**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to ensure the MD and Hospice were notified when Resident #1 had a change of condition on [DATE] with blood in his foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine). Resident #1 was sent to the ER on [DATE] for further evaluation and treatment and was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction, Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). Resident #1 later died in the hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 2:02 p.m. and an IJ template was given. While the IJ was removed on [DATE] at 5:03 p.m., the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for pain, hospitalization, and death. Findings included: Review of Resident # 1's face sheet dated [DATE] reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's disease (a movement disorder that affects the nervous system and cause tremor, stiffness, slowing of movement and other problems), Acute Kidney failure (also known as acute renal failure is a condition where your kidneys stop working suddenly), obstructive and reflux uropathy (occurs when urine flow is blocked, either partially or completely through the ureter, bladder, or urethra.), BPH (Benign prostatic Hyperplasia occurs when the cells of the prostate gland begin to multiply. These additional cells cause your prostate gland to swell, which squeezes the urethra and limit urine flow) with lower urinary tract symptoms, and history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder). Review of Resident #1's significant change MDS dated [DATE] indicated the Staff assessment of Mental Status reflected Resident #1 had short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter. Section J-Pain Assessment Interview reflected Resident #1 experience pain almost constantly. Review of Resident #1's care plan dated [DATE] reflected Resident #1 needed staff participation with ADLs due to weakness, Resident #1 required the use of indwelling catheter related to urinary retention with intervention to observe for signs and symptoms for UTI and notify charge nurse and physician for further assessment, medication as ordered, irrigate catheter per physician orders. It was noted that Resident #1 was at risk for pain related to disease process End Stage Parkinson with intervention to Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Review of Resident #1's progress notes from [DATE] through [DATE] did not indicate Resident #1's family, his Hospice nurse or the MD were notified of the change of condition. Review of Resident #1's hospital records dated [DATE] reflected he was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction, Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). Review of Resident #1's hospital records dated [DATE] reflected, Resident [#1] was admitted to inpatient Hospice services, symptoms were managed with IV medication. He expired peacefully on [DATE] while in the hospital. During an interview on [DATE] at about 9:46 a.m., Resident #1's family stated blood was noted in Resident #1's catheter tubing with no urine in the drainage bag on [DATE] and LVN B was made aware. Family also stated Blood was again noted in Resident #1's catheter on [DATE], about half a cup of fluid and LVN A was notified. Family stated they told LVN A that the last time there was blood in Resident #1's catheter, he had to be sent to the ER immediately and was told by LVN A that hospice do not work on the weekend and would be notified later. Resident #1's family stated Resident #1 was not sent to the ER until [DATE], was septic by the time he got to the hospital, was placed on inpatient hospice because of the severity of the infection. During an interview on [DATE] at 11:33 a.m., Resident #1's Hospice nurse stated she was made aware by LVN B on [DATE] of Resident #1 having blood in his foley catheter with urine output of 25cc. She stated she asked LVN B to irrigate the catheter and call back it there was no changes. She stated she was not made aware that Resident #1 had blood in his catheter since [DATE], she would have sent Resident #1 to the hospital sooner to replace his catheter. Resident #1's hospice nurse stated when she saw Resident #1 on [DATE] he was uncomfortable. During an interview on [DATE] at about 12:00 p.m., CNA F stated she worked with Resident #1 during the night shift on 5/16, 5/17 and [DATE]. CNA F stated Resident #1 had blood in his foley catheter and LVN C was aware. CNA F stated Resident #1 had pain all over but mainly his stomach and LVN C was aware of that. During an interview on [DATE] at about 12:13 p.m., CNA E, stated she worked with Resident #1 during the day shift on 5/16/, 5/17 5/18 and [DATE].CNA E stated Resident #1 started to have blood in his foley catheter bag from [DATE]. CNA E stated Resident #1 urine output was never over 50 cc and was all blood. CNA E stated it was brought to the attention of LVN A and B and they both stated they knew. CNA E also stated Resident #1 was pulling on the catheter like there was discomfort and he didn't want the catheter in., he was fidgeting. During an interview on [DATE] at about 12:39 p.m., LVN C stated he worked with Resident #1 on the weekend of 5/16 through [DATE] overnight. LVN C stated he got in report on [DATE] that Resident #1 had blood in his foley catheter. LVN C also stated Resident was making the AHHH sound while moaning and he gave Resident #1 pain medication on 5/17 and [DATE]. LVN C stated he did not document Resident #1's change in condition because Resident #1 was on hospice, and everyone was aware that there was blood in Resident #1's catheter and that Resident #1 was noted for pulling his catheter out. LVN C stated he did not notify the MD or Hospice. LVN C also stated they just pass it on in report from shift to shift each day the entire weekend. During an interview on [DATE] at 2:13 p.m., the DON stated If it was blood, I expect the staff to irrigate the catheter, make sure it was clear or clearer with documentation to say that. They are not ever supposed to wait for few days before notifying the hospice or the Doctor. During an interview on [DATE] at 3:22 p.m., the MD stated she was familiar with Resident #1. The MD stated, The patient was on hospice, PO intake was poor, enlarge prostate and the urine will not flow. The staff are supposed to check for output every shift, within 24 hours, if there was no output they should have notified someone. The MD stated the protocol was for staff to notify Hospice on-call nurse and MD, if unsuccessful, notify her team. The MD stated she was not notified. Review of facility's policy titled Change of Condition dated [DATE] reflected: Purpose To provide a standardized process for identifying, assessing, and responding to changes in the physical, cognitive, or emotional condition of nursing home residents, ensuring timely and appropriate notification to the physician, responsible party, and hospice care team (if applicable). Scope This policy applies to all nursing home staff, including nursing, medical, and administrative personnel, involved in the care and communication of residents' health status. Definitions o Change of Condition: A significant and noticeable alteration in a resident's health, behavior, or physical functioning. This can include changes in vital signs, cognitive function, mobility, skin integrity, or overall mental or emotional well-being. o Responsible Party: The individual designated by the resident or their legal representative (e.g., family member, legal guardian) who is responsible for making healthcare decisions or being notified of the resident's health status. o Physician: The attending or primary physician responsible for the overall medical care of the resident. o Hospice Care: Specialized care provided to terminally ill residents, focusing on comfort, pain management, and quality of life at the end of life. Physical Changes Cognitive Function: Sudden confusion, agitation, delirium, or memory decline. o Pain: Increased reports or signs of pain (verbal or non-verbal), requiring reassessment or pam management. Appetite _ or Fluid Intake: significant changes in eating or drinking patterns including refusal to eat or drink. 2. Assessment of Change of Condition Once a change of condition is identified, the responsible nursing staff member must perform a thorough assessment to determine the severity of the change and its potential causes. This includes: o Reviewing the Resident's Medical History: Consider any chronic conditions or known issues that might be exacerbated. o Monitoring Vital Signs: Repeat vital signs if necessary to confirm a significant change. o Assessment Tools: Use appropriate clinical assessment tools (e.g., Braden Scale for pressure ulcers, pain scales, delirium assessment tools) to measure and document the change. o Documentation: Thoroughly document all findings, including changes in symptoms, assessment details, interventions, and the time the change was first noted. 3. Notification Protocol Once a change in condition has been identified and assessed, the following notification protocols should be followed to ensure that all relevant parties are informed promptly and appropriately. 3.1 Notification of the Physician Immediate Notification: The attending physician must be notified of an) significant change in the resident's condition that could impact their health or require changes to their care plan. This should be done within one hour of identifying the change. Documentation: Document the time of the notification. the person contacted. and the physician's response or instructions in the resident's medical record. Critical Changes: If the change in condition is life-threatening or requires urgent intervention, notify the physician immediately. and follow up with any necessary interventions (e.g., emergency medication. transfer to the hospital). 3.3 Notification of Hospice (If Applicable) o Hospice Involvement: If the resident is under hospice care, the hospice care team must be notified promptly of any changes in condition, especially if the change indicates a worsening or imminent decline in the resident's health. o Timely Communication: Hospice care providers should be contacted immediately if the change of condition is related to end-of-life issues, such as increased pain, difficulty breathing, or changes in consciousness. o Collaboration: The nursing home staff should collaborate with the hospice team to discuss the next steps in care, including adjusting the hospice care plan, symptom management, and family support. Review of facility's policy titled Resident Rights dated [DATE] reflected: Policy Statement-- Employees shall treat all residents with kindness, respect, and dignity. I. equal access to quality of care regardless of source of payment. Review of facility's policy titled Hospice Program dated [DATE] reflected: Policy Statement Hospice services are available to residents at the end of life. In generally, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: a. Twenty-four-hour room and board care, b. Administering prescribed therapies, incl a. b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The Administrator and ADON were notified on [DATE] at 2:02 p.m., that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 10:25 a.m. Plan of Removal for F580 - Notification of Changes Regulatory Tag: F580 On [DATE], an abbreviated survey was initiated at the facility. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to ensure the MD and Hospice were notified when Resident #1 had a change of condition on [DATE] with blood in his foley catheter. Resident #1 was sent to the ER on [DATE] for further evaluation and treatment where Resident #1 was diagnosed with Sepsis without acute organ dysfunction, Acute urinary retention, Complicated Urinary tract infection associated with indwelling urethral catheter, Dehydration, and Retention of urine. 1. Immediate Protection for Resident #1 and Related Residents: Resident #1 expired in the hospital. The Physician was contacted by DON/ADON and updated on the two other residents that have a indwelling catheter or are on Hospice services. The responsible parties for the indwelling catheter residents and Hospice residents were notified by DON/ADON and documentation completed showing if there were any significant changes noted. Residents with indwelling catheter and/or on Hospice had their treatment plan reviewed and updated by the interdisciplinary team. These efforts will be documented on a facility-developed audit tool. Completed by: DON/ADON 0n [DATE]. 2. Education/Re-Education: The nurse(s) involved in the failure to notify were immediately re-educated on change of condition, notifying responsible Hospice entities, medical personnel, and responsible party by DON/ADON. Audit sheets will be made by ADON that address return knowledge. All licensed nurses and nursing staff were re-educated by DON/ADON on: o F580 regulatory requirements o Facility policy for significant change notifications o Timeframe expectations per policy o Proper documentation procedures o DON was reeducated by the Regional Nurse on [DATE]. In-service Completion Date: The DON/ADON will in-service and train each nursing staff member before their next assigned shift or they will not be allowed to work by [DATE]. Audit sheets will be made by ADON that address return knowledge. 3. Policy and Process Reinforcement: Facility policy regarding change in condition notifications was reviewed and updated by the DON/ADON. Standardized notification form/checklist was implemented requiring: o Date/time of physician/family notification. o Name of person notified. o Reason for notification o Signature of staff completing the communication o This form will be maintained at the nurses 24 report station. All nursing staff will be educated by DON/ADON (who were reeducated by the Regional Nurse on [DATE]) by [DATE] on the new form and required documentation prior to their next assigned shift or they will not be allowed to work. 4. Monitoring Plan for Continued Compliance: Beginning [DATE] DON or designee will review: o 5 resident charts per week for 4 weeks o Then 5 charts weekly for the next 8 weeks Random staff interviews conducted weekly to validate understanding of notification policy. Audit sheets will be made by ADON that address return knowledge. Results reported weekly to Standards of Care for ongoing tracking and follow-up will be managed by the DON or designee. These will flow to the monthly QAPI review for management. The Surveyor monitored the POR on [DATE] from 10:26 a.m. to 5:30 p.m. as follows: During interviews on [DATE] from 1:55 PM - 3:03 PM revealed four CNAs, one MA, one LVN, and one RN from different shifts all stated they were in-serviced before their shifts by the DON on catheter care, pain, and notifying the MD. The CNAs stated they were responsible for emptying the catheter bag before the end of their shift, making sure it was clean, and that peri care was provided. The CNAs stated they were responsible for charting the input and output of urine and notifying the nurse if there was anything abnormal such as blood in the urine, cloudiness, or if the resident was in pain. The nurses all stated it was their responsibility to set eyes on residents' catheters every shift to monitor if it was in place, if there was any sediment in the tubing, and that it was draining properly. The nurses stated if there was blood in the bag or if the resident was in uncontrolled pain, they would contact the MD immediately. Review of facility's in-services dated [DATE] and [DATE] reflected the following: Facility had an QAPI for identification of deficient practice on [DATE] at 7:20 pm Nurses and CMA checkoff on Foley Catheter Insertion, Hand hygiene, PPE/EBP with posttest. DON completed an audit on all Resident with foley Catheter. MD review all resident with catheter and were on hospice, reviewed their documents and there were no concerns. Review of facility's in-serviced dated [DATE] titled Completion and accuracy of charting - MD and families to be notified of all events/changes in condition/new onset of symptoms and charted. Accuracy of intake and output is paramount in coordinating care between all disciplines. Nurses stated they were in-serviced on making sure to chart any changes and notify the family and/or the MD. Review of facility's Change of condition and notification policy reflected it was updated on [DATE] and was approved by DON, and the , Regional Nurse Consultant. It reflected the purpose was to provide a standardized process for identifying assessing, and responding to changes in the physical, cognitive or emotional condition of nursing home residents, ensuring timely and appropriate notification to the physician, responsible party and hospice care team (if applicable.) Review of facility's in-service dated [DATE] reflected the DON was in-serviced by the Regional Nurse on the following topics: change of condition, significant change of conditions, pain and suffering management, pain management assessment, catheter care / management policy. Review of facility's in-services reflected LVN B and D were in-serviced on notification on [DATE]. LVN B confirmed verbally that she was in-serviced. Review of the facility's matrix dated [DATE] reflected there were 2 other residents with indwelling catheter in the facility. Both Residents progress notes dated [DATE] reflected care plan meeting was held with residents and their RPs regarding indwelling catheter and pain management. Review of Residents with indwelling catheter care plans reflected their care plans were updated on [DATE] by the MDS nurse. Review of facility's audit tools reflected all residents with indwelling catheter and were on hospice were listed and kept in the 24-hour report binder and there were no issues with their catheter and hospice care. On [DATE] at 05:03 p.m., the Administrator was informed the immediacy was removed. While the IJ was removed on [DATE] at 05:03 p.m., the facility remained out of compliance at a severity of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 3 residents review for catheter care. The facility failed to assess and intervene with Resident #1's foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine) when Resident #1's foley catheter was draining all blood from [DATE] until 3 days later on [DATE]; Resident #1 was sent to the local ER for further evaluation and treatment and was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction dated [DATE], Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 2:02 pm and an IJ template was given. While the IJ was removed on [DATE] at 05:03 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for hospitalization, Sepsis, and death. Findings included: Review of Resident # 1's face sheet dated [DATE] reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's disease (is a movement disorder that affects the nervous system and cause tremor, stiffness, slowing of movement and other problems), Acute Kidney failure (also known as acute renal failure is a condition where your kidneys stop working suddenly), obstructive and reflux uropathy (occurs when urine flow is blocked, either partially or completely through the ureter, bladder, or urethra.), BPH (Benign prostatic Hyperplasia occurs when the cells of the prostate gland begin to multiply. These additional cells cause your prostate gland to swell, which squeezes the urethra and limit urine flow) with lower urinary tract symptoms, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder). Review of Resident #1's significant change MDS dated [DATE] indicated Staff assessment of Mental Status reflected Resident #1 had short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter. Section J-Pain Assessment Interview reflected Resident #1 experience pain almost constantly. Review of Resident #1's care plan dated [DATE] reflected Resident #1 needed staff participation with ADLs due to weakness, Resident #1 required the use of indwelling catheter related to urinary retention with intervention to observe for signs and symptoms for UTI and notify charge nurse and physician for further assessment, medication as ordered, irrigate catheter per physician orders. It was noted that Resident #1 was at risk for pain related to disease process End Stage Parkinson with intervention to Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Review of Resident #1's progress notes reflected no documentation of change of condition on 5/16, 5/17 and [DATE]. Review of Resident #1's Hospice nurse notes dated [DATE] written by Hospice nurse reflected: Received call from facility, nurse [LVN A]. She stated pt had clotted blood in foley bag. States he's not showing sign or symptoms of UTI. Instructed to flush foley with sterile water and to call back it not better. Verbalized understanding. Updated family. Review of Resident #1's Hospice nurse notes dated [DATE] at 7:39 pm reflected: called [LVN A] back. Foley cath flushed without difficulty and had good return. Instructed to call back for any other concerns or questions. Review of Resident #1's progress notes dated [DATE] written by LVN D at 10:15 am reflected: RN with hospice attempted to replace foley catheter at this time due to concerns with current foley and not voiding. Upon inserting new foley, nurse hit resistance and noted large amounts of blood upon attempt to insert foley. Due to difficulty with inserting new catheter hospice is sending out to ER for catheter replacement. Review of Resident #1's interact form dated [DATE] reflected Resident #1 went to the ER for foley catheter re-insertion. Review of Resident #1's urine output reflected: [DATE] 01 :38 AM---800 cc [DATE] 13:54 (1:54 PM)---50 cc [DATE] 05:55 AM---0 cc [DATE] 05:59 AM-----0 cc [DATE] 13:59 (1:59 PM)----25 cc [DATE] 04: 11 AM-----0 cc Review of Resident #1's hospital records dated [DATE] reflected: chief complaint-Hematuria- is an 80 y.o. male patient presenting to the ED via EMS from hospice with c/o urination changes. EMS reports that the nurse checked on the pt this morning, who was not producing urine even with a foley catheter. EMS states that the nurse pulled out the foley catheter and found a clot after trying to flush out the catheter. EMS states that the pt's nurse was unable to put the catheter back in afterwards. Review of Resident #1's hospital records dated [DATE] reflected he was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction, Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). Final Diagnoses as of [DATE] at 11:26 am Acute urinary retention Complicated UTI (urinary tract infection), Dehydration, End of life care. Review of Resident #1's hospital records dated [DATE] reflected, Resident [#1] was admitted to inpatient Hospice services, symptoms were managed with IV medication. He expired peacefully on [DATE] while in the hospital. During an interview on [DATE] at about 9:46 a.m., Resident #1's family stated blood was noted in Resident #1's catheter tubing with no urine in the drainage bag on [DATE] and LVN B was made aware. Family also stated Blood was again noted in Resident #1's catheter on [DATE], about half a cup of fluid and LVN A was notified. Family stated they told LVN A that the last time there was blood in Resident #1's catheter, he had to be sent to the ER immediately and was told by LVN A that hospice do not work on the weekend and would be notified later. Resident #1's family stated Resident #1 was not sent to the ER until [DATE], was septic by the time he got to the hospital, was placed on inpatient hospice because of the severity of the infection. During an interview on [DATE] at about 10:46 a.m., LVN B stated she worked with Resident #1 on [DATE] and it was brought to her attention by Resident #1's family that there was blood in the Resident #1's foley catheter. LVN B stated Resident #1 was pulling on his foley catheter that is why there was blood in the catheter. LVN B stated she explained to Resident #1's family that there was a balloon in the catheter that would prevent the catheter from coming outside and it was causing trauma that is why there was blood in the catheter drainage bag. LVN B stated she gave Resident #1 fluids and checked placement and his catheter cleared out. LVN B stated she did not document any interventions, maybe she forgot. LVN B stated she should have documented change of condition. During an interview on [DATE] at about 11:52 a.m., LVN D stated she worked with Resident #1 on [DATE] the morning he was transferred to the ER. LVN B stated she got a verbal report that Resident #1 did not have urine output all night. LVN D stated she did not assess Resident #1 or provide any interventions. LVN D stated what she documented was what was done by Resident #1's Hospice nurse. LVN D stated when Resident #1's Hospice nurse got in the building at about 10:00 a.m., she told Resident #1's Hospice nurse that she got in report that Resident #1 did not have urine output during the night shift (12 hours shift). During an interview on [DATE] at about 12:35 p.m., Resident #1's Hospice nurse stated she was made aware by LVN A on [DATE] at about 2:00 p.m. of Resident #1 having blood in his foley catheter with urine output of 25 cc. Resident #1's Hospice nurse stated she asked LVN A to irrigate the catheter and call back if there were no changes. Resident #1's Hospice nurse stated when she saw Resident #1 on the morning of [DATE], there was blood in his catheter drainage bag, she flushed the catheter and there was return of clear fluids, and she knew something was not right because the output should have blood tinge and not clear. Hospice nurse stated she attempted to removed Resident #1's catheter and realized the bulb of the catheter was not in his bladder so his foley catheter was not draining urine. Hospice nurse stated she assessed Resident #1, and his abdomen was distended, she attempted to re-insert the foley catheter but was unsuccessful, so she transferred Resident #1 to the ER. The Hospice nurse stated distended bladder can cause discomfort and infection. She stated Resident #1 might have pull his catheter out, he had history of pulling his catheter out. During an interview on [DATE] at about 1:30 p.m., after the DON reviewed Resident #1's urine output which indicated the resident had no urine output on 5/17 and 25 cc on 5/18. The DON stated not having urine output with distended stomach can cause infection, if bad it can cause sepsis which can lead to death. The DON stated, if a resident was on hospice services, the hospice nurse would help sometimes to change the catheter. The charge nurses, DON, ADONs are responsible to ensure that the catheter is changed. Output for catheter should be document on the TAR by the charge nurses. The aides should get the output and the charge nurses document the output. During an interview on [DATE] at about 2:18 p.m., LVN A stated she worked with Resident #1 on [DATE] and there was blood coming from his catheter. LVN A stated Resident #1's family approached her about the blood in Resident #1's catheter and she called Resident #1's Hospice nurse around 2:00 p.m. and was told to flush the catheter. LVN A stated she flushed Resident #1's foley catheter and there was pinkish output of about 100 cc noted in the drainage bag. LVN A stated she did not tell the family that she would wait for the next day, she stated by the time she got back from calling Resident #1's Hospice nurse, the family had left. LVN A stated that she did not call Resident #1's Hospice nurse back and did not talk to Hospice nurse after. During an interview on [DATE] at 11:33 am, Resident #1's Hospice nurse stated she was not made aware the Resident #1 had blood in his catheter since [DATE], she would have sent Resident #1 to the hospital sooner to replace his catheter. Resident #1's hospice nurse stated when she saw Resident #1 on [DATE] he was uncomfortable. During interviews on [DATE] at about 12:00 p.m., CNA F stated she worked with Resident #1 during the night shift on 5/16, 5/17 and [DATE]. CNA F stated Resident #1 had blood in his foley catheter and LVN C was aware. CNA F stated Resident #1 had at least 100 cc in his foley bag, maybe she forgot to document Resident #1's output for the entire weekend. CNA F stated Resident #1 had pain all over but mainly his stomach and LVN C was aware of that. During an interview on [DATE] at about 12:13 p.m., CNA E, stated she worked with Resident #1 during the day shift on 5/16/, 5/17 5/18 and [DATE].CNA E stated Resident #1 started to have blood in his foley catheter bag from [DATE]. CNA E stated Resident #1 urine output was never over 50 cc and was all blood. CNA E stated it was brought to the attention of LVN A and B and they both stated they knew. CNA E also stated Resident #1 was pulling on the catheter like there was discomfort and he didn't want the catheter in., he was fidgeting. During an interview on [DATE] at about 12:39 p.m., LVN C stated he worked with Resident #1 on the weekend of 5/16 through [DATE] overnight. LVN C stated he got in report on [DATE] that Resident #1 had blood in his foley catheter. LVN C also stated Resident was making the AHHH sound while moaning and he gave Resident #1 pain medication on 5/17 and [DATE]. LVN C stated he did not document Resident #1's change in condition because Resident #1 was on hospice, and everyone was aware that there was blood in Resident #1's catheter and that Resident #1 was noted for pulling his catheter out. LVN C stated he did not notify the MD or Hospice. LVN C also stated they just pass it on in report from shift to shift each day the entire weekend. Later During an interview on [DATE] at 2:13 p.m., the DON stated it was documentation problems, the staff did intervene for Resident #1. The DON stated blood in the urine/catheter was normal for Resident #1. The DON stated, If it was blood, I expect the staff to irrigate the catheter, make sure it is clear or clearer with documentation to say that. You would monitor urine output but if you are not taking in anything, nothing would come out. We could not change it because of difficulty. They are not ever supposed to wait for few days before notifying the hospice or the Doctor. During an interview on [DATE] at 3:22 p.m., the MD stated she was familiar with Resident #1. The MD stated, The patient was on hospice, PO intake was poor, enlarge prostate and the urine will not flow. The catheter is to drain the urine from the bladder. He was always pulling on the catheter, and it was possible for the catheter to not be in the bladder when he pulled it. It can be a problem if there was no output for about 3 days, the staff were supposed to check for output every shift, within 24 hours, if there was no output they should have notified someone. Because he is on hospice, we cannot monitor him like the normal people. Distended bladder could cause discomfort, moaning is an indication of pain. Hard to say not having output would cause infection, it depends on how long he was distended. We have to do culture to know that. Review of facility's policy titled Foley Catheter insertion; Male Resident dated [DATE] reflected: Purpose The purpose of this procedure is to provide guidelines for the aseptic insertion of a urinary catheter. Documentation The following information should be recorded in the resident's medical record: The date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data (e.g., character, color, clarity, etc.) obtained during the procedure. The size of the Foley catheter inserted, and the amount of fluid used to inflate the balloon. How the resident tolerated the procedure. If the resident refused the procedure, the reason(s) why and the intervention taken. The signature and title of the person recording the data. Reporting Notify the supervisor if the resident refuses the procedure. Notify the physician of any abnormalities (i.e. bleeding, obstruction, etc.). Report other information in accordance with facility policy and professional standards of practice. Review of facility's policy titled Hospice Program dated [DATE] reflected: Policy Statement Hospice services are available to residents at the end of life. In generally, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: a. Twenty-four-hour room and board care, b. Administering prescribed therapies, incl a. b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The Administrator and ADON were notified on [DATE] at 2:02 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 10:25 am. Immediate Jeopardy Plan of Removal for F690 Tag: F690 - Bowel/Bladder Incontinence, Catheter, UTI On [DATE], an abbreviated survey was initiated at the facility. On [DATE]Tw the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to assess and intervene with Resident #1's foley catheter when it was draining all blood for 3 days before he was sent to the ER on [DATE] for further evaluation and treatment where Resident #1 was diagnosed with Sepsis without acute organ dysfunction, Acute urinary retention, Complicated Urinary tract infection associated with indwelling urethral catheter, Dehydration, and Retention of urine. Plan of Removal 1. Immediate Action Taken to Protect Resident #1 and Related Residents: Resident #1 expired in the hospital. The two residents with the indwelling catheters were assessed by the DON/ADON and/or Charge Nurses for signs/symptoms of UTI placement, drainage, and pain management and catheter necessity. This staff was re-trained/in serviced by the DON, who was re-in serviced by the Regional Nurse consultant. Seven Hospice residents were assessed by DON/ADON and/or Charge nurses for any signs or symptoms of pain and suffering. This staff was re-trained/in serviced by the DON, who was re-in serviced by the Regional Nurse consultant. All hospice residents were found to have no new signs/symptoms of infection or pain to report to the hospice entity/physician. 2. Education/Re-Education: There were 5 Nurses and 8 CNAs responsible for Resident #1's care were immediately re-trained on catheter care, infection control, and documentation standards. The success of the training was secured with return demonstration and question/answering. All licensed nurses and cnas will receive re-education on: o Catheter care protocol per facility policy o Signs and symptoms of UTI and urinary retention o catheter-associated urinary tract infection and proper hygiene o Signs and symptoms of pain and suffering Completed by: DON and ADON will complete the re-education before the employees' next assigned shift, or they will not be allowed to work. DON/ADON will use a catheter skills list to check off for nurse and cna roles by [DATE]. This will be to ensure return demonstration of knowledge from the in-service and a allow proper documentation of the intake/output record. 3. Facility-Wide Audit and Monitoring: A 100% audit of all residents with indwelling catheters was completed on [DATE] utilizing a facility developed audit tool by DON/ADON. Each catheterized resident was reviewed for: o Proper physician orders o Documentation of catheter necessity o Evidence of routine catheter care and hygiene o Monitoring for UTI symptoms Daily monitoring records were implemented for this catheter care documentation to be captured in the morning clinical meetings. Audit Completion Date: [DATE] 4. Infection Control Measures Enhanced: DON/ADON reviewed and revised the catheter care protocol to align with facility protocol. In-servicing of hand hygiene, PPE usage, and catheter technique conducted for all licensed staff/CNAs. Random observations of catheter care are now being performed daily for 2 weeks, weekly thereafter for 1 month. Completed by: DON and ADON will complete the re-education before the employees next assigned shift or they will not be allowed to work. An audit tool will be developed by ADON to assure return demonstration/competency of the in-service. 5. Medical Oversight and Ongoing Review: Medical Director reviewed all cases of catheter use and collaborated with nursing to eliminate unnecessary catheters. Hospice management entity review with facility on pain and suffering. Beginning [DATE] and ongoing Weekly interdisciplinary team (IDT) meetings include a catheter review component. Pharmacy consultant notified to assist in UTI surveillance and antibiotic stewardship with monthly reviews and electronic chart data. Audit tools will be developed for each of these areas by ADON. 6. Monitoring for Effectiveness: DON or designee will audit those catheterized residents weekly for compliance and document on a facility developed form beginning 06032025 and ongoing. DON/ADON will monitor new UTIs and catheter-associated urinary tract infection, report trends monthly to QAPI. This will be documented on an audit tool starting 06032025 and ongoing. Random staff interviews and skill checks on catheter care will occur weekly for 4 weeks and monthly thereafter beginning [DATE] and ongoing. The Surveyor monitored the POR on [DATE] from 10:26 am to 5:30 pm as follows: During interviews on [DATE] from 1:55 PM - 3:03 PM revealed four CNAs, one MA, one LVN, and one RN from different shifts all stated they were in-serviced before their shifts by the DON on catheter care, pain, and notifying the MD. The CNAs stated they were responsible for emptying the catheter bag before the end of their shift, making sure it was clean, and that peri care was provided. The CNAs stated they were responsible for charting the input and output of urine and notifying the nurse if there was anything abnormal such as blood in the urine, cloudiness, or if the resident was in pain. The nurses all stated it was their responsibility to set eyes on residents' catheters every shift to monitor if it was in place, if there was any sediment in the tubing, and that it was draining properly. The nurses stated if there was blood in the bag or if the resident was in uncontrolled pain, they would contact the MD immediately. Review of facility's in-services dated [DATE] and [DATE] reflected the following: Facility had an QAPI for identification of deficient practice 0n [DATE] at 7:20 pm Nurses and CMA checkoff on Foley Catheter Insertion, Hand hygiene, PPE/EBP with posttest. DON completed an audit on all Resident with foley Catheter. MD review all resident with catheter and were on hospice, reviewed their documents and there were no concerns. Review of facility's in-service dated [DATE] reflected the DON was in-serviced by the Regional Nurse on the following topics: change of condition, significant change of conditions, pain and suffering management, pain management assessment, catheter care / management policy. Review of facility's audit tools reflected all residents with indwelling catheter (2 residents) and were on hospice (7 residents) were listed and kept in the 24-hour report binder and there were no issues with their catheter and hospice care. It was reflected Resident were assessed and assessments were documented in the resident's EMR progress notes, assessments were done using either verbal or visual assess. Staff were in-serviced on s/s of UTIS, urinary retention, infection control, catheter care. Review of progress notes of Residents with indwelling catheter reflected it was reviewed by the MD on [DATE]. Review of facility's audit tools initiated [DATE] reflected 2 Residents in the facility with catheter. Audit tools tracs urine output, color clarity, odor, completion of catheter care, s/s of UTI, s/s of pain, signs of blood in urine. Observation on [DATE] of hospice residents and residents with indwelling catheter reflected no concerns or non-compliance. On [DATE] at 05:03 p.m., the Administrator was informed the immediacy was removed. While the IJ was removed on [DATE] at 05:03 p.m., the facility remained out of compliance at a severity of no actual harm and a scope of isolated, 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 records review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 3 residents review for pain management. The facility failed to provide effective pain interventions for Resident #1 from [DATE] through [DATE]. The facility failed to assess and intervene when Resident #1's foley catheter (a medical device, a thin flexible, sterile tube that is inserted through the urethra into the bladder to drain urine) when Resident #1's foley catheter was draining all blood from [DATE] until 3 days later on [DATE]; Resident #1 was sent to the local ER for further evaluation and treatment and was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction dated [DATE], Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (is a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). Resident #1 later died in the hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 2:02 pm and an IJ template was given. While the IJ was removed on [DATE] at 05:03 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for discomfort, hospitalization, and death. Findings included: Review of Resident # 1's face sheet dated [DATE] reflected an [AGE] year-old male admitted on [DATE] with diagnoses that included: Parkinson's disease (is a movement disorder that affects the nervous system and cause tremor, stiffness, slowing of movement and other problems), Acute Kidney failure (also known as acute renal failure is a condition where your kidneys stop working suddenly), obstructive and reflux uropathy (occurs when urine flow is blocked, either partially or completely through the ureter, bladder, or urethra.), BPH(Benign prostatic Hyperplasia occurs when the cells of the prostate gland begin to multiply. These additional cells cause your prostate gland to swell, which squeezes the urethra and limit urine flow) with lower urinary tract symptoms, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder). Review of Resident #1's significant change MDS dated [DATE] indicated the Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter. Section J-Pain Assessment Interview reflected Resident #1 experience pain almost constantly of 7 on the scale 0-10. Review of Resident #1's care plan dated [DATE] reflected Resident #1 needed staff participation with ADLs due to weakness, Resident #1 required the use of indwelling catheter related to urinary retention with intervention to observe for signs and symptoms for UTI and notify charge nurse and physician for further assessment, medication as ordered, irrigate catheter per physician orders. It was noted that Resident #1 was at risk for pain related to disease process End Stage Parkinson with intervention to Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Review of Resident #1's progress notes reflected no documentation of change of condition on 5/16, 5/17 and [DATE]. Review of Resident #1's interact form dated [DATE] reflected Resident #1 went to the ER for foley catheter re-insertion. Review of Resident #1's hospital records dated [DATE] reflected: Current Symptoms Seen on rounds. Not verbalizing other than moaning. Writhing in bed. RN at bedside providing pain medication. Symptom Management: 1.) Pain - Significant nonverbal signs of pain (PAINAD score 9) - Change to fentanyl 12.5-25 mcg IV q2h prn 2.) Anxiety/agitation - Change to Ativan 0.5 mg IV q4h prn PAINAD Breathing: Brief labored or hyperventilation periods Vocalization: Loud moans/groans. Repeated troubled calling out. Crying Expression: Grimacing Body Language: Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. Consolability: Unable to console, distract, or reassure. PAINAD SCORE: 9 Review of Resident #1's Physician order reflected: Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 12 hours as needed for Pain and Discomfort Give One 50mg Tab Every 12 hours as needed for pain dated [DATE] Morphine Sulfate Oral Solution 10 MG/5ML (Morphine Sulfate) Give 0.5 ml by mouth every 2 hours as needed for PAIN/SOB Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth two times a day for pain dated [DATE] Review of Resident #1's EMR reflected Resident #1 did not have any pain from [DATE] through [DATE] Review of Resident #1's MAR /TAR reflected Resident #1 was not given any breakthrough pain medication during the day shift. Review of Resident #1's Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg narcotic count sheet for the last week before Resident #1 was sent to the ER reflected the following: [DATE] at 8:30 pm- 0.5 ml administrator by LVN C [DATE] at 10:30 pm- 0.5 ml administrator by LVN C [DATE] at 10:45 pm- 0.5 ml administrator by LVN C [DATE] at 4:30 am- 0.5 ml administrator by LVN C [DATE] at 8:00 pm- 0.5 ml administrator by LVN C [DATE] at 11:0 pm- 0.5 ml administrator by LVN C Review of Resident #1's Morphine Sulfate Oral Solution 10 MG/5ML (Morphine Sulfate) narcotic count sheet for the last week before Resident #1 was sent to the ER reflected the following: [DATE] at 8:00 pm- 1 tab administrator by LVN C . Review of Resident #1's hospital records dated [DATE] reflected he was diagnosed with Sepsis (a serious condition in which the body responds improperly to an infection, causing organ damage and sometimes death) without acute organ dysfunction, Acute urinary retention (a sudden and often painful inability to empty the bladder, which can develop rapidly and may require immediate medical attention. Symptoms may include suprapubic pain, bloating, urgency, and distress), Complicated Urinary tract infection (a UTI with a higher risk of treatment failure) associated with indwelling urethral catheter, Dehydration (occurs when your body loses more fluids than it takes in, leading to insufficient water for normal bodily functions). Review of Resident #1's hospital records dated [DATE] reflected, Resident [#1] was admitted to inpatient Hospice services, symptoms were managed with IV medication. He expired peacefully on [DATE] while in the hospital. Review of Resident #1's hospital records dated [DATE] reflected, Resident [#1] was admitted to inpatient Hospice services, symptoms were managed with IV medication. He expired peacefully on [DATE] while in the hospital. During an interview on [DATE] at about 12:35 p.m., Resident #1's Hospice nurse stated she assessed Resident #1 on [DATE] at about 10:00 am, and his abdomen was distended, she attempted to re-insert the foley catheter but was unsuccessful, so she transferred Resident #1 to the ER. The Hospice nurse stated distended bladder can cause pain, discomfort and infection. She stated Resident #1 might have pull his catheter out, he had history of pulling his catheter out. During an interview on [DATE] at about 1:30 p.m., after the DON reviewed Resident #1's urine output which indicated the resident had no urine output on 5/17 and 25 cc on 5/18. The DON stated not having urine output with distended stomach can cause infection, if bad it can cause sepsis which can lead to death. During an interview on [DATE] at 11:33 a.m., Resident #1's Hospice nurse stated she was not made aware the Resident #1 had blood in his catheter since [DATE], she would have sent Resident #1 to the hospital sooner to replace his catheter. Resident #1's hospice nurse stated when she saw Resident #1 on [DATE] he was uncomfortable. During interviews on [DATE] at about 12:00 p.m., CNA F stated she worked with Resident #1 during the night shift on 5/16/, 5/17 5/18 and [DATE]. CNA F stated Resident #1 had blood in his foley catheter and LVN C was aware. CNA F stated Resident #1 had at least 100 cc in his foley bag, maybe she forgot to document Resident #1's output for the entire weekend. CNA F stated Resident #1 had pain all over but mainly his stomach area and LVN C was aware of that. During an interview on [DATE] at about 12:13 p.m., CNA E, stated she worked with Resident #1 during the day shift on 5/16/, 5/17 5/18 and [DATE].CNA E stated Resident #1 started to have blood in his foley catheter bag from [DATE]. CNA E stated Resident #1's urine output was never over 50 cc and was all blood. CNA E stated it was brought to the attention of LVN A and B and they both stated they knew. CNA E also stated Resident #1 was pulling on the catheter like there was discomfort and he did not want the catheter in, he was fidgeting. During an interview on [DATE] at about 12:39 p.m., LVN C stated he worked with Resident #1 on the weekend of 5/16 through [DATE] overnight. LVN C stated he got in report on [DATE] that Resident #1 had blood in his foley catheter. LVN C also stated Resident #1 was making the AHHH sound while moaning and he gave Resident #1 pain medication on 5/17 and [DATE]. LVN C stated he did not document Resident #1's change in condition because Resident #1 was on hospice, and everyone was aware that there was blood in Resident #1's catheter and that Resident #1 was noted for pulling his catheter out. LVN C also stated they just pass it on in report from shift to shift each day the entire weekend. During an interview on [DATE] at 3:22 p.m., the MD stated she was familiar with Resident #1. The MD stated, The patient was on hospice, PO intake was poor, enlarge prostate and the urine will not flow. The catheter is to drain the urine from the bladder. He was always pulling on the catheter, and it was possible for the catheter to not be in the bladder when he pulled it. Because he is on hospice, we cannot monitor him like the normal people. Distended bladder could cause discomfort, moaning is an indication of pain. Hard to say not having output would cause infection, it depends on how long he was distended. We have to do culture to know that. Review of facility's policy titled Pain Management Assessment Policy undated [DATE] reflected: Purpose To establish a comprehensive and Standardized approach to assessing and managing pain in nursing home residents, ensuring that pain is effectively identified, documented and managed in a timely and compassionate manner. Scope-This policy applies to all healthcare providers working in the nursing home, including nurses, physicians, certified nursing assistant (CNAs), and other staff involved in patient care. Definitions o Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain can be acute or chronic, and may involve physical, emotional, or psychological distress. o Verbal Cues: Spoken or written expressions of pain, discomfort, or distress. o Non-Verbal Cues: Body language, facial expressions, or behavioral changes that indicate the presence of pain or discomfort. o Uncontrolled Pain: Pain that remains at an unmanageable level despite administration of pain-relief interventions, requiring reassessment or escalation of treatment. 1.2 Non-Verbal Pain Cues For residents who are unable to communicate verbally (e.g., those with advanced dementia, nonverbal residents, or residents who are cognitively impaired), the following non-verbal cues should be closely observed: o Facial Expressions: o Grimacing, frowning, or clenching of the jaw. o Eyes wide open or squinting, especially when touched or moved. Body Movements: o Restlessness, agitation, or sudden jerking motions. o Posturing, guarding, or bracing certain body parts. o Decreased activity level or withdrawal. o Repetitive movements such as rocking or pacing. Behavioral Cues: o Increased irritability, crying, or sudden outbursts. o Changes in sleeping patterns (frequent waking or inability to sleep). o Refusing to participate in activities or to be touched. Assessment Tools for Non-Verbal Residents: o PAINAD Scale (Pain Assessment in Advanced Dementia): A validated tool that scores facial expression, body movements, vocalizations, and changes in behavior to assess pain levels in residents with advanced dementia or those who are non-verbal. ABC Charting: Observe and document behaviors or changes in appearance, such as agitation, that may suggest pain. o Timely Administration: o Ensure that pain medication is administered in accordance with the prescribed schedule to maintain consistent pain relief. o PRN (as needed) medications should be given in a timely manner when pain is reported or observed. If a resident has chronic pain, use a scheduled dosing regimen ( e.g., around-the-clock opioids for cancer pain) in addition to PRN medications for breakthrough pain. Review of facility's policy titled Hospice Program dated [DATE] reflected: Policy Statement Hospice services are available to residents at the end of life. In generally, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: a. Twenty-four-hour room and board care, b. Administering prescribed therapies, incl a. b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. (3) A need to transfer the resident from the facility for any condition. (4) The resident's death. d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day; The Administrator and ADON were notified on [DATE] at 2:02 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 10:25 am. Plan of Removal - F697: Pain Management Regulatory Tag: F697 On [DATE], an abbreviated survey was initiated at the facility. On 06/03 2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to assess and intervene with Resident #1's foley catheter for 3 days when his foley catheter was draining all blood for 3 days before he was sent to the ER on [DATE] for further evaluation and treatment where Resident #1 was diagnosed with Sepsis without acute organ dysfunction, Acute urinary retention, Complicated Urinary tract infection associated with indwelling urethral catheter, Dehydration, Retention of urine, unspecified 1. Immediate Corrective Actions: Resident-Centered Interventions for Resident #1 and Related Residents: o Resident #1 expired in the hospital. o There are two other residents with indwelling catheters. They were reviewed for appropriate pain management which included PRN and scheduled pain medications were reviewed. No changes to their med needs were identified. o To document this review a care plan meeting will be held with the physician and responsible party by [DATE] to understand the goals of the pain management program for these two residents. o Pain assessments re a part of our policy for nurses to complete per shift and quarterly by the MDS Coordinator. This will be completed on an on-going basis as part of our policy. This action addressed the residents with the two indwelling catheters. Physician and responsible party contacted as well. Staff Education/Re-Education: o All licensed nurses and medication aides will be in serviced immediately by the DON/ADON before their next assigned shift starting on [DATE] or they will not be allowed to work: Pain assessment procedures (verbal and non-verbal cues) Timely medication administration and documentation Notification protocols for uncontrolled pain o An audit of these competencies for the nurse and nurse aide will be conducted and signed off by the Director of Nursing/or Designee prior to staff beginning their next assigned shift. Their understanding will be reestablished by the return demonstration/question-answer of this in-service. The DON had her re-education completed by the Regional Nurse. These competencies must be completed, or they will not be allowed to work. This will be done by [DATE]. o Monitoring and Oversight: o DON or designee will begin on [DATE] conducting daily pain management audits for all residents with indwelling catheter for 2 weeks and monthly thereafter to ensure: Pain is assessed using a standardized tool (e.g., numeric or PAINAD) Timely and appropriate interventions are provided. Documentation reflects assessment, intervention, and outcome. Audits will be performed and documented during morning clinical reviews. 2. How the Facility Will Manage This Event Going Forward: Ongoing Training: o All current and new staff will receive mandatory pain management training upon hire and quarterly thereafter. The DON/ADON will be responsible for overseeing this process, after the re-education by the Regional Nurse. Interdisciplinary Review: o Pain management for indwelling catheters will be a standing item in weekly IDT meetings to discuss residents with pain concerns, review trends, and modify care plans. This will be started by [DATE] and be ongoing. Policy Review and Enforcement: o Pain Management Policy was reviewed by DON/ADON with Regional Nurse on [DATE] to reinforce expectations on identified residents for: Assessment Medication administration Documentation Physician notification o Policy implementation began on [DATE] and will be monitored by DON and IDT weekly for 30 days then monthly for QAPI. o Their understanding will be reestablished by the return demonstration/question-answer of this in-service. Quality Assurance Monitoring: o Pain documentation and effectiveness audits will be performed by the DON or designee weekly for 4 weeks, then monthly. This will start [DATE] and be on going. o Results reported to the Quality Assurance & Performance Improvement (QAPI) Committee monthly for continued evaluation and interventions. The Surveyor monitored the POR on [DATE] from 10:26 am to 5:30 pm as follows: During interviews on [DATE] from 1:55 PM - 3:03 PM revealed four CNAs, one MA, one LVN, and one RN from different shifts all stated they were in-serviced before their shifts by the DON on catheter care, pain, and notifying the MD. The CNAs stated they were responsible for emptying the catheter bag before the end of their shift, making sure it was clean, and that peri care was provided. The CNAs stated they were responsible for charting the input and output of urine and notifying the nurse if there was anything abnormal such as blood in the urine, cloudiness, or if the resident was in pain. The nurses all stated it was their responsibility to set eyes on residents' catheters every shift to monitor if it was in place, if there was any sediment in the tubing, and that it was draining properly. The nurses stated if there was blood in the bag or if the resident was in uncontrolled pain, they would contact the MD immediately. Review of facility's in-services dated 06/03 and [DATE]/2025 reflected the following: Facility had an QAPI for identification of deficient practice 0n [DATE] at 7:20 pm DON completed an audit on Residents with PRN pain medications. DON completed an audit on all Resident with foley Catheter. MD review all resident with catheter and were on hospice, reviewed their documents and there were no concerns. Review of facility's in-serviced dated 06/04 through [DATE] titled Pain management was conducted by the ADON and DON for all nursing staff. Nurses stated they were in-serviced on making sure to chart any changes and notify the family and/or the MD. Review of facility's Change of condition and notification policy reflected it was updated on [DATE] and was approved by DON, and the , Regional Nurse Consultant. It reflected the purpose was to provide a standardized process for identifying assessing, and responding to changes in the physical, cognitive or emotional condition of nursing home residents, ensuring timely and appropriate notification to the physician, responsible party and hospice care team (if applicable.) Review of facility's in-service dated [DATE] reflected the DON was in-serviced by the Regional Nurse on the following topics: change of condition, significant change of conditions, pain and suffering management, pain management assessment, catheter care / management policy. Review of facility's in-services reflected LVN B and D were in-serviced on notification on [DATE]. LVN B confirmed verbally that she was in-serviced on pain management. Review of the facility's matrix dated [DATE] reflected there were 2 other residents with indwelling catheter in the facility. Both Residents progress notes dated [DATE] reflected care plan meeting was held with residents and their RPs regarding indwelling catheter and pain management. Review of Residents with indwelling catheter care plans reflected their care plans were updated on [DATE] by the MDS nurse. Review of Residents with indwelling catheter pain assessment and pain medication reviews were completed on [DATE] and there were no concerns. Progress notes also revealed Physician and family were notified. Review of facility's audit tools reflected all residents with pain management were listed and kept in the 24-hour report binder and there were no issues relating to pain management. Audit revealed PRN pain medications were effective., Scheduled pain medications are assessed at the of administration and documented on the MAR with the use of the pain scale. On [DATE] at 05:03 p.m., the Administrator was informed the immediacy was removed. While the IJ was removed on [DATE] at 05:03 p.m., the facility remained out of compliance at a severity of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #1, Resident #2 and Resident #3 ) of 14 residents reviewed for accident hazards/supervision. There was one staff member in the memory care unit of the facility supervising 14 residents by herself., limiting adequate supervision for preventing accidents. An IJ was identified on 04/12/24. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure could affect all the memory care residents and place them at risk of not receiving the appropriate level of supervision to prevent physical harm, pain and accidents. Findings Included: Record review of resident roster on 04/03/24, dated 04/03/24, revealed 14 residents resided on the memory care unit (Hall 6). Record review of Resident #1's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Urinary Tract Infection, Dementia and Abnormal weight Loss. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 indicating Resident #1's cognition was severely impaired. Review of section E, G, H, J, N, O, P of the MDS reflected, Resident #1 did not have any hallucinations or Delusions however the frequency of behavior symptoms (not directed towards others.) were occurred 4 to 6 days/ week. She needed one person's extensive physical assistance for bed mobility, eating and toilet use and received 5 days of occupational therapy every week (at least 15 minutes/day) Record review of Resident #1's care plan dated 01/12/2024 revealed Resident #1: 1. Resident #1 wandered around facility with/without purpose related to dementia. The relevant interventions were, providing redirection as needed when observing Resident #1 out of room for wandering in/out of other room or wandering to unauthorized area and Offering verbal cues and redirection as needed to find own room, dining areas, activities area as needed. 2. Resident #1 was at risk for fall due to unsteady gait, decreased balance, medications, and poor safety awareness. The relevant intervention was promoting the use of a mobility device. 3. Resident #1 was impulsive and would get up and walk without walker. The interventions were assisting resident to bed after evening meal for safety and fall management and Encouraging Resident #1 to change positions slowly. 4. Resident #1 was at risk for decreased nutritional deficits and complications related to weight loss and dementia. The relevant interventions were, encouraging resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly and Monitor/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth. 5. Resident #1 displays conflictual behavior with other persons related to severe mental illness. The relevant intervention was, when any inappropriate behavior is observed, inform the resident that behavior is inappropriate and will not be tolerated. 6. Resident #1 was incontinent of bladder. The relevant interventions were, using disposable briefs and change per schedule and PRN and Clean peri-area with each incontinence episode. Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Mood Disorder, Major Depressive Disorder, Anxiety Disorder, Dementia, Type 2 Diabetes, Memory Deficit and Seizures. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS Score of 11 indicating Resident #2's cognition is moderately impaired. Review of section E, G, H, J, N, O, P of the MDS reflected, Resident #2 did not have any hallucinations or Delusions however the frequency of verbal behaviors directed towards others and other behavior symptoms ( not directed towards others) were occurred 1 to 3 days/ week and exhibited wandering behavior occurred 1 to 3 days. She required one person's extensive physical assistance for bed mobility, transfer and toilet use and limited assistance with eating. Resident #2 was on insulin injection every day and received 5 days of occupational therapy every week (at least 15minutes/day) Record review of Resident #2's care plan dated 01/18/2024 revealed: 1. Resident #2 exhibits behaviors that interfere with recreational activities, herself, and others. She curses and argues with other residents. The relevant interventions were offering assistance to activity functions as needed and Provide redirection and distractions for safety. 2. Resident #2 was at risk for elopement related to diagnosis of Anxiety and Vascular Dementia and resides on a secured unit. Relevant interventions were Monitoring for tail gaiting when visitor and staff exiting facility and Use of diversional activities when exit-seeking behavior is occurring. 1. Resident #2 prefers independent activities of choice such as sitting outside or in her room/ visits with her family member. The intervention was, facilitate to go outside when the weather is nice. 2. Resident #2 had multiple risk factors for falls such as dementia, history of falls and new environment. The relevant interventions were assisting for transfers and ambulation and Encouraging her to stay in common areas when up in wheelchair. 3. Resident #2 had an ADL Self Care Performance Deficit related to Aggressive Behavior, dementia, poor decision-making skills. Relevant intervention was two staff participation to use toilet, transfers, bathing and one staff participation with dressing, personal hygiene and oral care. Record review of Resident #3's face sheet revealed an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included Major Depressive Disorder, Anxiety Disorder, Dementia, Memory Deficit and Aphasia (Loss of ability to understand or express speech) Record review of Resident #3's MDS assessment dated [DATE] revealed that Resident #3 was unable to participate in the assessment as he was rarely/never understood the process. Review of section E, G, H, J, N, O, P of the MDS reflected, Resident #3 was on total dependence with eating and toilet use, and extensive assistance with bed mobility and transfer. He required two persons' support to accomplish these activities (for transfer and eating needed the help of one person). Record review of Resident #3's care plan dated 02/06/24 revealed: 1. Resident #3 has mixed bladder incontinence related to dementia The relevant intervention was checking the resident every 2 hours and as required for incontinence. 2. Resident #3 had an ADL self-care performance deficit. The relevant interventions were, dedicate one staff to provide bath/shower, extensive assist for repositioning and turning in bed, dressing, helping with eating, personal hygiene and oral care, incontinent care and transferring. Observation on 04/12/24 from 10:30 AM to 11:00AM of the memory care unit revealed there were 14 residents in the unit and only CNA A was scheduled for providing nursing care for them from 6AM to 2PM (verified with Daily Staffing Schedule records). There were no other staff member was present in the unit during that period. All the residents except Resident #3 were relaxing in the unit at various locations, out of their rooms. Resident #2 was in her wheelchair and stayed at the entrance door. She was in an elevated mood and talking to herself loudly. At about 10:45AM, Resident #1 approached Resident #2 in an intimidating manner and then they had heated arguments in between them. CNA A who was at the nursing station, situated at the middle of the unit and about 25 ft away from Resident #1 and Resident #2, walked towards them. Resident #1 raised her hand with the intention to hit Resident #2. CNA A rushed towards them, intervened and distracted Resident #1 from hitting Resident #2. CNA A then redirected Resident #1 to the sitting area near the nursing station and encouraged her to sit with other residents. 3 the residents were in and out of the courtyard together as well as various occasions without any supervision and the door towards the courtyard remain opened for their convenience. During an interview on 04/12/24 at 10:30AM CNA A stated she had worked at the facility for about 6 years and currently was 7 months pregnant. She was the only staff in the memory care unit to take care of 14 residents. She stated she managed to take care of them by herself during her shift for a while however the quality of care was compromised. When HHSC investigator requested her to elaborate further, she stated since she had to take care of everything about all the 14 residents in the unit, she had to compromise the care. When investigator asked her to give examples of compromised care, she said, there were occasions when she could not provide residents who needed shaving while giving them shower due to other nursing care commitments for other residents. She said, she kept open the shower room door while providing shower to the residents so that she could have an eye on other residents on the unit to ensure safety. CNA A stated she rarely got time to communicate therapeutically with residents due to other priority tasks. She added, from her experience, therapeutic communication resulted in better mental health and had positive impact on residents' behavioral problems. CNA A stated when she was alone at the unit, she had to spend some exclusive time to take care of Resident #3's needs including feeding. She stated he was a hospice resident and needed full support with ADLs including bed mobility and transfer. When investigator asked her who supervises other residents while providing 1:1 care to residents, CNA A stated, there was no one. She stated, in such situations there was potential risk of incidences like falls, resident to resident altercations, choking of food while eating or any other kinds of accidents. When the investigator asked about the supervision of residents while they were in the courtyard, CNA A stated she always had an eye on them from inside as she was unable to leave other residents alone in the unit and go out to supervise them in the courtyard. CNA A stated some days there were more than one staff and those days it was easier to accomplish all her tasks without safety concerns. During an interview on 04/12/24 at 11:00 CNA B stated she came to the unit to relieve CNA A for her break and found it difficult to supervise them by herself. CNA B stated this happens when more than one residents needed care and attention at the same time. CNA B stated she was asked to stay at the memory care only during CNA A's break time and provide care pertain only to that period of time. Observation on 04/12/24 at 10:55AM of Resident #3's room situated in the memory care unit revealed Resident #3 was laying in his bed and the door remained opened. Observation on 04/12/24 at 12:20PM revealed 10 residents including Resident #1 were having lunch in the dining room, unattended for about 5 minutes, until CNA A arrived from another area that was away from the dining room in the memory care unit. CNA C who was present in the unit was busy with administering afternoon medications. Observation and interview on 04/12/24 at 12:30PM of Resident #3 revealed, CNA D was feeding Resident #3. CNA D stated she was the Restorative Aide at the facility and mostly busy with helping residents with physiotherapy however took over some of the CNA's tasks at the facility, whenever she had time. CNA D stated she helps with the task of feeding Resident #3 once in a while to support the staff in the memory care unit. Record review of the Staffing Schedule between 03/17/24 and 04/12/24 revealed, on 6AM to 2PM shift in Hall 6 (memory care unit), there was only one CNA scheduled on 03/17, 03/18, 03/19, 03/21, 03/22, 03/23, 03/24, 03/26, 03/27, 03/28, 04/01, 04/02, 04/03, 04/04, 04/07, 04/08, 04/12. On 2PM to 10PM shift, there was only one CNA on 03/17, 03/19, 03/20, 03/21, 03/22, 03/23, 03/24, 03/25, 03/26, 03/27, 03/28, 03/29, 03/30, 04/01, 04/02, 04/03, 04/04, 04/08 and 04/11. During an interview on 04/12/24 at 5:00PM LVN A stated she was responsible for making the daily staffing schedule at the facility. When the investigator asked if one staff was enough considering the memory care nursing demands, LVN A stated though there was only one CNA scheduled for some days, on those days, other CNA's went to the memory care unit from time to time to help the CNA there. She stated on 04/12/24, CNA C was designated to work in her free time after the completion of medication administration. During observations and interview on 04/12/24 at 5:15PM CNA C stated she was the Medication Aide at the facility for many years and worked at the facility from 8:00 AM to 8:00PM shift. She stated, after the completion of her medication administration task, she worked in the memory care to support the CNA there. During observations at 9:30AM, 10:30AM and 12:15PM, CNA C was busy with administering medications. At 3:30PM and 5:00PM, CNA C was present at the nursing station located outside the memory care unit of the facility. During an interview on 04/12/24 at 5:30PM ADM stated he did not believe the nursing care at the memory care was compromised on the days when only one CNA was working there. He stated, CNAs from the other side went and supported the CNA at the memory care on such days. He stated, recently two staff members were terminated from the facility as part of a disciplinary action, and they might be behind this baseless allegation of supervision issue in memory care. He stated the safety of the residents at the facility was his priority and did not do anything that compromises the quality of care. Record review on 04/15/24 of facility policy Safety and Supervision of Residents revised in July, 2017 reflected: Our facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. . Our individualized resident centered approach to safety addresses safety and accident hazards for individual residents. Record review on 04/15/24 of facility policy Staffing revised in October, 2017 reflected: Our facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . staffing numbers and skill requirements of direct care staff are determined by the needs of residents based on each resident's plan of care. Record review on 04/15/24 of facility's undated job description for Certified Nursing Assistant reflected: Major Duties and Responsibilities: Provides supportive services to nurse(s) and other staff as needed and performs duties as assigned. Assists resident with or perform Activities of daily living for resident in accordance with care plans and established policies and procedures. Assists resident with lifting. turning moving. positioning, and transporting into and out of beds, chairs, bathtubs. wheelchairs. lifts, etc. Coordinates dining room services at assigned mealtimes, including set-up and clean-up, meal tray delivery, feeding assistance and documentation of meal intake. Delivers nutritional supplements to residents at assigned times and provides assistance as necessary to ensure intake. Documents intake accordingly. Assists nursing staff in carrying out toileting program activities. An Immediate Jeopardy was identified on 04/12/24 at 5:12PM. The IJ Template was provided to the facility ADM on 04/12/24 at 6:00 PM. The following Plan of Removal submitted by the facility was accepted on 04/13/24 at 9:00AM and indicated the following: [Facility name] F689 Plan of Removal 04/13/2024 Immediate Corrective Action for residents affected by the alleged deficient practice: The residents residing on the unit had the potential to affected by this deficiency. Residents on the unit were assessed by Staff LVN/Wound Care Nurse and noted to be stable as of 04/13/2024. Our staffing schedule is determined based on the acuity of our residents and based on this the facility will add an additional staff member from 10:00am-6:00pm to the secure unit to ensure proper supervision. The administrator and staffing coordinator will ensure that these staff members are present on the hall during the AM and evening shifts, and the night shift. The secure unit schedule will be adjusted effective immediately and checked daily accordingly. Actions taken to prevent a serious adverse outcome from recurring: This deficient practice had the potential to affect all residents residing on the unit. The administrator, and assistant director of nursing were educated on properly staffing the secure unit/facility, ensuring the residents are safe from accidents and hazards, and quality of care by our Regional Nurse Consultant 0n 04/13/2024. In turn training of facility staff on proper staffing, keeping residents free of accidents and hazards, as well as providing quality care to all was initiated by the Administrator and ADON on 04/13/2024. The administrator has created a scheduling audit to monitor the staffing of the facility with an emphasis on the secure unit on 04/12/2024. The administrator, staffing coordinator, or designee will ensure the new staffing schedule is correctly adhered to daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. Administrator or ADON will continue to audit the schedule daily in the morning standup meeting as an ongoing process. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency (F689) on 04/13/2024 and an Ad-Hoc (When necessary) QAPI meeting was held on 04/13/2024 to discuss the findings. All findings will be reported to the QAPI team monthly for quality assurance. When Actions will be complete: The facility will have completed education by 04/13/2024, if any staff member working on the unit is unable to be educated, they will be removed from the schedule until training has been provided. All staff that will work on the unit will receive this training whether full, part time or contract, The facility requests the removal of the immediate jeopardy on 04/13/2024. The surveyor confirmed the facility implemented their plan of removal sufficiently from 04/12/24 through 04/15/24 to remove the IJ by: 1. Record review of the staffing schedule and interview of ADM on 04/15/24 revealed the staffing was done carefully and appropriately. There were two staff on 6AM to 2PM and 2PM to 10PM shifts on 4/13, 4/14 and 4/15 in the locked unit. 2. During interview on 04/15/24 at 12:45pm LVN A stated she had done an assessment on staffing demands on 04/15/24 and said on that day there were two staff members in the memory care unit as two residents at the unit were hyper. 3. Observation on 4/15/24 at 12:50 pm revealed CNA E and CNA D were scheduled at memory care unit. Residents were engaged in coloring activities with CNA D, and it appeared they were enjoying it. CNA E was supervising other residents. LVN A was in the memory care monitoring the staff performance. 4. Record review on 04/15/24 of the In-services Log revealed all staff members completed the Inservice. 5. The following staff members interviewed on 04/13/24 to confirm their attendance. CNA E, CNA F, LVN A, CNA C, CNA G , CNA H , CNA I The following staff members were interviewed on 04/15/24. LVN A, ADM 6. Record review of the QAPI meeting attendance revealed the meeting was conducted on 4/12/24. MD, ADM, LVN A, MD, BO and DR attended. An IJ was identified on 04/12/24. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including accurate acquiring, and administering of all drugs and biologicals to meet the needs for 1 (Resident#1) of 8 resident reviewed for pharmaceutical services. The facility failed to ensure Resident #1's scheduled medications were acquired and administered. Resident #1 was not given Acyclovir for a total of 8 times, one post-dialysis dose of 400 MG on 10/16/2023, and seven 200 MG doses from 10/31/2023 through 11/05/2023. Resident #1 was not given Trifluridine a total of 59 times from 7/23/2023 through 11/28/2023, with 22 of the 59 missed Trifluridine doses having been missed in the month of November 2023. This failure resulted in the Resident #1's eye infection not healing effectively, and Resident #1 being considered for corneal transplant. An IJ was identified on 12/01/2023. The IJ Template was provided to the facility on [DATE] at 04:17 p.m. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their scheduled medications in an accurate and timely manner to promote healing and to meet the needs and care of resident. Findings included: Review of Resident #1's face sheet, dated 11/30/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, and kidney disease. Review of Resident #1's quarterly MDS assessment, dated 09/02/2023, reflected a BIMS of 15 indicating his cognition was intact. Further review revealed her vision was assessed as a 1 indicating impaired vision (sees large print, but not regular print in newspapers/books). Review of Resident #1's care plan, date Initiated: 06/01/2022, revised on: 10/23/2023, with a Target Date: 01/22/2024, reflected a goal that Resident #1 would have no indication of acute eye problems through the review date, and an intervention to arrange consultation with eye care practitioner as required. Review of Resident #1's Ophthalmologist orders and progress notes, dated, 08/14/2023, reflected to continue Trifluridine, 9x (9 times) a day OD (Ocular [NAME]-right eye) without missing at all. Further review reflected additional orders dated 08/15/2023 stating, requiring approval from nephrologist for loading dose of Acyclovir. Please give attached loading prescription to Nephrologist for approval to be started once approved., Further review revealed Resident #1's Acyclovir medication schedule proposed from Ophthalmologist was as follows: Sunday: Morning 200 MG-8AM, Night 200 MG-8PM Monday: 200 MG-8AM, Night 400 MG-After Dialysis Tuesday: 200 MG-8AM, Night 200MG-8PM Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Thursday: 200 MG-8AM, Night 200MG-8PM Friday: Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Saturday: 200 MG-8AM, Night 200MG-8PM Review of Resident #1's Orders, no date, reflected an order for Acyclovir Oral Capsule, Directions to Give 200 MG by mouth two times a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday), Sun (Sunday) for eyes, ordered 08/31/2023, start 08/31/2023. Further review reflected a second order for Acyclovir Oral Capsule 200 MG (Acyclovir), Direction to Give 200 MG by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes AND Give 400 MG by mouth in the evening every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes., ordered 08/31/2023, start 09/01/2023. Further review of Resident #1's orders reflected an order for Trifluridine Ophthalmic Solution 1% (Trifluridine), Directions Instill 1 drop in right eye every 3 hours for Herpes Infection of the right eye 1 drop right eye 9x (9 times) a day, ordered 07/18/2023, start 07/19/2023. Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Acyclovir capsules on: 10/16/2023 Monday 18:00 (06:00 p.m.) 10/31/2023 Tuesday 20:00 (08:00 p.m.) 11/02/2023 Thursday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/04/2023 Saturday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/05/2023 Sunday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Trifluridine on: 07/23/2023 Sunday 06:00 (06:00 a.m.) 07/27/2023 Thursday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/02/2023 Wednesday 21:00 (09:00 p.m.) 08/03/2023 Thursday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.) 08/05/2023 Saturday 06:00 (06:00 a.m.) 08/09/2023 Wednesday 06:00 (06:00 a.m.) 08/11/2023 Friday 06:00 (06:00 a.m.) 08/12/2023 Saturday 18:00 (06:00 p.m.) 08/18/2023 Friday 06:00 (06:00 a.m.) 08/21/2023 Monday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/27/2023 Sunday 06:00 (06:00 a.m.) 09/12/2023 Tuesday 21:00 (09:00 p.m.) 09/13/2023 Wednesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 09/21/2023 Thursday 21:00 (09:00 p.m.) 09/24/2023 Sunday 06:00 (06:00 a.m.) 09/28/2023 Thursday 21:00 (09:00 p.m.) 09/29/2023 Friday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/16/2023 Monday 18:00 (06:00 p.m.) 10/22/2023 Sunday 15:00 (03:00 p.m.), 18:00 (06:00 p.m.) 10/24/2023 Tuesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/25/2023 Wednesday 07:00 (07:00 a.m.) 10/26/2023 Thursday 07:00 (07:00 a.m.) 10/27/2023 Friday 07:00 (07:00 a.m.) 10/28/2023 Saturday 07:00 (07:00 a.m.) 10/29/2023 Sunday 07:00 (07:00 a.m.) 10/30/2023 Monday 07:00 (07:00 a.m.) 10/31/2023 Tuesday 07:00 (07:00 a.m.) 11/01/2023 Wednesday 07:00 (07:00 a.m.) 11/02/2023 Thursday 07:00 (07:00 a.m.) 11/03/2023 Friday 07:00 (07:00 a.m.) 11/04/2023 Saturday 07:00 (07:00 a.m.) 11/07/2023 Tuesday 07:00 (07:00 a.m.) 11/08/2023 Wednesday 07:00 (07:00 a.m.) 11/09/2023 Thursday 07:00 (07:00 a.m.), 19:00 (07:00 p.m.) 11/10/2023 Friday 07:00 (07:00 a.m.) 11/11/2023 Saturday 07:00 (07:00 a.m.) 11/12/2023 Sunday 07:00 (07:00 a.m.) 11/13/2023 Monday 07:00 (07:00 a.m.) 11/14/2023 Tuesday 07:00 (07:00 a.m.) 11/16/2023 Thursday 07:00 (07:00 a.m.) 11/17/2023 Friday 07:00 (07:00 a.m.) 11/18/2023 Saturday 07:00 (07:00 a.m.) 11/19/2023 Sunday 07:00 (07:00 a.m.) 11/21/2023 Tuesday 07:00 (07:00 a.m.) 11/22/2023 Wednesday 07:00 (07:00 a.m.) 11/25/2023 Saturday 07:00 (07:00 a.m.) 11/27/2023 Monday 07:00 (07:00 a.m.) 11/28/2023 Tuesday 07:00 (07:00 a.m.) Review of Resident #1's Ophthalmologist records, dated 11/28/2023, reflected an exam performed revealed Ocular Adnexa (parts of the body that are connected to the surrounded eye) and Anterior Segment (eye cavity, front-most region of eye, includes the cornea, iris, and lens.) OD (oculus [NAME]-right eye), noted 2+Descemet Folds (manifestation of edema or inflammation in the cornea), Central Epithelial (body tissue) Defect with Rolled Edges, 1+Fluress Staining of Cornea. Procedure Prokera Slim (amniotic membrane that is thin and clear placed on the surface of the eye damaged tissue while inserted.) Interview on 11/30/2023 at 01:29 p.m., Resident #1's Ophthalmologist revealed concerns of Resident #1 receiving her medications for her eye infection. He further stated they had a typed version, of her schedule, of the Acyclovir, because there were concerns Resident #1 was not receiving it. He stated the ophthalmology provider started seeing Resident #1 in July for her right eye. He stated, her vision was somewhat decent, but from then on, her vision decreased. The Ophthalmologist stated that, Resident #1 went from being able to see large letters, to not being able to that all anymore, it (vision) has gotten worse. The Ophthalmologist further stated, It became apparent she (Resident #1) wasn't getting treatment, based on the exams, her (Resident #1) visual acuity has gotten worse. The Ophthalmologist stated that, its 100 percent important for all the orders to be completed, and I want to add that it is extremely important for her (Resident #1) to get the Acyclovir as prescribed and to be given consistently, despite her (Resident #1) history of diabetes, if she (Resident #1) had her consistent treatment, this would have been avoided, due to her (Resident #1) renal dialysis, she was getting less than the usual standard of care for the Acyclovir, therefore its more important to get it as when she gets dialyze the medication is removed from her system. The Ophthalmologist stated that, there was scarring in the cornea, in her (Resident #1) right eye, and we are suggesting corneal transplant. The Ophthalmologist explained, the last exam revealed the back layers, the Descemet folds, is a sign of edema (swelling) and/or infection. The rolled edges listed in her exam mean that the epithelial tissue is trying to grow back due to damage. Interview on 11/30/2023 at 02:46 p.m., Resident #1 stated when she got back from all her doctor's appointments, she gave the discharge orders and changes to her medications to nursing staff. Resident #1 stated there are times she does not have her eye medications for a week. Resident #1 stated that her right eye is the eye that she cannot see out of, and she stated that her vision got worse. Interview on 11/30/2023 at 03:26 p.m., ADON stated that when any resident returns from a specialist or outside provider visit, it was encouraged that residents are to give the discharge orders to the nurse, the nurse updates the orders in the resident's EHR, as prescribed, as instructed, as directed. Staff are to administer medications as instructed and document the process. ADON stated that the facility obtained its medications from an outside pharmacy provider, as ordered, and if medications are not available, staff are to contact the MD or NP and are to follow the procedure communicating with providers, checking the emergency medication kit. No other statement was made on Resident #1's missing medication administration. Interview on 12/01/2023 at 11:42 p.m., the MD stated she was only informed that (Resident #1) did not get her Trifluridine, MD is not aware of the other items related to the missing medication administrations. MD stated that when orders come in from outside providers, they are documented in the resident's EHR and followed. MD is not aware if Resident #1 gave her orders to the nurse, or if the ophthalmologist faxed the orders over, the MD stated there is no set protocol for this type of occasion as residents are encouraged to give their discharge orders from outside providers. Interview on 12/01/2023 at 01:54 p.m., the NP stated she was not aware of the missing medications, and that outside specialist usually do not call us, typically nurses would communicate with her on all items that involve a resident, from changes of conditions to medications not being available. Interview on 12/01/2023 at 2:10 p.m., MA A stated being familiar with Resident #1. MA A stated, if medications are not available, staff notify the resident's nurse, DON, and ADON, and medications can be reordered through the residents EHR, and that I can call pharmacy myself., MA A further stated, we attempt to keep medication filled and re-order medication five to seven days before the medications are expected to run out. MA A added that she was aware that Resident #1's Acyclovir was not available, although she cannot recall the exact time, it had been ordered, and as well as the Trifluridine. MA A stated the residents have these medications for a reason, their conditions, to treat the residents so they may, get better. MA stated that when Resident #1's medications were not available, she did not successfully administer the ordered medications to Resident #1. Interview on 12/01/2023 at 2:32 p.m., LVN A stated that, there are orders for medications, and when residents let us know the orders from outside providers, we placed them in, instructions, frequency, all details of the medications into the resident's EHR system. LVN A stated, to reorder medications, we use the EHR, orders are refilled five to seven days before medications are out to avoid missing medications, and if an event occurs in that there are no medications, we call the pharmacy, the NP or MD, and ask for alternatives. LVN A stated to check the overstock medications and the emergency medication kit. LVN A stated if the procedures for medication administration are not followed, it is detrimental to a resident's health and his or her plan of care. Record review of the facility's Medication: Reordering policy, effective 04/01/2017 and last reviewed 03/22/2023, reflected that, it is the policy of the facility to reorder medications when supply is running low (2 days prior), purpose is to ensure that all meds re available in sufficient quantity to fulfill MD orders. 5. Nurse responsibility, if medications is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor, manager and DNS/ADNS (Director of nursing/Assistant director of nursing). 6. Nurse responsibility, if medication is not available for the specific medication notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medications form pharmacy through the EMR. Contacts pharmacy to ensure that reorder was received and confirmed estimated delivery time. 7. DNS/ADNS/NM/RNS responsibility, the nursing supervisor/NM or nursing administration will run a random report to ensure that all meds are administered as per MD order. Record review of the facility's Administering Medications policy, revised April 2019, reflected, Policy statement that Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. The individual administering the medication initials the resident's MAR in the appropriate line after giving each medication and before administering he next ones. The ADM was notified on 12/01/2023 at 04:17 p.m., that an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on 12/03/2023 at 09:36 a.m., and included: Immediate action: 12/02/2023 The resident affected by this deficiency (F755), was assessed and noted to be stable as of 12/02/2023. An audit of this resident's current list of medications was performed by the Administrator on 12/02/2023 and revealed that all current medications for this resident were delivered and are available in the facility. The administration of the resident medications was assigned to the charge nurse on the hall. The am and pm doses were adjusted so they would align with her blood sugar checks. An audit of this resident's medication administration record (MAR), conducted on 12/02/2023 by the administrator, revealed that all current ordered medications are being administered according to the instructions on the physician orders. Training of staff and audits of all medication were initiated by the Administrator and ADON on 12/02/2023 Identification of others: All residents have the potential to be impacted by this deficient practice. The Administrator conducted an audit of the medication list of all residents within the facility on 12/02/2023 and found that all medications are available within the facility. The Administrator conducted a medication administration record (MAR) audit for all residents in the facility on 12/02/2023 to ensure accuracy of medication administration and found that all ordered medications were being administered to all residents accurately according to physician's orders. No other resident was found to be affected. The Administrator has started an education for all Nursing staff on Medication Administration with a focus on ensuring accuracy, expected completion date is 12/2/23. All staff that administer medications and receive orders have been educated as of 12/02/2023. The Regional Nurse Consultant provided an education on conducting medication list audits to the administrator, Director of Nursing, and ADON on 12/02/2023. The Regional Nurse Consultant provided and education on conducting MAR audits to the administrator and Director of Nursing on 12/02/2023. The Regional Nurse Consultant has updated the facility's procedure for communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, on 12/02/2023. The Regional Nurse Consultant has updated the facility's policy on communication, contacting Physicians and confirming orders, on 12/02/2023 to reflect these new changes. The Regional Nurse Consultant has provided education to the administrator, Director of Nursing, and ADON on 12/02/2023, regarding these changes and policy updates. The Regional Nurse Consultant has educated the Administrator, DON and ADON on conducting audits of the facility's communication procedure, including contacting physicians and confirming orders, on 12/02/2023. The administrator has created and audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. Audits will be conducted by the ADON daily for two weeks, weekly for 2 weeks and monthly for two months. Any negative findings will be reported to the administrator for immediate correction. The Administrator and ADON has started an education for all staff on communicating, contacting physicians and verifying orders, expected completion date is 12/02/2023. The administrator has created a MAR audit to monitor for accuracy of medication administration on 12/02/2023. ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. The DON, or ADON will continue to audit the medication administration in the building on Mondays and Thursday as part of the facility ongoing process to ensure accuracy of medication administration. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency (F755) on 12/01/2023 and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings. All findings will be reported to the QAPI team for QAPI. Expected compliance date is 12/02/2023. The Survey Team monitored the Plan of Removal on 12/03/2023 to 12/04/2023: Interview on 12/03/2023 from 04:15 p.m. to 04:17 p.m., CNA A, CNA B and CNA C confirmed they have taken in-services on education administration or missing medications to notify ADM, DON, ADON immediately, stating that if they heard a resident had a medication issue to tell the MA, DON, ADON or the ADM. Interview on 12/03/2023 from 04:20 p.m. to 04:35 p.m., MA A and MA B confirmed they have taken the in-services on medication pass education and education administration/missing medications to notify ADM, DON, ADON immediately. Interview on 12/04/2023 at 10:45 a.m., MA C confirmed in-services on medication pass education and education on administration/missing medications to notify ADM, DON, ADON immediately. MA C stated, when medications are reordered, and the medications are not at the facility in a timely manner, we call the pharmacy, get the nurse, the ADM, DON and ADON involved. MA C stated, we look in the residents' MAR to see what medications are missing, and fax orders to the pharmacy, or order medications through the resident's EHR, and call the pharmacy to check status and estimated time of delivery. MA C confirmed education on checking the facility's overflow medications if missing medications are available. MA C is aware that MD and NP are to be notified by nurses to check for alternative medications. Interview on 12/04/2023 from 10:52 a.m. to 11:09 a.m., the DON and ADON confirmed in-services, education and process of medication administration with a focus on ensuring accuracy, conducting medication list audits and sending audits to ADM, communicating with outside physicians and clinics, contacting physicians and confirming orders, audit to monitor compliance of the facility's communication procedure for contacting physicians and confirming orders. DON and ADON confirmed audits are conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. DON and ADON confirmed that negative are to be reported to the ADM for immediate correction. DON and ADON confirmed process to conduct MAR audits to ensure the accuracy of medication administration daily for two weeks, weekly for two weeks, and monthly for two months. DON and ADON confirmed any negative findings are to be taken to the Administrator for immediate correction. DON and ADON stated that the MD was notified of deficiency and Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss findings and provide immediate interventions. DON and ADON stated that the facility has a new for called the missing medication form. The form documents the name of the resident, missing medication, name of nurse notified, time pharmacy called, pharmacy staff name, ETA of medication delivery, and was medication delivered as stated in the ETA of medication delivery. Interview on 12/04/2023 at 11:12 a.m., TS A confirmed an updated process during specialist or outside provider visits, TS A would have outside providers complete a form called a visit summary. The summary is given to the DON, ADON, and charge nurse. Staff stated this form would be used to assure accurate discharge orders are given to the nurse. Interview on 12/04/2023 at 11:38 a.m., MA A stated she took the in-services on medication pass education and education administration/missing medications. MA A stated, If I hear a resident has a medication issue to tell the DON ADON or the ADM. and it is important to follow up on the new process, and the risks of not following the process could negatively affect residents' health and well-being. Interview on 12/04/2023 on 01:09 p.m., the MD stated that an Ad-Hoc QAPI meeting was attended on 12/02/2023 to discuss non-compliance IJ, and plan of intervention. MD stated that there are new processes as well to electronically fax all new orders to her to make sure they are in residents EHR. Interview on 12/04/2023 on 01:11 p.m., the NP stated that all new medication orders will be placed in her care folder to be reviewed and to assure communication is accurate, check all medication, and ensure all new medications are in the residents' EHR. Interview on 12/04/2023 on 01:32 p.m., the ADM stated and confirmed in-services, education, and process of Medication Administration with a focus on ensuring accuracy, conducting medication list audits that are to be sent to her, communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. ADM stated audits will be conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. Any negative findings will be reported to her for immediate correction. ADM stated DON and ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks, and monthly for two months. Any negative findings will be taken to her for immediate correction. The ADM stated that the MD was notified of the deficiency and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings and provide immediate interventions. ADM stated that the facility has a new form, missing medication form, that is used if the medication is unable to be obtained to notify nurse management. The ADM stated the next QAPI meeting is scheduled on 12/18/2023, audits will be discussed to assure accuracy. ADM stated that MA A has been documented of having a corrective action placed in her employee file. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents completed. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents with no significant findings. Record review on 12/04/2023, reflected orders in Resident #1 EHR, Acyclovir Oral Capsule 200 MG and Trifluridine Drops 9 x daily. Record review on 12/04/2023, reflected medication administration for scheduled Acyclovir and Trifluridine, no medications missed. Record review on 12/04/2023, reflected in-services and education on Medication Administration with a focus on ensuring accuracy, conducting medication list audits to the administrator, education for all staff on communicating, contacting physicians, and verifying orders, and Ad-Hoc QAPI conduced on 12/02/2023. Record review on Communication with Consultants policy, last review 05/28/2023, it is policy of facility to maintain effective communication between members of the care team, including but not limited to MDs, Nurses, Consultants, outside clinics and health care facilities (hospitals, nursing homes, etc.). General information, the License nurse will ensure that a copy of the facility's consultation form, is sent with each resident going for an outside appointment. Will prefill the consult form with the resident's name, DOB and reason for visit, upon return the License nurse will receive and review the returning consultation form, which would not have been completed by the consulting physician, with findings and recommendations/orders where necessary. If the form is not returned, or returned incomplete, the license nurse will reach out to clinic, hospital, or local MD office to obtain recommendations for the target resident, following their appointment, will repeat the information once received to ensure accuracy and completeness, will request a fax copy of this information if possible. Record review on 12/04/2023, reflected a Personnel Action form for MA A, dated 12/02/2023, : failure to obey orders, Remarks: 1. Medication not administered in a timely fashion. 2. OTC not administered. 3. Nurse not notified the medications not available. It is the expectation that all medications will be administer as ordered and within the timeline parameters. Issues with meds (medications) will be reported immediately. Due to severity of actions this is a level 3., signed and dated by ADM on 12/02/2023. The ADM was notified on 12/04/2023 at 2:19 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident#1) of 8 resident reviewed for pharmaceutical services. The facility failed to follow prescribers' orders and professional standards and principles which apply to professionals providing services for Resident #1's scheduled medications. Resident #1 was not given Acyclovir for a total of 8 times, one post-dialysis dose of 400 MG on 10/16/2023, and seven 200 MG doses from 10/31/2023 through 11/05/2023. Resident #1 was not given Trifluridine a total of 59 times from 7/23/2023 through 11/28/2023, with 22 of the 59 missed Trifluridine doses having been missed in the month of November 2023. This failure resulted in the Resident #1's eye infection not healing effectively, and Resident #1 being considered for corneal transplant. An IJ was identified on 12/01/2023. The IJ Template was provided to the facility on [DATE] at 04:17 p.m. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of discomfort or jeopardizes his or her health and safety. Findings included: Review of Resident #1's face sheet, dated 11/30/2023, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses End Stage Renal Disease, Dependence on Renal Dialysis, and kidney disease. Review of Resident #1's quarterly MDS assessment, dated 09/02/2023, reflected a BIMS of 15 indicating his cognition was intact. Further review revealed her vision was assessed as a 1 indicating impaired vision (sees large print, but not regular print in newspapers/books). Review of Resident #1's care plan, date Initiated: 06/01/2022, revised on: 10/23/2023, with a Target Date: 01/22/2024, reflected a goal that Resident #1 would have no indication of acute eye problems through the review date, and an intervention to arrange consultation with eye care practitioner as required. Review of Resident #1's Ophthalmologist orders and progress notes, dated, 08/14/2023, reflected to continue Trifluridine, 9x (9 times) a day OD (Ocular [NAME]-right eye) without missing at all. Further review reflected additional orders dated 08/15/2023 stating, requiring approval from nephrologist for loading dose of Acyclovir. Please give attached loading prescription to Nephrologist for approval to be started once approved., Further review revealed Resident #1's Acyclovir medication schedule proposed from Ophthalmologist was as follows: Sunday: Morning 200 MG-8AM, Night 200 MG-8PM Monday: 200 MG-8AM, Night 400 MG-After Dialysis Tuesday: 200 MG-8AM, Night 200MG-8PM Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Thursday: 200 MG-8AM, Night 200MG-8PM Friday: Wednesday: 200 MG-8AM, Night 400 MG-After Dialysis Saturday: 200 MG-8AM, Night 200MG-8PM Review of Resident #1's Orders, no date, reflected an order for Acyclovir Oral Capsule, Directions to Give 200 MG by mouth two times a day every Tue (Tuesday), Thu (Thursday), Sat (Saturday), Sun (Sunday) for eyes, ordered 08/31/2023, start 08/31/2023. Further review reflected a second order for Acyclovir Oral Capsule 200 MG (Acyclovir), Direction to Give 200 MG by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes AND Give 400 MG by mouth in the evening every Mon (Monday), Wed (Wednesday), Fri (Friday) for eyes., ordered 08/31/2023, start 09/01/2023. Further review of Resident #1's orders reflected an order for Trifluridine Ophthalmic Solution 1% (Trifluridine), Directions Instill 1 drop in right eye every 3 hours for Herpes Infection of the right eye 1 drop right eye 9x (9 times) a day, ordered 07/18/2023, start 07/19/2023. Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Acyclovir capsules on: 10/16/2023 Monday 18:00 (06:00 p.m.) 10/31/2023 Tuesday 20:00 (08:00 p.m.) 11/02/2023 Thursday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/04/2023 Saturday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) 11/05/2023 Sunday 08:00 (8:00 a.m.), 20:00 (8:00 p.m.) Review of Resident #1's MAR, dated 11/30/2023, reflected no documentation that Resident #1 received Trifluridine on: 07/23/2023 Sunday 06:00 (06:00 a.m.) 07/27/2023 Thursday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/02/2023 Wednesday 21:00 (09:00 p.m.) 08/03/2023 Thursday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.) 08/05/2023 Saturday 06:00 (06:00 a.m.) 08/09/2023 Wednesday 06:00 (06:00 a.m.) 08/11/2023 Friday 06:00 (06:00 a.m.) 08/12/2023 Saturday 18:00 (06:00 p.m.) 08/18/2023 Friday 06:00 (06:00 a.m.) 08/21/2023 Monday 06:00 (06:00 a.m.), 18:00 (06:00 p.m.) 08/27/2023 Sunday 06:00 (06:00 a.m.) 09/12/2023 Tuesday 21:00 (09:00 p.m.) 09/13/2023 Wednesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 09/21/2023 Thursday 21:00 (09:00 p.m.) 09/24/2023 Sunday 06:00 (06:00 a.m.) 09/28/2023 Thursday 21:00 (09:00 p.m.) 09/29/2023 Friday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/16/2023 Monday 18:00 (06:00 p.m.) 10/22/2023 Sunday 15:00 (03:00 p.m.), 18:00 (06:00 p.m.) 10/24/2023 Tuesday 00:00 (12:00 a.m.), 03:00 (03:00 a.m.), 06:00 (06:00 a.m.) 10/25/2023 Wednesday 07:00 (07:00 a.m.) 10/26/2023 Thursday 07:00 (07:00 a.m.) 10/27/2023 Friday 07:00 (07:00 a.m.) 10/28/2023 Saturday 07:00 (07:00 a.m.) 10/29/2023 Sunday 07:00 (07:00 a.m.) 10/30/2023 Monday 07:00 (07:00 a.m.) 10/31/2023 Tuesday 07:00 (07:00 a.m.) 11/01/2023 Wednesday 07:00 (07:00 a.m.) 11/02/2023 Thursday 07:00 (07:00 a.m.) 11/03/2023 Friday 07:00 (07:00 a.m.) 11/04/2023 Saturday 07:00 (07:00 a.m.) 11/07/2023 Tuesday 07:00 (07:00 a.m.) 11/08/2023 Wednesday 07:00 (07:00 a.m.) 11/09/2023 Thursday 07:00 (07:00 a.m.), 19:00 (07:00 p.m.) 11/10/2023 Friday 07:00 (07:00 a.m.) 11/11/2023 Saturday 07:00 (07:00 a.m.) 11/12/2023 Sunday 07:00 (07:00 a.m.) 11/13/2023 Monday 07:00 (07:00 a.m.) 11/14/2023 Tuesday 07:00 (07:00 a.m.) 11/16/2023 Thursday 07:00 (07:00 a.m.) 11/17/2023 Friday 07:00 (07:00 a.m.) 11/18/2023 Saturday 07:00 (07:00 a.m.) 11/19/2023 Sunday 07:00 (07:00 a.m.) 11/21/2023 Tuesday 07:00 (07:00 a.m.) 11/22/2023 Wednesday 07:00 (07:00 a.m.) 11/25/2023 Saturday 07:00 (07:00 a.m.) 11/27/2023 Monday 07:00 (07:00 a.m.) 11/28/2023 Tuesday 07:00 (07:00 a.m.) Review of Resident #1's Ophthalmologist records, dated 11/28/2023, reflected an exam performed revealed Ocular Adnexa (parts of the body that are connected to the surrounded eye) and Anterior Segment (eye cavity, front-most region of eye, includes the cornea, iris, and lens.) OD (oculus [NAME]-right eye), noted 2+Descemet Folds (manifestation of edema or inflammation in the cornea), Central Epithelial (body tissue) Defect with Rolled Edges, 1+Fluress Staining of Cornea. Procedure Prokera Slim (amniotic membrane that is thin and clear placed on the surface of the eye damaged tissue while inserted.) Interview on 11/30/2023 at 01:29 p.m., Resident #1's Ophthalmologist revealed concerns of Resident #1 receiving her medications for her eye infection. He further stated they had a typed version, of her schedule, of the Acyclovir, because there were concerns Resident #1 was not receiving it. He stated the ophthalmology provider started seeing Resident #1 in July for her right eye. He stated, her vision was somewhat decent, but from then on, her vision decreased. The Ophthalmologist stated that, Resident #1 went from being able to see large letters, to not being able to that all anymore, it (vision) has gotten worse. The Ophthalmologist further stated, It became apparent she (Resident #1) wasn't getting treatment, based on the exams, her (Resident #1) visual acuity has gotten worse. The Ophthalmologist stated that, its 100 percent important for all the orders to be completed, and I want to add that it is extremely important for her (Resident #1) to get the Acyclovir as prescribed and to be given consistently, despite her (Resident #1) history of diabetes, if she (Resident #1) had her consistent treatment, this would have been avoided, due to her (Resident #1) renal dialysis, she was getting less than the usual standard of care for the Acyclovir, therefore its more important to get it as when she gets dialyze the medication is removed from her system. The Ophthalmologist stated that, there was scarring in the cornea, in her (Resident #1) right eye, and we are suggesting corneal transplant. The Ophthalmologist explained, the last exam revealed the back layers, the Descemet folds, is a sign of edema (swelling) and/or infection. The rolled edges listed in her exam mean that the epithelial tissue is trying to grow back due to damage. Interview on 11/30/2023 at 02:46 p.m., Resident #1 stated when she got back from all her doctor's appointments, she gave the discharge orders and changes to her medications to nursing staff. Resident #1 stated there are times she does not have her eye medications for a week. Resident #1 stated that her right eye is the eye that she cannot see out of, and she stated that her vision got worse. Interview on 11/30/2023 at 03:26 p.m., ADON stated that when any resident returns from a specialist or outside provider visit, it was encouraged that residents are to give the discharge orders to the nurse, the nurse updates the orders in the resident's EHR, as prescribed, as instructed, as directed. Staff are to administer medications as instructed and document the process. ADON stated that the facility obtained its medications from an outside pharmacy provider, as ordered, and if medications are not available, staff are to contact the MD or NP and are to follow the procedure communicating with providers, checking the emergency medication kit. No other statement was made on Resident #1's missing medication administration. ADON could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 11:42 p.m., the MD stated she was only informed that (Resident #1) did not get her Trifluridine, MD is not aware of the other items related to the missing medication administrations. MD stated that when orders come in from outside providers, they are documented in the resident's EHR and followed. MD is not aware if Resident #1 gave her orders to the nurse, or if the ophthalmologist faxed the orders over, the MD stated there is no set protocol for this type of occasion as residents are encouraged to give their discharge orders from outside providers. MD could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 01:54 p.m., the NP stated she was not aware of the missing medications, and that outside specialist usually do not call us, typically nurses would communicate with her on all items that involve a resident, from changes of conditions to medications not being available. NP could not determine why Resident #1 missed the undocumented medications orders. Interview on 12/01/2023 at 2:10 p.m., MA A stated being familiar with Resident #1. MA A stated, if medications are not available, staff notify the resident's nurse, DON, and ADON, and medications can be reordered through the residents EHR, and that I can call pharmacy myself., MA A further stated, we attempt to keep medication filled and re-order medication five to seven days before the medications are expected to run out. MA A added that she was aware that Resident #1's Acyclovir was not available, although she cannot recall the exact time, it had been ordered, and as well as the Trifluridine. MA A stated the residents have these medications for a reason, their conditions, to treat the residents so they may, get better. MA stated that when Resident #1's medications were not available, they were not here, she did not successfully administer the ordered medications to Resident #1. Interview on 12/01/2023 at 2:32 p.m., LVN A stated that, there are orders for medications, and when residents let us know the orders from outside providers, we placed them in, instructions, frequency, all details of the medications into the resident's EHR system. LVN A stated, to reorder medications, we use the EHR, orders are refilled five to seven days before medications are out to avoid missing medications, and if an event occurs in that there are no medications, we call the pharmacy, the NP or MD, and ask for alternatives. LVN A stated to check the overstock medications and the emergency medication kit. LVN A stated if the procedures for medication administration are not followed, it is detrimental to a resident's health and his or her plan of care. Record review of the facility's Medication: Reordering policy, effective 04/01/2017 and last reviewed 03/22/2023, reflected that, it is the policy of the facility to reorder medications when supply is running low (2 days prior), purpose is to ensure that all meds re available in sufficient quantity to fulfill MD orders. 5. Nurse responsibility, if medications is not received in a timely manner, recalls the pharmacy to obtain estimated delivery time. Notifies nursing supervisor, manager and DNS/ADNS (Director of nursing/Assistant director of nursing). 6. Nurse responsibility, if medication is not available for the specific medication notifies MD/NP to obtain hold order or substitute medication which may be available in emergency stock. Reorders medications form pharmacy through the EMR. Contacts pharmacy to ensure that reorder was received and confirmed estimated delivery time. 7. DNS/ADNS/NM/RNS responsibility, the nursing supervisor/NM or nursing administration will run a random report to ensure that all meds are administered as per MD order. Record review of the facility's Administering Medications policy, revised April 2019, reflected, Policy statement that Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 22. The individual administering the medication initials the resident's MAR in the appropriate line after giving each medication and before administering he next ones. The ADM was notified on 12/01/2023 at 04:17 p.m., that an IT situation was identified due to the above failures and the IT template was provided. The plan of Removal was accepted on 12/03/2023 at 09:36 a.m., and included: Immediate action: 12/02/2023 The resident affected by this deficiency (F755), was assessed and noted to be stable as of 12/02/2023. An audit of this resident's current list of medications was performed by the Administrator on 12/02/2023 and revealed that all current medications for this resident were delivered and are available in the facility. The administration of the resident medications was assigned to the charge nurse on the hall. The am and pm doses were adjusted so they would align with her blood sugar checks. An audit of this resident's medication administration record (MAR), conducted on 12/02/2023 by the administrator, revealed that all current ordered medications are being administered according to the instructions on the physician orders. Training of staff and audits of all medication were initiated by the Administrator and ADON on 12/02/2023 Identification of others: All residents have the potential to be impacted by this deficient practice. The Administrator conducted an audit of the medication list of all residents within the facility on 12/02/2023 and found that all medications are available within the facility. The Administrator conducted a medication administration record (MAR) audit for all residents in the facility on 12/02/2023 to ensure accuracy of medication administration and found that all ordered medications were being administered to all residents accurately according to physician's orders. No other resident was found to be affected. The Administrator has started an education for all Nursing staff on Medication Administration with a focus on ensuring accuracy, expected completion date is 12/2/23. All staff that administer medications and receive orders have been educated as of 12/02/2023. The Regional Nurse Consultant provided an education on conducting medication list audits to the administrator, Director of Nursing, and ADON on 12/02/2023. The Regional Nurse Consultant provided and education on conducting MAR audits to the administrator and Director of Nursing on 12/02/2023. The Regional Nurse Consultant has updated the facility's procedure for communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, on 12/02/2023. The Regional Nurse Consultant has updated the facility's policy on communication, contacting Physicians and confirming orders, on 12/02/2023 to reflect these new changes. The Regional Nurse Consultant has provided education to the administrator, Director of Nursing, and ADON on 12/02/2023, regarding these changes and policy updates. The Regional Nurse Consultant has educated the Administrator, DON and ADON on conducting audits of the facility's communication procedure, including contacting physicians and confirming orders, on 12/02/2023. The administrator has created and audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. Audits will be conducted by the ADON daily for two weeks, weekly for 2 weeks and monthly for two months. Any negative findings will be reported to the administrator for immediate correction. The Administrator and ADON has started an education for all staff on communicating, contacting physicians and verifying orders, expected completion date is 12/02/2023. The administrator has created a MAR audit to monitor for accuracy of medication administration on 12/02/2023. ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks and monthly for two months. Any negative findings will be taken to the administrator for immediate correction. The DON, or ADON will continue to audit the medication administration in the building on Mondays and Thursday as part of the facility ongoing process to ensure accuracy of medication administration. The results of the new audit process will be reported to the QAPI team. The Medical Director was notified of the deficiency (F755) on 12/01/2023 and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings. All findings will be reported to the QAPI team for QAPI. Expected compliance date is 12/02/2023. The Survey Team monitored the Plan of Removal on 12/03/2023 to 12/04/2023: Interview on 12/03/2023 from 04:15 p.m. to 04:17 p.m., CNA A, CNA B and CNA C confirmed they have taken in-services on education administration or missing medications to notify ADM, DON, ADON immediately, stating that if they heard a resident had a medication issue to tell the MA, DON, ADON or the ADM. Interview on 12/03/2023 from 04:20 p.m. to 04:35 p.m., MA A and MA B confirmed they have taken the in-services on medication pass education and education administration/missing medications to notify ADM, DON, ADON immediately. Interview on 12/04/2023 at 10:45 a.m., MA C confirmed in-services on medication pass education and education on administration/missing medications to notify ADM, DON, ADON immediately. MA C stated, when medications are reordered, and the medications are not at the facility in a timely manner, we call the pharmacy, get the nurse, the ADM, DON and ADON involved. MA C stated, we look in the residents' MAR to see what medications are missing, and fax orders to the pharmacy, or order medications through the resident's EHR, and call the pharmacy to check status and estimated time of delivery. MA C confirmed education on checking the facility's overflow medications if missing medications are available. MA C is aware that MD and NP are to be notified by nurses to check for alternative medications. Interview on 12/04/2023 from 10:52 a.m. to 11:09 a.m., the DON and ADON confirmed in-services, education and process of medication administration with a focus on ensuring accuracy, conducting medication list audits and sending audits to ADM, communicating with outside physicians and clinics, contacting physicians and confirming orders, audit to monitor compliance of the facility's communication procedure for contacting physicians and confirming orders. DON and ADON confirmed audits are conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. DON and ADON confirmed that negative are to be reported to the ADM for immediate correction. DON and ADON confirmed process to conduct MAR audits to ensure the accuracy of medication administration daily for two weeks, weekly for two weeks, and monthly for two months. DON and ADON confirmed any negative findings are to be taken to the Administrator for immediate correction. DON and ADON stated that the MD was notified of deficiency and Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss findings and provide immediate interventions. DON and ADON stated that the facility has a new for called the missing medication form. The form documents the name of the resident, missing medication, name of nurse notified, time pharmacy called, pharmacy staff name, ETA of medication delivery, and was medication delivered as stated in the ETA of medication delivery. Interview on 12/04/2023 at 11:12 a.m., TS A confirmed an updated process during specialist or outside provider visits, TS A would have outside providers complete a form called a visit summary. The summary is given to the DON, ADON, and charge nurse. Staff stated this form would be used to assure accurate discharge orders are given to the nurse. Interview on 12/04/2023 at 11:38 a.m., MA A stated she took the in-services on medication pass education and education administration/missing medications. MA A stated, If I hear a resident has a medication issue to tell the DON ADON or the ADM. and it is important to follow up on the new process, and the risks of not following the process could negatively affect residents' health and well-being. Interview on 12/04/2023 on 01:09 p.m., the MD stated that an Ad-Hoc QAPI meeting was attended on 12/02/2023 to discuss non-compliance IT, and plan of intervention. MD stated that there are new processes as well to electronically fax all new orders to her to make sure they are in residents EHR. Interview on 12/04/2023 on 01:11 p.m., the NP stated that all new medication orders will be placed in her care folder to be reviewed and to assure communication is accurate, check all medication, and ensure all new medications are in the residents' EHR. Interview on 12/04/2023 on 01:32 p.m., the ADM stated and confirmed in-services, education, and process of Medication Administration with a focus on ensuring accuracy, conducting medication list audits that are to be sent to her, communicating with outside Physicians and Clinics, which includes contacting physicians and confirming orders, audit to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders. ADM stated audits will be conducted daily for two weeks, weekly for 2 weeks, and monthly for two months. Any negative findings will be reported to her for immediate correction. ADM stated DON and ADON will conduct MAR audits to ensure the accuracy of medication administration, daily for two weeks, weekly for two weeks, and monthly for two months. Any negative findings will be taken to her for immediate correction. The ADM stated that the MD was notified of the deficiency and an Ad-Hoc QAPI meeting was held on 12/02/2023 to discuss the findings and provide immediate interventions. ADM stated that the facility has a new form, missing medication form, that is used if the medication is unable to be obtained to notify nurse management. The ADM stated the next QAPI meeting is scheduled on 12/18/2023, audits will be discussed to assure accuracy. ADM stated that MA A has been documented of having a corrective action placed in her employee file. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents completed. Record review on 12/04/2023, reflected medication administration record (MAR) audit for all residents with no significant findings. Record review on 12/04/2023, reflected orders in Resident #1 EHR, Acyclovir Oral Capsule 200 MG and Trifluridine Drops 9 x daily. Record review on 12/04/2023, reflected medication administration for scheduled Acyclovir and Trifluridine, no medications missed. Record review on 12/04/2023, reflected in-services and education on Medication Administration with a focus on ensuring accuracy, conducting medication list audits to the administrator, education for all staff on communicating, contacting physicians, and verifying orders, and Ad-Hoc QAPI conduced on 12/02/2023. Record review on Communication with Consultants policy, last review 05/28/2023, it is policy of facility to maintain effective communication between members of the care team, including but not limited to MDs, Nurses, Consultants, outside clinics and health care facilities (hospitals, nursing homes, etc.). General information, the License nurse will ensure that a copy of the facility's consultation form, is sent with each resident going for an outside appointment. Will prefill the consult form with the resident's name, DOB and reason for visit, upon return the License nurse will receive and review the returning consultation form, which would not have been completed by the consulting physician, with findings and recommendations/orders where necessary. If the form is not returned, or returned incomplete, the license nurse will reach out to clinic, hospital, or local MD office to obtain recommendations for the target resident, following their appointment, will repeat the information once received to ensure accuracy and completeness, will request a fax copy of this information if possible. Record review on 12/04/2023, reflected a Personnel Action form for MA A, dated 12/02/2023, : failure to obey orders, Remarks: 1. Medication not administered in a timely fashion. 2. OTC not administered. 3. Nurse not notified the medications not available. It is the expectation that all medications will be administer as ordered and within the timeline parameters. Issues with meds (medications) will be reported immediately. Due to severity of actions this is a level 3., signed and dated by ADM on 12/02/2023. The ADM was notified on 12/04/2023 at 2:19 p.m. that the Immediate Jeopardy was lowered. While the IJ was removed on 12/04/2023, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not Immediate Jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.