the Regional Nurse Consultant said ADON/RN D and Administrator did not find any nurse that admitted to seeing the x ray results for Resident #1 on the weekend. He said it appeared the first time the x rays were noted was on 2/10/25. During an interview on 2/13/25 at 10:34 a.m. the Administrator said they did not find any nurse that discovered the x ray results for Resident #1 over the weekend. She said she was aware of what the NP always said he would send a resident to the hospital if they had a change in condition. The Administrator said she had reached out to the nurses on the weekend they thought the order was complete for Resident #1's antibiotics because the completion date was 2/7/25 and it fell off the system orders. She said they did not see any issues and they did not review the records to see if there was a problem because they thought the antibiotic was completed. Resident #2 Record review of Resident #2's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was last admitted [DATE] with diagnoses of surgical amputation, absence of left leg below the knee, and absence of right leg below the knee. Record review of an admission MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. The resident required substantial to maximum assistance with the helper doing more than half the effort for sit to lying, sit to stand, and transfers. Record review of Resident #2's care plan dated 12/26/24 and revised on 1/3/25 indicated a problem of the resident was at risk for skin integrity related to reduced mobility due to bilateral amputation, poor nutrition and immune comprised. Some of the interventions were to monitor and document size and location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Record review of Resident #2's prior to facility admission hospital records dated 1/27/25 indicated to cleanse left BKA site daily with antibacterial soap and water or wound cleanser, apply no stick dressing and secure with ace wrap compression. Start taking Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg oral one tablet two times a day for 10 days. Record review of Resident #2's MAR for February 2025 indicated Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg give one tablet by mouth q 12 hours for cellulitis for 10 days with a start dated on 1/27/25. The medication was noted to be last given on 2/6/25 at 8:00 a.m. Record review of Resident #2's TAR for February 2025 indicated cleanse left BKA site with antibacterial soap and water or wound cleanser, apply nonstick dressing, secure with ace wrap compression one time a day every Tuesday, Thursday, and Saturday for wound care with start date of 1/30/25. The TAR indicated the last time wound care was provided was Tuesday 2/4/25. On Thursday 2/6/25 the TAR indicated to see the nurses' notes on Saturday 2/8/25 indicated the drug refused. Record review of Resident #2's nursing notes dated 2/6/25 indicated Resident #2 refused wound care. Signed by treatment nurse. Record review of Resident #2's wound evaluation dated 2/7/25 at 6:22 a.m. indicated a surgical wound with 38 staples on the left below the knee amputation site. The area of the wound was 44.65 cm, and the length was 8.14 cm and 7.58 cm. the wound was one to 3 months old. It had 50 percent granulation and 50 percent slough. There was evidence of infection such as increased drainage, increased pain, redness/inflammation, warmth, and bleeding. There was moderate sanguineous bloody drainage. The was pitting edema that extended 4 cm around the wound and was warm, the pain was at a level 4 with continuous frequency. The wound evaluation indicated the wound was deteriorating and the physician diagnosed the infection. The wound evaluation was signed by the treatment nurse. Record review of Resident #2's nursing note dated 2/7/25 at 11:09 a.m. indicated surgery for BKA revision rescheduled for 2/12/25 arrival at 9:30 a.m. for 11:30 a.m. procedure. Record review of Resident #2's nursing note dated 2/8/25 at 6:15 p.m. indicated cleanse left BKA site with antibacterial soap or wound cleanser and apply dressing. Record review of Resident #2's change in condition notes dated 2/9/25 at 1:00 p.m. indicated Resident #2 had a change in condition that consisted of lethargy, confusion, loss of appetite, elevated heart rate at rest started 2/9/25 and had stayed the same. His primary diagnosis was orthopedic aftercare following surgery. his blood pressure was 106/68, pulse 115 (irregular), respiration 16, temp 98.9, oxygen status 96. Signed by LVN A Record review of nursing notes dated 2/9/25 at 2:40 p.m. indicated Resident #2 was sent to the hospital. Record review of Resident #2's hospital records dated 2/9/25 indicated the resident was admitted at 12:53 p.m. He was admitted with complaints of left lower extremity wound pain and fever. He had a recent BKA performed at another hospital his blood pressure was 173/95, pulse 114, respirations 16, temp 100.4 and oxygen status 99 percent. The x rays were concerning for gas within the wound that could be either an abscess or gaseous gangrene. He was started on antibiotics and wanted to be transferred to another hospital. The disposition summary on 2/9/25 at 4:51 p.m. indicate a diagnosis of sepsis unspecified organism/left BKA infection. During an interview on 2/11/25 at 3:45 p.m. LVN B said Resident #2 was on antibiotics and had finished them a few days prior to going to the hospital. She said he was sent to the hospital to have surgery on an amputation that needed a revision. During an interview and observation on 2/12/25 at 2:00 p.m. with the treatment nurse and the RN C, the treatment nurse said Resident #2 came to the facility after he had an amputation. She said the wound care physician would not see him because his wound was surgical. She said the last time she completed an assessment on Resident #1 was Friday, 2/7/25. She said Resident #2's surgical wound had deteriorated by her assessment. She said she did not call NP or the physician because she thought Resident #2 was going to surgery center that day. She said she wanted to see the wound herself and document what was going on with the wound before he left for his surgery. She said on Friday, 2/7/25 she noted a change to the wound. She said it did not look like that the week before. She said she had taken a picture that was observed by the surveyor. She described the wound with drainage and yellow slough (a layer of dead tissue formed when cells and other debris are trapped in the wound, and do not get properly removed. It can impede wound healing) around the circumference of the wound. The treatment nurse said Resident #2's leg was cut below the knee, it black above the staples on the wound. The treatment nurse said LVN B had assisted her with wound care on 2/7/25. During a telephone interview on 2/12/25 at 2:20 p.m. LVN B said Resident #2 had an appointment on 2/7/25 for a surgical revision to his BKA. She said it was right on the computer, but it was placed on the transport log with the wrong date. LVN B said when they realized the resident was not at his appointment they had called the clinic and were initially told to bring the resident to the appointment late. She said in about an hour the clinic called back and said the physician said to reschedule. She said the appointment was rescheduled to 2/12/25. She had written the note about the rescheduled appointment, but had not notified anyone he missed the appointment. She said she had assisted the Treatment Nurse on 2/7/25 when she provided wound care to Resident #2. LVN B said Resident #2's surgical wound had drainage, no odor, and the darkness above the wound had grown larger. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he was informed Resident # 2 had a change in condition when they were sending him to the hospital. He said he was not informed Resident #2's wound had deteriorated. Review of the facility policy on Notification of Changes dated 10/24/22 indicated the purpose of the policy was to ensure the facility promptly informed the resident, consulted with the resident physician. The facility must inform the resident, consult with the resident's physician when there is a change requiring such notification such as a significant change. Such as life threatening conditions or clinical complications. Circumstances that require a need to alter treatment such as adverse consequences, acute condition or exacerbation of symptoms. Due to the above findings, it was determined the facility was in an Immediate Jeopardy (IJ) situation on 2/13/25 at 5:00 p.m. The Administrator, Regional Nurse Consultant, and ADON/RN G were informed on 2/13/25 at 5:00 p.m. an email was sent to the Administrator. The facility's Plan of Removal was accepted on 2/14/25 at 10:51 a.m. Plan of Removal for F580: [To Identify Any Other Residents to Have the Potential: Beginning 2/13/25, the Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record. All residents, evaluated, validated and documented on 2/13/25 with no additional cases identified. Education/ System Change: On 2/12/25, the Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: o Documentation in Medical Record o Medication Administration o Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results o When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. o Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation). o Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. Monitoring: Beginning 2/13/25, and going forward, the Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 2/13/25, and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 2/13/25, and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology to ensure that Medical Providers are notified of results. An Ad Hoc QAPI {quality assurance and performance improvement} Meeting was conducted on February 13, 2025, by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F580 Notification of Changes and plan to correct.] On 02/14/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of in-services dated 2/13/25 and 2/14/25 indicated staff were trained on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. Record review of 24-hour reports dated 2/13/25 and 2/14/25, the PCC Skin and Wound Module, and the PCC Results Module revealed no concerns. Record review of the facilty's QAPI meeting attendance sheet indicated they met on 2/13/25. Interviews on 2/14/25 with the ADON, Regional Clinical Specialist and Administrator indicated in-services were completed with staff on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. They said staff had knowledge and were able to explain procedures on notification of changes, changes in medication administration, wound care, radiology/lab results, and documentation in the medical record. They said staff were knowledgable on giving report during shift change from the 24 hour report that was generated from the clinical documentation. They said staff were able to explain procedures on changes of condition and notifying the provider of the change, and documentating in the clincial record. They said they went over the 24 hour reports during their morning meeting. Interviews and record reviews were conducted on 02/14/25 from 4:00 p.m. through 8:00 p.m. and included 3 RNs, 4 LVNs, ADON, Regional Clinical Specialist and Administrator. Staff were able to explain documentation in medical record and medication administration. Staff had knowledge on notification of changes policy and to include changes in medication administration, wound care, and abnormal radiology results. The staff successfully provided an explanation when a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. The staff was well-informed about licensed nurses will give shift report from the PCC generated 24-hour report. (PCC {point click care- facility medical records system} generated from clinical documentation). Also, Staff was able to explain licensed nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. All residents in the facility were evaluated for any change in condition, validated and documented on 2/13/25 with no additional cases identified. This was verified by interview with the ADON (DON Designee), the Administrator and record review of 24-hour summary listing resident name, room number and progress notes dated 2/13/25. During an observation on 2/14/25 at 6:35 p.m. of a shift change and reporting between LVN E and LVN I, there were no issues noted. The Administrator and ADON/RN G were informed on 2/14/25 at 7:35 p.m. the IJ was removed. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate threat with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide care and treatment in accordance with professional standards of practice based on the comprehensive assessment for 2 of 7 residents (Resident #1 and Resident #2) reviewed for quality of care. The facility failed to ensure Resident #1 received IV antibiotics when his PICC line was dislodged on 2/5/25. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to address Resident #1's chest x-ray that was ordered and sent back to the facility on 2/7/25 until 2/10/25. The facility notified Resident #1's MD on 02/10/25 that Resident #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. Resident #1 was admitted to the hospital on [DATE] with diagnoses of right lobe pneumonia due to ESBL(extended spectrum beta lactamase). The facility failed to ensure Resident #2's surgical wound did not worsen. Resident #2 was admitted to the hospital on [DATE] with left lower leg pain and fever. He had a diagnosis of sepsis ( a life threatening complication of an infection) left below the knee amputation infection. An Immediate Jeopardy (IJ) situation was identified 2/13/25 at 5:00 p.m. While the IJ was removed on 2/14/25 at 7:35 p.m., the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures caused life threatening consequences for these two residents and put other residents at risk for not receiving timely medical interventions. Findings included: Record review of Resident #1's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was readmitted on [DATE] with diagnoses of Diffused traumatic brain injury, osteomyelitis, pneumonia, covid 19, quadriplegia, contracture of the right and left hand, and presence of left artificial elbow joint. Record review of Resident #1's admission MDS dated [DATE] indicated he was moderately impaired in decision making. He was unable to complete the BIMS. The resident had impaired range of motion on both sides of his upper extremity (shoulder, elbow, wrist, and Hand) and his lower extremity (hip, knee, ankle, and foot.) He required a wheelchair for mobility. He was dependent on staff for all activities of daily living. The MDS indicated the resident had an indwelling catheter and ostomy. Record review of Resident #1's care plan dated 1/28/25 indicated a problem of altered respiratory status/difficulty breathing related to recent hospitalization stay for Covid and pneumonia. The resident will be on IV antibiotics for pneumonia with an initiation date of 1/27/25 and a revision date of 2/7/25. Some of the interventions were to monitor and document changes in orientation. Monitor for signs and symptoms of respiratory distress and report to the physician increased respirations, decreased pulse oximetry, increased heart rate, restlessness, lethargy, confusion, and cough. A care plan problem of IV medications related to pneumonia. The care plan interventions were related to complications related to IV therapy such as infiltrated IV, drainage, or inflammation. Record review of Resident #1's prior to facility admission hospital records dated 1/31/25 indicated a diagnosis of pneumonia due to covid dated 1/23/25, ESBL Extended spectrum beta lactamase: producing bacterial infection dated 9/17/24 still present, Acute osteomyelitis of the right elbow dated 12/24/24 still present. His discharge medication included meropenem 1 GM. Record review of Resident #1's nursing notes dated 1/31/25 at 6:17 p.m. indicated the resident was returning to the facility from the hospital. Signed by RN H. Record review of Resident #1's physician order indicated Meropenem Intravenous Solution Reconstituted use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days dated 2/1/25. Record review of Resident #1's MAR indicated Meropenem Intravenous Solution Reconstituted 1 GM use 1 gram intravenously every 8 hours for pneumonia due to covid for 7 days. With a start date of 2/1/25. The MAR indicated the medication was to be administered at 7:00 a.m., 3:00 p.m., and 11:00 p.m. The MAR indicated the mediation was given 3 times daily with the last dose 2/5/25 at 11:00 p.m. Record review of Resident #1's nursing notes indicated: On 2/6/25 at 1:27 p.m. meropenem intravenous Solution reconstituted 1GM was not given due to loss of PICC access. The PICC company was notified for replacement. The NP was made aware. Signed by LVN C. On 2/6/25 at 10:13 p.m. indicated the resident refused midline, would not let staff unbend arm to pace midline. Signed by LVN F. On 2/7/25 at 1:40 p.m. the company that replaced PICC lines was called to replace Resident #1's PICC line. Signed by LVN E On 2/7/25 at 2:58 p.m. no PICC line in place for administration of medication. Signed by LVN E On 2/7/25 at 10:12 p.m. no PICC line access. Signed by LVN F On 2/8/25 at 12:17 a.m. resident remained without IV access signed by LVN F. On 2/10/25 at 11:38 a.m. Resident #1's PICC line was dislodged on 2/5/25 and the NP was informed. An outside service provider attempted to replace and insert new PICC line in the facility. The technician was unsuccessful due to contraction of upper extremities of patient. The patient did not complete antibiotic therapy and missed several doses. The nurse contacted NP regarding situation and current symptoms to include cough, abnormal lung sounds, abnormal chest x ray. The nurse received an order to send Resident #1 to the ER. His blood pressure was 116/64, oxygen status on room air was 91 percent, his temperature was 98.8 and his pulse was 80. Signed by LVN E. Record review of a change in condition note dated 2/10/25 at 6:57 p.m. indicated Resident #1 had increased cough, a positive chest x ray, incomplete antibiotic therapy, these things made the condition worse. Signed by LVN E. Record review of Resident #1's x ray report dated 2/7/25 and signed electronically on 2/7/25 at 11:07 a.m. indicated Resident #1 had patch bilateral lung opacities (area of increased density or darkness in the lungs.) This was consistent with bilateral pneumonia. The findings are worse compared with prior. Record review of Resident #1's hospital records dated 2/10/25 indicated Resident #1 was receiving IV antibiotics for pneumonia. He lost his PICC line assess, and the facility attempted to have it replaced but was unsuccessful. The resident had an x ray showing he still had pneumonia and was sent to the hospital for PICC line replacement. He has a history of pneumonia. He is nonverbal and quadriplegic, unable to move upper or lower extremities, with severe contractions noted. The hospital records indicated they spoke with the RN at the facility and was informed the PICC line had been out since 2/5/25. He had a diagnosis of pneumonia of the right lower lobe due to infectious organism ESBL (extended spectrum beta -lactamase) producing bacterial infection. Record review of a nursing note dated 2/10/25 at 9:56 p.m. indicated the nurse called to check on Resident #1's status. He was admitted to the hospital with a diagnosis of right lower lobe pneumonia, acute osteomyelitis, ESBL. Signed by LVN E During an interview and record review on 2/12/25 at 3:21 p.m. LVN C said Resident #1 did not have PICC line access when she came in on 2/6/25. She said she had gotten the ADON/RN D to come in and help her assess the resident. She said the NP was in the building doing rounds. She said the NP told them to contact a company that replaced PICC lines. She said she had contacted that company on 2/6/25 for them to come out and replace Resident #1's PICC line. A review of the nursing notes with LVN C indicted Resident #1 had refused the reinsertion on 2/6/25. LVN C said she was not aware the company had been contacted again on 2/7/25 by LVN E and she did not know what had happened with Resident #1's PICC line. During an interview on 2/12/25 at 3:44 p.m. ADON/RN D said she was not sure if Resident #1's PICC line had been noted as displaced by the prior shift on 2/5/25. She said Resident #1's right arm was contracted, and he held it tightly to his biceps. The ADON/RN said she did not know how the PICC line came out. She said LVN C had asked her to come in and assess Resident #1 on the morning of 2/6/25. She said the NP was in the building and the NP and told them to contact a company that replaced PICC lines. She said she knew LVN C had called the company. She did not know Resident #1 had refused or how many times the company had been called or why the PICC line was not replaced. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he had gotten a text earlier on the morning of 2/6/25 that Resident #1's PICC line had come out. He said he told them to call the PICC line replacement company and have them to come out to replace the PICC line. He said the facility did not inform him they were unable to replace the PICC line. He said he was not informed Resident #1 was not taking the antibiotic. The NP said if they had informed him Resident #1 was not able to finish his antibiotic, he would have told them to send him to the hospital. During a telephone interview on 2/12/25 at 4:31 p.m. the DON said on 2/7/25 LVN E told her that the PICC line company said they would not come back to the facility to try and reinsert Resident #1's PICC line. They said they were unable to do so due to his contractures. She said she told LVN E to call the physician and let him know. The DON said on the morning of Monday, 2/10/25 after the x rays were reviewed, she told LVN E to call the physician and send Resident #1 to the hospital. During a telephone interview on 2/12/25 at 4:32 p.m. LVN E said she had talked to the PICC line company, and their nurse said they were not coming out. She said the nurse said Resident #1 was too contracted and they were not able to place the PICC line. LVN E said she was leaving for the day and told the DON what the company had said. The DON told her to make the physician aware. She told the oncoming nurse LVN F about the situation during report. She said she did not know what happened after then. During a telephone interview on 2/12/25 at 4:55 p.m. LVN F said that on Friday 2/7/25 LVN E told her the PICC line company had refused to come out. She said it was mentioned in the conversation about notifying the physician, but she thought LVN E had notified the physician. LVN F said she had not notified the physician because she thought it was already done. During an interview on 2/13/25 at 7:21 a.m. LVN C said she did not know anything about Resident #1's x rays results until Monday, 2/10/25. She said she worked PRN and was under the impression x rays results would be sent by fax. She said that on Monday, 2/10/25 Resident #1 had a cough that was deeper than on 2/7/25 and she was told he had x ray results that indicated pneumonia and to send him out to the hospital. During an interview on 2/13/25 at 10:30 a.m. the Regional Nurse Consultant said ADON/RN D and Administrator did not find any nurse that admitted to seeing the x ray results for Resident #1 on the weekend. He said it appeared the first time the x rays were noted was on 2/10/25. He said they did not have a policy on change in condition. During an interview on 2/13/25 at 10:34 a.m. the Administrator said they did not find any nurse that discovered the x ray results for Resident #1 over the weekend. She said she was aware of what the NP always said he would send a resident to the hospital if they had a change in condition. The Administrator said she had reached out to the nurses on the weekend they thought the order was complete for Resident #1's antibiotics because the completion date was 2/7/25 and it fell off the system orders. She said they did not see any issues and they did not review the records to see if there was a problem because they thought the antibiotic was completed. Resident #2 Record review of Resident #2's face sheet dated 2/11/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. He was last admitted [DATE] with diagnoses of surgical amputation, absence of left leg below the knee, and absence of right leg below the knee. Record review of an admission MDS dated [DATE] indicated a BIMS score of 11 which indicated moderate cognitive impairment. The resident required substantial to maximum assistance with the helper doing more than half the effort for sit to lying, sit to stand, and transfers. Record review of Resident #2's care plan dated 12/26/24 and revised on 1/3/25 indicated a problem of the resident was at risk for skin integrity related to reduced mobility due to bilateral amputation, poor nutrition and immune comprised. Some of the interventions were to monitor and document size and location and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician. Record review of Resident #2's prior to facility admission hospital records dated 1/27/25 indicated to cleanse left BKA site daily with antibacterial soap and water or wound cleanser, apply no stick dressing and secure with ace wrap compression. Start taking amoxicillin potassium-clavulanate (Augmentin) 875-125 mg oral one tablet two times a day for 10 days. Record review of Resident #2's MAR for February 2025 indicated Amoxicillin potassium-clavulanate (Augmentin) 875-125 mg give one tablet by mouth q 12 hours for cellulitis for 10 days with a start dated on 1/27/25. The medication was noted to be last given on 2/6/25 at 8:00 a.m. Record review of Resident #2's TAR for February 2025 indicated cleanse left BKA site with antibacterial soap and water or wound cleanser, apply nonstick dressing, secure with ace wrap compression one time a day every Tuesday, Thursday, and Saturday for wound care with start date of 1/30/25. The TAR indicated the last time wound care was provided was Tuesday 2/4/25. On Thursday 2/6/25 the TAR indicated to see the nurses' notes on Saturday 2/8/25 indicated the drug refused. Record review of Resident #2's nursing notes dated 2/6/25 indicated Resident #2 refused wound care. Signed by treatment nurse. Record review of Resident #2's wound evaluation dated 2/7/25 at 6:22 a.m. indicated a surgical wound with 38 staples on the left below the knee amputation site. The area of the wound was 44.65 cm, and the length was 8.14 cm and 7.58 cm. the wound was one to 3 months old. It had 50 percent granulation and 50 percent slough. There was evidence of infection such as increased drainage, increased pain, redness/inflammation, warmth, and bleeding. There was moderate sanguineous bloody drainage. The was pitting edema that extended 4 cm around the wound and was warm, the pain was at a level 4 with continuous frequency. The wound evaluation indicated the wound was deteriorating and the physician diagnosed the infection. The wound evaluation was signed by the treatment nurse. Record review of Resident #2's nursing note dated 2/7/25 at 11:09 a.m. indicated surgery for BKA revision rescheduled for 2/12/25 arrival at 9:30 a.m. for 11:30 a.m. procedure. Record review of Resident #2's nursing note dated 2/8/25 at 6:15 p.m. indicated cleanse left BKA site with antibacterial soap or wound cleanser and apply dressing. Record review of Resident #2's change in condition notes dated 2/9/25 at 1:00 p.m. indicated Resident #2 had a change in condition that consisted of lethargy, confusion, loss of appetite, elevated heart rate at rest started 2/9/25 and had stayed the same. His primary diagnosis was orthopedic aftercare following surgery. his blood pressure was 106/68, pulse 115 (irregular), respiration 16, temp 98.9, oxygen status 96. Signed by LVN A Record review of nursing notes dated 2/9/25 at 2:40 p.m. indicated Resident #2 was sent to the hospital. Record review of Resident #2's hospital records dated 2/9/25 indicated the resident was admitted at 12:53 p.m. He was admitted with complaints of left lower extremity wound pain and fever. He had a recent BKA performed at another hospital his blood pressure was 173/95, pulse 114, respirations 16, temp 100.4 and oxygen status 99 percent. The x rays were concerning for gas within the wound that could be either an abscess or gaseous gangrene. He was started on antibiotics and wanted to be transferred to another hospital. The disposition summary on 2/9/25 at 4:51 p.m. indicate a diagnosis of sepsis unspecified organism/left BKA infection. During an interview on 2/11/25 at 3:45 p.m. LVN B said Resident #2 was on antibiotics and had finished them a few days prior to going to the hospital. She said he was sent to the hospital to have surgery on an amputation that needed a revision. During an interview and observation on 2/12/25 at 2:00 p.m. with the treatment nurse and the RN C, the treatment nurse said Resident #2 came to the facility after he had an amputation. She said the wound care physician would not see him because his wound was surgical. She said the last time she completed an assessment on Resident #1 was Friday, 2/7/25. She said Resident #2's surgical wound had deteriorated by her assessment. She said she did not call NP or the physician because she thought Resident #2 was going to surgery center that day. She said she wanted to see the wound herself and document what was going on with the wound before he left for his surgery. She said on Friday, 2/7/25 she noted a change to the wound. She said it did not look like that the week before. She said she had taken a picture that was observed by the surveyor. She described the wound with drainage and yellow slough (a layer of dead tissue formed when cells and other debris are trapped in the wound, and do not get properly removed. It can impede wound healing) around the circumference of the wound. The treatment nurse said Resident #2's leg was cut below the knee, it black above the staples on the wound. The treatment nurse said LVN B had assisted her with wound care on 2/7/25. During a telephone interview on 2/12/25 at 2:20 p.m. LVN B said Resident #2 had an appointment on 2/7/25 for a surgical revision to his BKA. She said it was right on the computer, but it was placed on the transport log with the wrong date. LVN B said when they realized the resident was not at his appointment they had called the clinic and were initially told to bring the resident to the appointment late. She said in about an hour the clinic called back and said the physician said to reschedule. She said the appointment was rescheduled to 2/12/25. She had written the note about the rescheduled appointment, but had not notified anyone he missed the appointment. She said she had assisted the Treatment Nurse on 2/7/25 when she provided wound care to Resident #2. LVN B said Resident #2's surgical wound had drainage, no odor, and the darkness above the wound had grown larger. During a telephone interview on 2/12/25 at 4:30 p.m. the NP, he said he was informed Resident # 2 had a change in condition when they were sending him to the hospital. He said he was not informed Resident #2's wound had deteriorated. Record review on the policy on Laboratory Services and Reporting dated 4/8/23 indicated. The facility must provide or obtain laboratory services when ordered. The facility responsible for the timeliness of services. The facility will promptly notify the ordering physician, or nurse practitioner of the laboratory results that fall outside the clinical reference range. Due to the above findings, it was determined the facility was in an Immediate Jeopardy (IJ) situation on 2/13/25 at 5:00 p.m. The Administrator, Regional Nurse Consultant, and ADON/RN G were informed on 2/13/25 at 5:00 p.m. an email was sent to the Administrator. The facility's Plan of Removal was accepted on 2/14/25 at 10:51 a.m. Plan of Removal for F684: [To Identify Any Other Residents to Have the Potential: Beginning 2/13/25, the Licensed Nurse will evaluate all other residents in the center for any change in condition. Should any changes be evaluated, the physician will be notified. The evaluation will be documented in the resident's clinical record. All residents, evaluated, validated and documented on 2/13/25 with no additional cases identified. Education/ System Change: On 2/12/25, the Director of Nursing /Designee initiated reeducation with Licensed Nurses on the following topics: o Documentation in Medical Record o Medication Administration o Notification of Changes Policy to include changes in medication administration, wound care and abnormal radiology results o When a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. o Licensed Nurses will give shift report from the PCC generated 24 hour report. (PCC generated from clinical documentation). o Licensed Nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. Re-education will continue until 100% of nursing staff are reeducated. Those that are PRN, agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. DON/Designee will provide training. Monitoring: Beginning 2/13/25, and going forward, the Director of Nursing / designee will review the 24- hour report, the PCC Skin and Wound Module and the PCC Results Module in the morning clinical meeting to ensure that changes of condition documented in the clinical record are identified and communicated with the physician and the resident representative. Beginning 2/13/25, and on-going, the Director of Nursing or designee will monitor compliance each weekly morning. Results of findings will be discussed in the monthly QAPI meeting for three months and the plan will be continues as needed. Beginning 2/13/25, and on-going, the Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the 24-hour report in the morning clinical meeting to identify changes in condition. The Weekend Supervisor will review the 24-hour report in PCC as well as the Results Module (Lab and Radiology to ensure that Medical Providers are notified of results. An Ad Hoc QAPI {quality assurance and performance improvement} Meeting was conducted on February 13, 2025, by the Administrator, with the Medical Director, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning [Quality of Care] and plan to correct.] On 02/14/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of in-services dated 2/13/25 and 2/14/25 indicated staff were trained on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. Record review of 24-hour reports dated 2/13/25 and 2/14/25, the PCC Skin and Wound Module, and the PCC Results Module revealed no concerns. Record review of the facilty's QAPI meeting attendance sheet indicated they met on 2/13/25. Interviews on 2/14/25 with the ADON, Regional Clinical Specialist and Administrator indicated in-services were completed with staff on provider notification, shift hand off/reporting, 24-hour report, accessing/reviewing lab/radiology, medication administration, documentation in the medical record and abuse/neglect. They said staff had knowledge and were able to explain procedures on notification of changes, changes in medication administration, wound care, radiology/lab results, and documentation in the medical record. They said staff were knowledgable on giving report during shift change from the 24 hour report that was generated from the clinical documentation. They said staff were able to explain procedures on changes of condition and notifying the provider of the change, and documentating in the clincial record. They said they went over the 24 hour reports during their morning meeting. Interviews and record reviews were conducted on 02/14/25 from 4:00 p.m. through 8:00 p.m. and included 3 RNs, 4 LVNs, ADON, Regional Clinical Specialist and Administrator. Staff were able to explain documentation in medical record and medication administration. Staff had knowledge on notification of changes policy and to include changes in medication administration, wound care, and abnormal radiology results. The staff successfully provided an explanation when a licensed nurse identifies a change in condition, they will evaluate the resident and document their evaluation in the clinical record. The Licensed Nurse will notify the Medical Provider of the change in condition and document that notification in the clinical record. The staff was well-informed about licensed nurses will give shift report from the PCC generated 24-hour report. (PCC {point click care- facility medical records system} generated from clinical documentation). Also, Staff was able to explain licensed nurses will review the Results Module in PCC (Lab and Radiology) at the shift change to notify the Medical Provider of results. During an observation on 2/14/25 at 6:35 p.m. of a shift change and reporting between LVN E and LVN I, there were no issues noted. All residents in the facility were evaluated for any change in condition, validated and documented on 2/13/25 with no additional cases identified. This was verified by interview with the ADON (DON Designee), the Administrator and record review of 24-hour summary listing resident name, room number and progress notes dated 2/13/25. The Administrator and ADON/RN G were informed on 2/14/25 at 7:35 p.m. the IJ was removed. The facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed based on the comprehensive assessment to ensure residents received the care and services in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for quality of care. The facility failed to assess the resident when she complained of pain or document where the pain was located. The facility failed to ensure the complete/accurate documentation of the resident's bowel elimination. Resident #1 was transferred to the hospital and diagnosed with fecal impaction. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/25/23 at 3:00 p.m. While the IJ was removed on 5/26/23, the facility remained out of compliance at actual harm that is not immediate jeopardy 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. These failures could place residents at risk of not receiving thorough assessments, fecal impactions, and decreased quality of care resulting in hospitalization or death. Findings included: Record review of Resident #2's face sheet with a print date of 4/20/23 indicated this 68 -year- old female was admitted to the facility on [DATE]. Some of her diagnoses were heart failure, schizoaffective disorder (combination of psychotic disorder with mood disorder), lack of coordination, and pacemaker. Record review of Resident #2's 5-day MDS indicated she had moderate cognitive impairment. The MDS indicated Resident #2 required limited assistance of one person for bed mobility, extensive assistance for transfers with one person. The resident required existence assistance of one person for toilet use Record review of Resident #2's care plan with an initiated date of 2/14/23 indicated Resident #2 had a problem with bowel and bladder incontinence related to impaired mobility. The interventions were, clean peri-area with each incontinence episode, ensure the resident had an unobstructed path to the bathroom. When incontinent, check every 2 hours and as need as required for incontinence. The resident had a problem of pain and history of gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints) and generalized pain and a frozen shoulder. Some of the interventions were administer pain relief cream, monitor, and document for probable causes of each pain episode, monitor, record, and report complaints of pain and or pain medication requests. Review of Resident #2's computerized physician orders indicated she had an order dated 2/9/23 for tramadol one table 50 mg by mouth as needed for pain two times a day. An order for Tylenol (Acetaminophen) (no dosage) give two tablets by mouth as need for mild pain and fever. A side effect of Tramadol is constipation. There were no orders for any stool softeners. An order dated 3/11/23 indicated to assess and document pain level for 0-10 every shift. Record review of Resident #2 bowl elimination record indicated: On 3/21/23 Morning no documentation- Evening -2 for no BM- Night- had X (no explanation for what X stood for) On 3/22/23 Morning no documentation - Evening -2 - no bowel movement- Night-2 no bowel movement On 3/23/23 Morning 1- incontinence, medium- formed BM - Evening no documentation -Night- X (no explanation for what X stood for) On 3/24/23 Morning 1 for incontinent, size small and formed BM- Evening 2 no BM -Night- X (no explanation for what X stood for) On 3/25/23 Morning 2 for no BM- Evening -no documentation -Night- had X (no explanation for what X stood for) On 3/26/23 Morning no documentation -Evening no documentation Night-X (no indication of what that means in the table of contents) On 3/27/23 Morning 1 for incontinent medium formed BM- initialed by CNA L- Evening incontinent large Putty (mushy) like- Initialed by CNA M- Night- incontinent large putty like- Initialed by CNA M On 3/28/23 Morning- incontinent medium formed/normal initialed by CNA J Record review of Resident #2's MAR indicated she received Tramadol HCL 50 mg tablet as needed for pain on 3/24/23 and 3/25/23. She received Tylenol (no mg listed) give two by mouth as need for mild pain or fever on 3/26/23 and 3/27/23 both time by LVN H. Record Review of Resident #2's MAR for assess and document pain level 0-10 every shift indicated on 3/24/23, 3/25/23, 3/26/23 was checked indicating the pain level was assessed. Record review of Resident #2's nursing notes dated 03/24/23 at 10:39 p.m. indicated Tramadol 50 mg was given. The nursing note did not address where Resident #2's pain was located or the indication of why Tramadol was given. The nursing note indicated the Tramadol 50 mg was effective. Record review of Resident #2's nursing notes dated 03/25/23 at at 6:43 p.m. indicated Tramadol 50 mg was given for arm and leg pain and it was effective. Record review of Resident #2's nursing note dated 3/26/23 at 10:33 p.m. indicated Resident #2 received Tylenol two tablets as need for mild pain or fever of 100.6 or greater. The nursing note did not indicate if Resident #2 had pain or fever. The nursing note indicated the Tylenol was effective. Record review of Resident #2's nursing note dated 3/27/23 at 9:09 p.m. indicated Resident #2 received Tylenol two tablets as need for mild pain or fever of 100.6 or greater. The nursing note did not indicate if Resident #2 had pain or fever. The nursing note indicated the Tylenol was effective. Written by LVN H. Record review of Resident #2's nursing note dated 3/28/23 at 8:34 a.m. the NP was notified this morning regarding large blood clots in Resident #2's brief during care. At 8:45 a.m. the NP ordered stat labs. At 10:38 a.m. the resident was seen by the wound care doctor for wound on the right buttock. At 1:03 p.m. Resident #2 complained of lower abdominal pain, distended abdomen noted. The NP was notified, and resident was sent to the hospital. Written by LVN I. Record Review of Resident #2's Change of Condition Communication Form dated 3/28/23 at 2:20 p.m. indicated the change in condition was lower abdominal discomfort that had worsened. The abdomen was distended, and decreased appetite. The dated of last BM was blank. Urine output indicated not applicable. Filled out by LVN I. Record review of Resident #2's hospital records dated 3/28/23 indicated she was admitted to the hospital due to stomach pain. The record indicated the Nursing Home said she had not had a Bowel Movement in 5 days. She had large clots of blood in her brief. Her diagnosis at the hospital was Fecal Impaction (hard stool stuck in the rectum). There was a manual dis-impaction preformed and aggressive bowel regimen with stool softeners. She had Stercorol Colitis (occurs when the patient had chronic constipation leading to a stagnation of fecal matter and a diagnosis of Adynamic ileus (pathological obstruction of the bowel due to failure of smooth muscle to contract.) The resident also had a diagnosis of Acute Kidney Failure. The hospital records indicated constipation caused the bladder outlet syndrome of urinary retention. A Foley Catheter was inserted with initial output of 1 liter of urine with 900 ml more slowly. During a telephone interview on 4/26/23 at 9:33 a.m. LVN H said she did not remember Resident #2. Her nursing note indicated she had given the Resident #2 pain medication on at least two occasions prior to her going to the hospital. She said if she gave pain medication she did not know why or what Resident #2's pain complaint was. LVN H said she had not worked at the facility in a while and could not remember anything about Resident #2. During an interview on 4/26/23 at 9:44 a.m. LVN I said she had been off for 3 days and did not know how the resident had done while she was off. She said she was the nurse that sent Resident #2 to the hospital on 3/28/23. She said CNA J called her to the room. She said when she arrived Resident #2 had abnormal bleeding that had saturated her brief pad, and she notified NP- N. He wanted to complete stat labs. She said the resident was complaining of pain and not having a bowel movement. The LVN said she heard Resident #2 tell the paramedics she had not had a BM in days. LVN I said she did not tell the paramedics it had been days, the resident did. LVN I said Resident #2 was incontinent and required assistance with going to the bathroom. LVN I said she looked at the ADL sheets on 3/28/23 to determine if the resident was having BMs. She said she could not tell for sure if the resident was having bowel movements or not. She said she could tell nothing by the ADL sheets. She was also afraid the staff especially agency did not always document correctly. The LVN said by the amount of blood in her brief the recommendations for labs did not sit right. LVN I said she called the NP back and told him Resident #2 was still bleeding, complaining of pain, and she wanted to go to the hospital. The resident was sent out. During an interview and record review on 4/26/23 at 10:30 a.m. CNA K/ staffing coordinator said they work 12-hour shifts. She reviewed Resident #2's ADL sheet for bowel and bladder elimination the last few days prior to the resident's hospitalization. She said that the two aides, CNA L and CNA M, were agency staff that had signed those sheets. During a telephone interview on 4/26/23 at 10:24 a.m. CNA L said she did not know Resident #2, she did not remember her at all. If there was something going on with her, she said she did not remember. CNA L said she cannot recall what she wrote on ADL sheets. She said she worked for agency and had been to multiple other facilities since 3/28/23. During a telephone interview on 4/26/23 at 10:51 a.m. CNA M said she did not remember Resident #2 and did not recall any care she may have provided for her. CNA M said she was in and out of lot of facility, some residents were memorable, and some were not. During a telephone interview on 4/26/23 at 11:15 a.m. CNA J said she had been off for 3 days and did not know how Resident #2 had done during that time. CNA J said on the morning of 3/28/23 Resident #2 was noted with big clumps of blood clots, coming out with BM. The BM was not a lot, but it just kept coming out. CNA J said the BM was soft and still running when wiped. She said she continued to wipe, and it continued to run. CNA J said she had never saw anything like that and had sent for LVN I. CNA J. She said she did not recall what she documented on the ADL sheet. She said Resident #2 did have a BM, but it was not like anything she had ever seen, it was bad. During an interview on 4/26/23 at 11:22 a.m. RN/ADON F said a fecal impaction can cause nausea vomiting, loss of appetite, loose watery stool, or soft stool. During an interview on 4/26/23 at 11:29 a.m. the NP-N said he was informed on yesterday by the facility that Resident #2 had a fecal impaction. He said as far as he knew her symptoms started on the morning of 3/28/23. He said the nurse called him and told him the resident had some blood and abdominal pain. He remembered he had ordered some labs. He did not remember if anyone else had called him about the resident prior to 3/28/23. He said a stool softener could have helped to prevent the fecal impaction. However, as far as he knew no one had told him she had any issues. He said she did not have a history of constipation. During an interview on 4/26/23 at 12:20 p.m. LVN I said she did not know if she wrote a note about the change in condition; she said Resident #2 complained of pain in her stomach and her stomach was distended. She said she checked for bowel sounds and they were present. LVN J said she did not know if she had written that in a note either. LVN I said the CNA J had called her to the room on 3/28/23. She said the resident did have BM or something mixed with the blood, but it was not really a BM. LVN I said it was not formed (ADL sheet documented formed/normal and medium) She said it was just runny slimy stuff. During an interview and record review on 4/26/23 at 12:30 p.m. the DON reviewed Resident #4's Bowel and bladder sheets. She said on 3/25/23 and 3/26/23 Resident #2 did not have any documentation. She said on 3/27/23 the charting indicated she had a medium BM that was Formed and during the night shift a large Putty BM. She said perhaps their documentation needed work, but it indicated on the 3/27/23 she had a BM. During an interview on 4/26/23 at 1:03 p.m. the Interim Administrator said the staff did what they were supposed to do. He said the nurse saw the signs and symptoms of distress on the morning, of 3/28/23 with Resident #2, the physician was notified, and the resident was sent to the hospital. During an interview on 4/26/23 at 1:10 p.m. the DON said they saw a change in Resident #2's condition, notified the physician and sent her to the hospital which is what they were supposed to do. The DON said they did not have a policy on fecal impaction. During an interview on 5/9/23 at 3:18 p.m. the Medical Director said he had reviewed Resident #2's hospital records and they indicated they got their information from the paramedics and had not consulted the resident about her bowel movements. The Medical Director said Resident # 2 was fully capable to telling them when the last time she had a BM. He said the resident had contributing factors that led to her fecal impaction such and bed bound, and diabetes. He said there were also other factors that could have led to the urinary retention other than a fecal impaction. He said she had several chronic issues. He said he could not say how long it took the resident to have a fecal impaction. It depended on her hydration. Some people it could take from 1 day to 5. He said some people have BMs with fecal impactions. Some of the major indicators of fecal impaction were distended abdomen, pain, nausea, and vomiting. Record review of the facility policy on Pain Management implemented 8/15/22 indicated the facility will utilize a systematic approach for recognition, assessment, treatment, and monitoring pain. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status to assist staff in consistent assessment of resident pain. Identifying key characteristics of pain: duration, frequency, location, timing, pattern, and radiation of pain. Facility staff will reassess residents pain management for effectiveness and or adverse consequences (such as constipation, sedation, anorexia, change in mental status, delirium, respiratory depression, nausea, or vomiting. The facility was notified of the Immediate Jeopardy (IJ) on 5/25/23 at 3:00 p.m. and the Administrator was provided the Immediate Jeopoardy template. The facility was asked to provie a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal (POR) was accepted on 5/26/23 at 4:15pm and indicated the following: Plan of Removal - F684 Quality of Care On May 25, 2023, the facility learned that an IJ was being called due to F684 Quality of Care. The Facility failed to: Provide effective treatment and care for Resident #2 to prevent the development of a fecal impaction. Monitor Resident #2 for constipation/fecal impaction. (Resident #2 was prescribed Tramadol for pain as needed, which has the side effect of constipation). Accurately document and monitor Resident #2's BM, hydration, and meal intake to prevent a fecal impaction. Assess and document pain when giving PRN pain medication. Properly document Resident #2's BMs from 3/21/2023 through 3/28/2023. Have a policy and procedure in place for assessing residents and monitoring BMs to prevent a fecal impaction when residents are at risk for constipation. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent the development of a fecal impaction which could lead to serious harm or death. Director of nursing and ADON performed 100% rounds for building census of 109 residents that are at risks for fecal impaction on May 25, 2023, to ensure we are providing effective treatment and prevention the development of a fecal impaction. No immediate intervention was needed after sweep. All proper orders were in place regarding prevention of fecal impaction. On May 25, 2023, the Director of Nurses reeducated Licensed Nurses, CNAs, and CMAs to observe sign and symptoms of fecal impaction and prevention of fecal impaction. Additionally, reeducated nursing staff on documenting all bowel movements, meal intakes and snacks in the medical record. Charge nurses will ensure all documentation from their shift is entered in the electronic point of care and EMAR before shift ends. The Director of nursing / designee will monitor the proper documentation of bowel movements, meal intakes, and snacks in the medical record three times per week for one month. Nursing staff includes agency that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. On May 25, 2023, The CNAs were reeducated by the Director of Nursing on reporting any changes in bowel elimination to the Charge Nurses. The Charge Nurses were reeducated by the Director of Nursing on May 25, 2023, that they must then look at alerts in the medical record reported and document the results of the examination in the medical record. The Charge Nurse will contact the attending physician to notify of a change in condition in bowel movements and to obtain stool softeners, interventions, or orders as indicated. The Charge Nurse will notify the DON and/or ADON of changes of bowel elimination when identified. The Director of Nursing / designee will monitor compliance three times per week by audit of clinical charts for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. Director of nursing and ADON performed 100% rounds for all residents on pain medication on May 25, 2023, to ensure pain medication that is schedule and as needed is documented properly to include effectiveness, source, and location of pain. No immediate intervention was needed after sweep. On May 25, 2023, the Director of Nursing reeducated Licensed Nurses on proper documentation of pain medication that includes assessment for pain including effectiveness of pain medication, source of pain, and location of pain. Additionally, Licensed Nurses were reeducated on the pain medication side effects that includes but not limited to a fecal impaction. The Director of Nursing / designee will monitor compliance three times per week by audit of clinical charts three times a week for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on- one setting on paper. On May 25, 2023, the Director of Nurses reeducated Licensed Nurses, CNAs, and CMAs, including the Director of Nursing on revised policy on Activities of Daily Living that will include documentation of ADLs in the electronic record. The Administrator / designee will monitor compliance three times per week for one month. Nursing staff including agency staff that was not on duty at the time reeducation, will receive the reeducation before the start of their next scheduled shift. 90% of all staff have been reeducated in a one-on-one setting on paper. The Director of Nursing / designee will educate the newly hired nursing staff upon hire, prior to working including agency staff which includes and nurses and CNAs, on-going. 90% of all staff have been reeducated in a one-on-one setting on paper. Director of Nursing will monitor daily during morning clinical meeting to ensure proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are report and follow up on any order related to change. The results will be discussed in the monthly QAPI meeting for three months and continued as needed. An AdHoc QAPI was conducted on May 25, 2023 at 1630, by the Administrator, with the Medical Director, Nurse Practitioner, Social Worker, Director of Nursing, Medical Records, Treatment Nurse, MDS' nurses, Maintenance Director, Dietary Manager, Activities Director, ADONs, Regional [NAME] President, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning quality of care related to proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are reported and to develop the above-mentioned plan of care. On 05/26/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: All residents on pain medication were assessed and charts was audited to ensure pain medication that is schedule and as needed is documented properly to include effectiveness, source, and location of pain by Director of nursing and ADON. This was verified by interview with DON and record review of audit sheets listing resident name and room number, pain: yes or no, pain location, pain medication, pain med effective, notification, and intervention. All residents' charts were reviewed that are at risk for fecal impaction to ensure they were provided effective treatment and preventing the development of a fecal impaction, completed by Director of nursing and ADON. This was verified by interview with DON and record review of audit sheets listing resident name and room number, last BM, GI system, GI Pain, Notification and Intervention. Chart audit was done on all residents to ensure bowel elimination was being documented completed by Regional Clinical Specialist (RCS). This was verified by interview with RCS and record review of 29-page B&B- Bowel Elimination audit date range 5/22/23 to 5/26/23 on all the residents. In-Services addressed bowel movements, meal intakes, documentation, reporting and observing. Staff was in-serviced to assess for sign and symptoms of fecal impaction and prevention of fecal impaction. Additionally, reeducated nursing staff on documenting all bowel movements, meal intakes and snacks in the medical record. Charge nurses will ensure all documentation from their shift is entered in the electronic point of care and EMAR before shift ends. CNAs will be asked if they don't have a log in and will document before leaving their shift and to report any changes in bowel elimination to the Charge Nurses. The Charge Nurses must then look and report alerts in the medical record and document the results of the examination in the medical record. Also, nurses will contact the attending physician to notify of a change in condition in bowel movements and to obtain stool softeners, interventions, or orders as indicated. Licensed Nurse will properly document the pain medication that includes assessment for pain including effectiveness of pain medication, source of pain, and location of pain. Additionally, Licensed Nurses were reeducated on the pain medication side effects that includes but not limited to fecal impaction. The training was completed on 05/25/23 and is ongoing. This was verified by record review of staff in-services signature sheets and staff interviews. Interviews and record reviews were conducted on 05/26/23 from 1:00 p.m. through 4:15 p.m. and included 4 LVNs, 7 CNAs, DON, and Regional Clinical Specialist. Staff were able to explain how to assess for sign and symptoms of fecal impaction and prevention of fecal impaction. Staff had knowledge on documenting all bowel movements, meal intakes, pain medications that includes assessment for pain including effectiveness of pain mediation, source of pain, and location of pain and snacks in the medical records. Revised policy on Activities of Daily Living included documentation of ADLs in the electronic record. This was verified by interviews with staff and record review of revised policy titled Activities of Daily Living dated 5/26/23. The Director of Nursing / designee will educate the newly hired nursing staff upon hire, prior to working including agency staff which includes and nurses and CNAs, on-going. 90% of all staff have been reeducated in a one-on-one setting on paper. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Clinical Specialist verified an AdHoc QAPI was conducted to discuss the immediate jeopardy concerning quality of care related to proper documentation on pain medication, bowel movements, meal intake, and prevention of fecal impaction are reported and to develop the above-mentioned plan of care. On 05/26/23 at 4:15 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy 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 observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for 1 of 2 residents reviewed for pressure ulcers (Resident #1), in that: 1. The facility failed to turn and reposition Resident #1 for about 5 hours; 2. Resident #1 was left in her feces and urine for about 5 hours; 3. Resident #1 did not have the physician ordered bandage covering her wound on the right buttock which had prolonged exposure to urine and feces; 4. Resident #1's wound increased in size in 7 days, on 4/18/23 the wound measured 2.5 x 1x 0.3 and on 4/25/23 it measured 9 x8 x0.3 cm; 5. Resident #1's wound was noted to be infected on 5/1/23. An Immediate Jeopardy (IJ) situation was identified on 05/08/23 at 5:14 p.m. While the IJ was removed on 05/9/23 at 4:51 p.m., the facility remained out of compliance at actual harm with a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems These failures could cause resident skin breakdown and the development/worsening of pressure sores and infection. Findings included: Record review of a face sheet with a print date of 4/20/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, contracture to the right hand, paralysis of one side of the body and hemoptysis following traumatic stroke, muscle weakness, cognitive deficit, muscle wasting, pressure ulcer to the right buttock stage 3 (a wound that was full thickness tissue loss, subcutaneous fat may be visible). unspecified protein calorie malnutrition and diabetes. Record review of a brief interview for mental status dated 2/15/23 indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's MDS dated [DATE] indicted she required extensive assist with all ADLs. The MDS indicated Resident #1 had one pressure ulcer that was a stage 3. Review of Resident #1's Care Plan with initiated date of 11/20/18 indicated Resident #1 had a problem of ADL self-care performances deficit due to Paralysis and right-hand contracture. Interventions were the resident is a two person transfer with lift and extensive assist from one to two people for grooming, bathing, toileting, and bed mobility. The resident is totally dependent on one staff for repositioning and turning in bed frequently and as necessary. The resident is bedfast most of the time, the resident is totally dependent on one staff for addressing, the resident is not toileted. A problem dated 11/20/18 indicated Resident # 1 had a problem with bladder and bowel incontinence related to mobility. The interventions were clean peri area with each incontinent episode. Resident #1 had a care plan problem with an initiate date of 1/16/23 of a Stage 3 pressure ulcer of the right buttock. The interventions were to administer treatments as ordered and monitor for effectiveness. Follow facility policies and protocols to prevent skin breakdown. The resident is seen weekly by wound physician. Record review of Resident #1's computerized physician orders dated 11/21/22 indicted multivitamin tablet, and liquid protein. Record review of Resident #1's Norton Scale (measured the risk of getting a pressure sore) dated 4/15/23 indicated her physical condition was fair, her mental status was fair, and she was bedfast. Her mobility was slightly limited and she could make frequent though slight changes in body or extremities to position independently. Resident #1 was double incontinent and no control of bowel or bladder indicated frequent fecal soiling. Her score was 11 High Risk (14-10 High Risk.) Record review of Resident #1's Wound evaluation and Management Summary dated 4/18/23 indicated Resident #1 had a stage 3 pressure wound that measured 2.5 x 1 x 0.3. The wound had serous drainage (thin watery fluid that is produced in response to local inflammation), with slough (yellow material covering the wound bed) covering 10 percent of the wound and 90 percent with granulation tissue (healthy tissue). The surface of the area was 2.5 cm. The wound had improved. Resident #1's dressing treatment was alginate calcium, apply once daily for 30- days, and collagen powder applied once daily for 30 days. The secondary dressing was Gauze Island (a sterile dressing indicated for surgical as well and nonsurgical wounds). The Dakin's was to be discontinued. The Recommendations were to limit sitting to 60 minutes, repositioned per facility protocol, off load wound, and turn side to side, and front to back in bed every 1 to 2 hours. Surgical debridement (surgical removal of dead tissue to promote wound healing) procedure the wound surgically remove tissue including slough with removal at a depth of 0.3 centimeters and healthy bleeding tissue was observed because of this procedure. The non-visible tissue in the wound decrease from 10% to 0% no bleeding was achieved, and a clean dressing applied. Record review of Resident #1's computerized physician orders indicated an order dated 4/5/23 to cleanse the right buttocks with normal saline and apply Dakins (a topical antibiotic) soaked gauze and dry dressing. Record review of Resident #1's TAR indicated a treatment to cleanse the right buttock with normal saline, apply Dakin's soaked gauze and a dry dressing, daily. The order started 4/6/23. The record indicated that treatment was not provided on Saturday and Sunday 4/8/23 and 4/9/23. Treatments appeared to have been applied daily after that. The record indicated that the treatment was provided on 4/18/23 and 4/19/23 after there were recommendations to change the treatment from the wound care doctor on 4/18/23. During an interviews and observation on 4/20/23 between 9:25 a.m. to 9:53 a.m. Resident #1 was observed in bed and had a feeding tube infusing. LVN A was asked to check Resident #1 to see if she was wet. She said Resident #1 required two people to turn and left the room. Resident#1 did not speak when spoken to. LVN A went to get help and was gone for quite a few minutes. LVN A said the aides were busy, so she got LVN B to assist. LVN B went to the far side of the bed. Once the investigator got closer to the bed the smell of urine was strong. When asked if Resident #1 was wet LVN A pulled her wet gown down around Resident#1's legs and said yes. LVN B pulled back the covers on her side and said, there is bigger problem here. Observation of Resident #1 showed she had on a brief and her legs were opened. In between her legs was a pile of BM that was a shade of green and the outer edges were a darker color. The pile was about 3 inches around with a height of about 3 to 4 inches. A larger ring in between the resident's legs showed some darker colored liquid BM that was about 4 to 5 inches in a [NAME] circle, and the edges of that BM were also darker. There was a brown ring of urine from one side of the bed to the other around the resident's legs. Resident#1 was positioned with pillows. The pillows on both sides of the resident had pillow covers that were wet with brown rings. Her hospital gown was wet from the waist down. LVN A said she was really saturated. LVN A said she needed an aide to help turn Resident #1. She could not turn Resident #1 by herself. CNA C and CNA D entered the room and said this was their first time in the room this morning to provide care to Resident #1. CNA D said she had assisted the roommate with eating breakfast. She had asked Resident #1 if she wanted anything for breakfast (she had feeding tube but ate sometimes) and she said the resident said no. CNA D said she had not gone to that side of the room. CNA C said they had just finished with breakfast. CNA C said she had started on her rounds but had not gotten into this room today. CNA C and CNA D cleaned Resident #1, Resident #1 asked for them to put cream between her legs when they finished. Resident #1 said this was the first time someone had cleaned her since last night. LVN A said Resident #1 had a pressure sore on her bottom, and when they rolled her over, CNA C and LVN A said there was no bandage on the wound. CNA D said the whole bed was wet. LVN B said the whole bed was wet and the smell of urine was strong. During an observation and interview on 4/20/23 at 9:42 a.m. RN/ ADON F came into the room, and she looked at the wound on Resident #1's bottom. The aides were still cleaning Resident #1. The RN/ADON F said the wound should have had a bandage on it. She said Resident #1had a stage 3, an open wound with no eschar. During an observation and interview on 4/20/23 at 9:52 a.m. LVN G/ treatment nurse said 4/18/23 was the last time Resident#1 was seen by the wound care doctor, and her wound was 2.5 x 1x 0.3 and was staged at a stage 3. The RN/ADON and LVN G/ wound care nurse measured her wound at that time and it was 3 by 1.2 depth 0.7. The aides were still cleaning Resident #1. During an interview on 4/20/23 at 9:57 a.m. CNA C and CNA D said they have not provided care to Resident #1 today. They had not been in to conduct two-hour rounds and had not checked her when they arrived at work. They said the night shift must have left her dirty due to the poor condition Resident #1 was in. They said the BM had not dried but it was obvious she had more BMs than one. They said the BM was up the front of her brief to almost her waist. CNA C and CNA D said with the brown rings on the sheets, and the condition of Resident #1, it had been more than a few hours since she was changed. During an interview on 4/20/23 at 10:05 a.m. LVN E/Treatment nurse said Resident # 1's treatment orders changed on 4/18/23. He said he had not changed the order in the chart as of today 4/20/23. He said he is the nurse that completed her treatments and knew what they were. He said he was not always at the facility and admitted other nurses might not be aware of the change in treatment. During an interview on 4/20/23 at 11:00 a.m. the former Administrator said the roommate, Resident #3's family had a camera in the room. The Family member said two aides had come in around 4:30 a.m. and had gone to Resident #1's side of the room. The family member said she thought they changed Resident #1 at that time. The family member said the nurse (LVN A) came in and checked on Resident #1 about 7 a.m. The family member said they came in and brought Resident #3 a tray and asked Resident #1 if she wanted anything to eat about 8:00 a.m. and she said no. The Former Administrator said she wrote up CNA C, CNA D, CNA AA, and LVN A. The former Administrator said LVN A could have checked on Resident #1 and she could have provided her care. The former Administrator said she was terminating the aide that said Resident #1 was not her resident and refused to help. She said she was probably going to terminate the nurse because by all the accounts she had gotten. The nurse had been in the room at 7:00 a.m. and the smell of urine was strong enough for her to smell. The former Administrator said LVN A likely knew the resident was dirty and did not try to clean her, or get the aides to do so at that time. During an interview on 4/20/23 at 11:20 a.m. Resident #1 said she stayed in bed all the time and they did not put her to bed last night. She said they only changed her one time during the night. She said she was very uncomfortable, and it was burning between her legs and she wanted some cream on her legs and bottom to stop the burning. During an interview on 4/20/23 at 11:45 a.m. LVN B said when she walked on the side of Resident #1's bed she smelled a strong urine odor. She said the resident should have been changed. LVN B said even if Resident #1 was a heavy wetter, she should not have been found in that condition. During an interview on 4/20/23 at 12: 06 p.m. CNA C said LVN A stopped her and CNA AA earlier in the hallway and told them to provide care to a resident right away, but she did not hear who it was. She said CNA AA heard her because she said that resident was not her resident. CNA C said it took a long time to clean Resident #1 because she was so soiled. She said the night shift must have left her that way. She had not done rounds this morning when she arrived late to work. During an interview on 4/20/23 at 12:26 P.M. CNA D said she had gone in the room earlier that morning to feed Resident # 3 around 8:00 a.m. and the curtain between the beds was pulled. She said she asked Resident #1 if she wanted breakfast, and she said no. CNA D said she did not smell anything at that time. She said when she was summoned to the room by LVN A, and when she walked to Resident #1's side of the room there was a strong smell of urine. She said she smelled both urine and BM. CNA D said Resident #1 was not a heavy wetter. She said she had never seen her look like that, and usually Resident #1 would pull the call light for care. CNA D said Resident #1 often asked for cream on her bottom and between her legs. She said the whole time they were cleaning Resident #1 she kept saying over and over I am sorry, I am sorry. CNA D said she had been an aide for 21 years and had never seen any resident in that poor of condition. She said there were dried brown rings of urine, the resident was saturated, and it looked like Resident #1 had more than one BM. CNA D said it looked like she had been that way for some time. She said the BM was up in the front of the brief and it took them about 20 minutes to clean her up. CNA D said when they finished the sheets were in such bad condition, she did not think they could be cleaned, and they put them in the trash. During an interview on 4/20/23 at 4:48 p.m. the former Administrator said Resident #1 feces consistency may be due a recent completion of antibiotic regimen due to C Diff- Her flora in her stomach had not builder back up. She said however it did not really matter. The former Administrator said Resident #1 should not have been left in that condition. Record review of Resident #1's nursing note dated 4/1/23 indicted on 4/1/23 the resident returned from the hospital with a diagnosis of C-Diff, and acute blood loss. She had a new order for Vancomycin 125 mg every 6 hours until 4/10/23. During an interview with the former Administrator on 4/20/23 at 5:45 p.m. she said she had suspended LVN A and CNA AA. She said she would likely fire them. She said the nurse was aware of the condition the resident was in at 7:00 a.m. and did not assist Resident #1 in any way. The former Administrator said she had written up all staff involved. The condition of Resident #1 was unacceptable. She had also put a do not allow to return on the two aides that worked for the agency on the night shift. She said the aides should have checked Resident #1 before they left, and the oncoming aides should have checked Resident #1 when they arrived. During a telephone interview on 5/8/23 at 3:39 p.m. the family member of Resident #3 said she was asked by the former administrator to look at her camera footage on the morning of 4/20/23. The family member said she did not go back and look at the whole night but around 4:30 a.m. two aides came in and provided care to Resident #3. The family member said they went to the other side of the room and possibly provided care to Resident #1. The family member said they could not be sure because the curtain was pulled. The next time the family member noted someone in the room was around 7:00 a.m. and that was the nurse. Then around 8:00 a.m. they passed breakfast trays. The aide who assisted their family member with eating asked Resident #1 if she wanted breakfast and she said no. The family member said that staff are usually good about going into the room to provide care. She said Resident #1 would pull the call light, sometimes quite a bit. The family member said they thought staff did not turn Resident #1 often enough because she was always on her back. The family member said staff went in regularly generally every two hours and they had no real concerns. Record review of Resident #1's nursing note dated 4/20/23 created at 4:29 a.m. indicated at approximately 9:20 a.m. this morning Resident #1 was lying in bed with stage 3 to right buttock measuring 3.0 x 1.2 x 0.7 with no eschar, no slough and no odor noted to wound. The NP was in the building and notified of the wound and measurements and order from the Wound physician stated to start a new order today for Dakins. The new order was placed on the TAR. Record review of in-service training dated 4/20/23 indicated to check and change every two hours and must be completed and as needed. The training requirements were to recognize task, activities that pose risk or risk potential. Record review of in-service dated 4/20/23 indicated staff were in serviced on wounds and dressings. All wounds must be dressed per orders. If the dressing is missing or out of place or anything wrong, you must notify the nurse. Any changes notification must be placed and completed. If the order does not have an as needed order, you should obtain one as needed. If the order changes it must be updated. Record review of LVN G/Treatment Nurse Employee Counseling report dated 4/20/23 indicated he had a level 2 warning for failing to meet job expectations. He failed to enter physician orders in a timely manner. During an interview on 5/8/23 at 11:15 a.m. the DON said when an order is received from the physician it is to be put into the computer system immediately. She said there should not be a delay, and it should be put in a timely manner. She said LVN G was educated on 4/20/23 on putting orders in timely. She said on 4/20/23 staff were educated on what is expected for dependent resident care. The residents are to be turned and repositioned every 2 hours and as needed. Record Review of Resident #1's computerized physician orders dated 4/24/23 indicated may have foley catheter for wound management. Record review of Resident #1's Wound Management Summary dated 4/25/23 indicated the resident had a pressure sore stage 3 on the right buttock. There is moderate serous exudate (a clear thin, watery fluid with relatively low protein content, usually observed in acute or mild inflammation). The wound size was 9 x8 x0.3 cm with a surface area of 72 cm. with 100 percent granulation tissue. The wound had deteriorated. The wound was worse from urine, but foley was replaced. The wound dressing was alginate calcium apply twice daily with gauze island and apply twice daily. Record review of an in service completed on 4/28/23 indicated staff were in serviced on turning and rotating patients after changing them and every two hours. The training session summary indicated to make sure patients were being changed, if the brief is soiled, and check on patients every two hours. If the patient was changed be sure to turn and rotate them, these actions would help the patient be more comfortable and prevent skin breakdown. If they have a wound dressing and it came off during care stop and get the nurse to re-apply the dressing. Record review of Resident # 1's computerized physician order dated 5/1/23 indicated to cleanse the wound with Dakin's, pat dry, and apply Calcium Alginate two times daily. Record review of Resident #1's TAR for May 1, 2023 indicated the resident received treatment of cleanse wound with Dakins, pat dry, and apply Calcium alginate two times daily. She also had an as needed order to apply if the wound becomes soiled or the dressing came off. Record review of Resident #1's comprehensive metabolic panel (labs) dated 5/1/23 indicated BUN (too little fluid in the body) was high at 42 (range 7-24). Her Albumin (is protein made by the liver) was low (2.9 (range 3.5-5.0). Record review of Resident #1's dietary note dated 5/2/23 at 10:23 indicated the NP notified the dietician the resident needed to be evaluated due to the pressure sore protocol. The resident was on nocturnal feeding currently. Her current weight was 143.6 pounds, and her body mass index was 25.8 which was healthy for her age with a plus 6.53-pound weight gain in 30 days. The resident had a stage 3 to the right buttock. She was likely meeting her estimated needs at this time. Her by mouth intake is noted at 75 to 100 percent in last 3 days. She had fortified cereal recommended three times daily. She was to receive Glucerna 1.5 continuous via tube for 12 hours at a rate of 50 ml per hour from 6 p to 6a and 455 ml free water. Water flushes of 250 ml every 6 hours. Record review of Resident #1's wound care note dated 5/2/23 indicated a stage 3 pressure ulcer measured 9 x 8x 0.3 cm, with moderate serous exudate, there was 20 percent slough and 80 percent granulation tissues. The progress of the wound and the context surrounding the progress were considered in greater depth today. Diabetes is a relevant condition that effect wound healing and was considered. Recommended pain medication be give 30 min prior to wound care. The treatment was alginate calcium apply twice daily for 30 days. The wound was debrided. Record review of Resident #1's Clinically Unavoidable Pressure Ulcer form dated 5/4/23 indicated the resident had interventions in place prior to the development of the pressure ulcer, such as abnormal labs with interventions, turn every two hours, vitamin supplements, draw sheet, low air loss mattress, bed positioning wedge, and nutritional supplements. Contributing factors were pressure ulcer, history of ulcer, Norton Score indicating high risk, impaired mobility, bowel incontinence, and head of bed elevated due to medical necessity. The contributing lab factors were low serum prealbumin less than 16. Record review of Resident #1's computerized physician orders dated 5/8/23 indicted Augmentin (antibiotic) 500 mg to be given via tube and Tramadol (pain medication). Record review of two statements both signed by the DON with no dates indicated CNA Z said she changed Resident #1 three times during the night of 4/19/23 and the last time was about 4:45 a.m. Another statement from CNA M indicated she had changed Resident #1 throughout the night on 4/19/23 and the last time was about 4:55 a.m. Record review of an email dated 5/9/23 at 12:57 p.m. indicated LVN Y sent an email indicating that on the night of 4/19/23 to 4/20/23 she had gone into Resident #1's room several times that night and witnessed the aides providing care. They said on her final round around 6:10 a.m., Resident #1 was awake and alert and had no complaints. During a telephone interview on 4/26/23 at 10:51 a.m. CNA M (worked for none facility staffing agency) said she remembered what happened on the night of 4/19/23. She said around 4:30 a.m. she and another aide had gone into Resident #1's room to change her. She said Resident #1was saturated. She said she had cleaned her and changed her. She said they put the draw sheet under her, positioned her with pillows behind her, and pulled her up in the bed. During an interview on 5/8/23 at 11: 20 a.m. Resident #1 said she knew when she is wet. Resident #1 said she did not pull the call light on 4/20/23 because she did not have the call light within reach. Resident #1 said she was left dirty for long periods of time occasionally, but not often. She said they came in to turn her about every two hours, and they put pillows and wedges under her sides to keep her off her bottom. She said she thought her bottom was better. During an interview on 5/8/23 at 11: 25 a.m. LVN P said Resident #1 was on Augmentin, an antibiotic for a pressure sore for 10 days. She said Resident #1 was placed on the antibiotic on 5/1/23 due to infection in her wound. During an interview on 5/8/23 at 11:27 a.m. LVN G/treatment nurse said he started at the facility in April and on 4/20/23 he had been in that position of treatment nurse for about 4 days. He said Resident #1 had a Foley Catheter placed on 4/25/23. He said Resident #1 had a catheter in the past, and the wound was getting better. He did not know why they removed the catheter. He said on 4/20/23 he was counseled by the ADON and DON on putting orders in the Resident computer record timely. LVN G said he had found Resident #1 wet a few times. He said he would change her but had never walked in and she was saturated. He said Resident #1 had the wound on her right buttock since 2019 and looking at the chart it had never healed. It would get worse, then better, and then worse. LVN G said when Resident #1's wound got worse he called the wound care doctor on 5/1/23. The doctor ordered antibiotics but did not have the wound cultured. LVN G said when he looked at the wound it looked worse, and the outside skin looked a little more macerated (occured when skin is in contact with moisture too long). He said when the wound care doctor saw her on 5/2/23 he confirmed the wound was infected. He said he had completed an unavoidable pressure ulcer form on Resident #1 on 5/4/23. He said the physician did not sign the document, but he knew they had talked to the wound care physician. During an interview on 5/8/23 at 11:44 a.m. the Wound Care Doctor said they took the foley out and he thought Resident #1 was a heavy wetter. He said he felt that was what caused her wound to worsen. He said he did not know why the catheter was removed. The Physician said he had not seen her wet when he was at the facility, but he was only at the facility for about an hour a week. He said he had put Resident #1 on an antibiotic, due to her wound having an odor and more drainage on 5/1/23. He did not get the wound cultured, he prescribed antibiotics from a previous culture result. He said they had gotten cultures in the past and she had done well on antibiotics to increase her changes of healing. The Physician said he was not sure what Resident #1's blood sugars were, but her diagnosis of diabetes was a contributing factor for a non-healing wound. He said the facility had talked to him about the wound being unavoidable due to the wound not healing for years. He said they try to keep her off the area, keep her dry, and clean which are also contributing factors. He said he was not sure if he signed anything saying she was an unavoidable pressure sore or not. However, it was likely Resident #1's condition indicated she had an unavoidable pressure sore. Record review of a Wound Culture dated 1/24/23 indicated Resident #1 had a many Group B streptococcus (an infection caused by common bacterium.) Record review of Resident #1's the Wound Care Physician progress note dated 5/8/23 at 2:59 p.m. indicated: Discussion with treatment nurse, DON, Administrator, and State regarding the wound. as stated previously, this wound is very difficult to heal from multiple reasons. We have tried to offload the wound as best as possible with the level two mattress and wedges. However, the patient does not wish to turn to her side. The patient has diabetes and blood sugars that are stable. We have treated this wound in the past with IV antibiotics, with improvement. However, the wound worsened when the foley was removed. The patient is a heavy wetter, and the urine caused the wound to break down. We have subsequently replaced the foley. We have restarted her on oral antibiotics last week per the previous wound culture sensitivities. During an interview with the DON on 5/8/23 at 12: 45 p.m. she said Resident #1's wound developed back in 2019. She said she had worked at the facility for about a year but during that time Resident #1's wound had been up and down and good and bad. It had not healed. During an interview on 5/8/23 at 12:47 p.m. NP-O said she and the staff talked about Resident #1's pressure sore last week and she referred them to the Wound Care Doctor. She said she did not specialize in wounds and would agree with whatever the wound specialist thought was right. NP O said the catheter was taken out and restarted a couple of times, one time to see if Resident #1 could void her own. She said Resident #1's catheter stopped up a couple of times. The NP said Resident #1 had a decline a year ago. However, her labs looked good her BUN was high and her Albumin was low. The dietician was notified and made some changes. The NP said other than that, the resident appeared healthy as far as her labs were concerned. During an interview on 5/8/23 at 1:10 p.m. the Corporate Regional Nurse consultant of clinical operations said they do not have a policy for unavoidable pressure sores. She said they could not have completed an unavoidable pressure form on Resident #1without the physician agreement. She said they only use the form after discussing with physician. The pressure ulcer had not changed from a stage 3. During an interview on 5/9/23 at 2:37 p.m. CNA R said Resident # 1 would refuse to turn sometimes when she helped other aides. She said sometimes she would refuse food it appeared to be based on how she felt at the time. CNA R said and sometimes she was fine with anything they tried to do for her. She said she never refused to be cleaned. During an interview on 5/9/23 at 2:54 p.m. CNA D said she had received an in service on abuse and neglect today and many times in the past. CNA D said she was familiar with what neglect was and neglect was a failure to provide care to residents in a timely manner. She said failing to turn and reposition the resident, and failure to keep them clean and dry were neglect. She said the incident with Resident # 1 on 4/20/23 was a failure to provide care. She said if she had found her in that condition, she would have reported it as an allegation of neglect. She said she did not see a bandage, anywhere on 4/20/23 when she changed the resident. She said Resident #1 would not refuse to turn but did not like to turn. Resident #1 would sometimes scoot back to the position she liked to be in when turned. During an interview on 5/9/23 at 3:18 p.m. the Medical Director said he remembered Resident #1 had gone to the hospital the last of March 2023. He said Resident #1 had come back to the facility with a diagnosis of C-Diff. He said she had a stage 3 wound on her sacrum. He said at one time they were considering putting her on Hospice. The Medical Director said Resident #1's Albumin was low and that likely meant she was not getting enough nutrition even with the feeding tube. He said if they left the catheter in then there would be a different set of problems with urinary tract infections. He said the facility staff did talk to him about Resident #1's pressure sore being unavoidable. He said Resident #1 did not get out of bed and that was a factor. He thought they were talking about putting measures in place to help with the healing of the wound. He said he must have misunderstood; however, Resident #1 did have a multiplicity of underlying conditions that could contribute to the wound not healing. During an interview on 5/9/23 at 3:43 p.m. CNA V said Resident #1 was not a heavy wetter. She said she had not worked with Resident #1 lately. She said most of the time the resident was fine with turning and repositioning. She would refuse every now and then, but they used pillows and wedges to keep her off her bottom if she did. Record review of the facility Pressure Injury Prevention and Management policy implemented on 8/15/22 indicated interventions for prevention and to promote healing- evidence based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to minimize exposure to moisture and keep the skin clean, especially of fecal contamination. Treatments for an identified area were documented on the treatment administration record. The facility was notified of the Immediate Jeopardy on 5/8/23 at 5:14 p.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for Immediate Jeopardy was accepted on 05/09/23 at 2:[TRUNCATED]