**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for accidents. Resident #1 walked out of the facility unattended with a wander guard on and was missing for approximately 10 - 20 minutes on 05/01/2025.The noncompliance was identified as a PNC. The IJ began on 05/01/2025 and ended on 05/02/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for serious injury or death. Findings Include: Record review of Resident #1's face sheet dated 08/12/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident discharged to another from facility on 05/03/2025. Admitting diagnosis was Metabolic Encephalopathy (a condition where brain's dysfunction occurs due to issues with the body's metabolism, which can manifest confusion, impaired thinking, or even coma); Cerebral Infarction, Unspecified (a stroke where there is an unspecified blockage of blood flow to the brain, resulting in brain tissue damage); Aphasia following Cerebral Infarction (a language disorder that affects the ability to communicate, stemming from damage to the brain's language centers). Record review of Resident #1's admission MDS assessment dated [DATE] revealed his BIMS score to be 03 indicating severe cognitive function. Resident #1 exhibited inattention which caused resident to have difficulty focusing attention, was easily distracted, and had difficulty keeping track on what was being said to him. Resident #1 had disorganized or incoherent thinking which led to rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. Resident #1 ambulated independently. Record review of Resident #1's care plan initiated 04/02/2025 revealed resident was an elopement risk/wanderer r/t impaired safety awareness. Resident wandered aimlessly. Goals were to maintain resident's safety through next review. Interventions: distract resident from wandering, identify pattern of wandering; provide structured activities; wander guard left ankle; monitor closely when sister would leave due to being a trigger for increased wandering and elopement; picture and personal information update placed in elopement notebook at nurse's station and receptionist desk; resident placed on 1:1 on 05/01/2025; Wander Guard placement was checked each shift with functionality. Record review of Resident #1's Order Summary Report revealed resident required a Wander Guard r/t exit seeking behavior. Check Wander Guard placement every shift. Order date: 04/02/2025. End Date 04/29/2025 Wander Guard Placement Secured LEFT ANKLE CHECK FOR PLACEMENT Q SHIFT CODE ALERT#9000-0413M every shift for Wander Guard Placement Secured. Order date: 04/29/2025. End date: 05/02/2025 Wander Guard Placement Secured Right ANKLE CHECK FOR PLACEMENT Q SHIFT CODE ALERT#9000-0413M Expiration date 030228 every shift for Wander Guard Placement Secured. Order Date: 05/02/2025. End date: 05/03/2025. Wander Guard three times a day for check Wander Guard. Verbal 04/01/2025 Discontinued 04/02/2025 updated Resident requires a Wander Guard r/t exit seeking behavior every shift for check Wander- guard. Verbal Discontinued 04/02/2025 04/02/2025 04/27/2025. Record review of Resident #1's Elopement assessment dated [DATE] revealed he was a high risk of elopement. Resident #1 was cognitively impaired with poor decision-making skills, ambulated independently, and was a new admission who did not accept the new situation. Elopement assessment dated [DATE] revealed he continued to be a high risk of elopement with cognitively impaired with poor decision-making skills and ambulated independently. Record review of Resident #1's social services note dated 03/31/2025 at 4:30 PM p.m. signed by the SW revealed she met with Family Member #1 and Family Member #2 of Resident #1 the day of admission. During the conversation, one of the Family Members stated, Do not be surprised if he tries to leave. SW asked Family Member in the conversation if Resident #1 tried to leave the hospital and Family Member said no but he did not like being there. SW notified nursing staff that Resident #1 was an elopement risk. Record review of Resident #1's progress note dated 04/01/2025 at 11:46 a.m. and signed by DON revealed Resident #1 continued to be confused at baseline and able to walk through the community unsupervised. Resident #1's family members had discussed the safety of Resident #1 and came to the agreement that he would be safer on the secured unit. Resident #1 transferred to the secured unit due to confusion and wandering. On 04/01/2025 at 7:15 p.m., his family requested Resident #1 to be moved off secured unit due to resident not adjusting well to the change. Resident #1 was confused and wandering. Wander Guard was placed on Resident #1's ankle. Record review of Resident #1 Licensed Nurse MAR for April 2025 and May 2025 indicated staff checked his Wander Guard device on ankle every shift to ensure it was activated and working correctly. Record review of Resident #1's progress notes report dated 04/29/25 at 11:50 a.m. prepared by the ADON reported that the resident tried to follow his visitors out to the parking lot. Family Member #3, Family Member #4, and CNA were there. CNA redirected the resident back into the building without incident. Physician, DON, ADM were aware of occurrence. Wander Guard had been ordered to be removed from left ankle on 04/27/2025 due to slight swelling of ankle by MD. New order given to place left ankle Wander Guard back on Resident #1. Record review of Resident #1's nursing noted dated 05/01/2025 at 3:05 p.m. written by DON noted that Resident #1 was back in the facility with Family Member #3 at side. Resident #1 went to his room with a nurse and family member. A head-to-toe assessment was completed with no injuries or s/s of distress. No c/o pain or discomfort voiced. ROM to all ext. noted. Resident #1 ambulating without difficulty. Wander Guard intact and functioning to left ankle. Resident #1 answered simple questions and conversed with Family Member #3 and staff without difficulty. Resident #1 refused for vital signs to be taken. Resident #1 was placed on 1:1 immediately with staff. MD entered facility and made aware. Call placed to Family Member #1, and she was aware of resident leaving. Progress note did not indicate resident eloped from the facility. In an interview on 08/12/2025 at 12:29 p.m. Family Member #1 stated Family Member #3 and Family Member #4 looked after Resident #1 while he was at the facility because they resided nearby. She stated she knew Resident #1 was always talking about wanting to go back home. The day that he eloped from the facility, Family Member #4 was coming to see him at the facility. She found him at the stop light outside the facility gate. Family Member #4 stopped and asked him what he was doing, and he replied that he was going home. Family Member #4 was able to get him in her car and took him back to the facility. She stated the elopement occurred Thursday, 05/01/2025, but she not sure of the time. She stated maybe early afternoon because she was at work. She stated she came in town on 05/03/2025 and took Resident #1 to the hospital. He is now at another long-term care facility. He has not tried to elope there. He was placed on the 3rd floor and now he was on the 2nd floor. She stated she had never experienced having a loved one in a nursing home, so she really did not know what to expect. In an interview on 08/12/2025 at 2:20 p.m. with the DON revealed Resident #1 eloped around 2 p.m. on 05/01/2025. She stated Resident #1 would ambulate throughout the facility. He was located by the gates up front of property but was still on the property. His Family Member was coming to visit and found him by the gates. No injuries noted. This was the only time Resident #1 left the building. Drills were completed quarterly now with the staff. Pink binders are at the nurse's station and the code is Code Pink for elopement. She stated she had been employed since April 07, 2025. She stated she had read that Resident #1's Family Members did not want him back on the unit. The facility placed a Wander Guard on the resident. On 08/13/2025 at 11:28 a.m., in a second phone interview with the DON, revealed in completing the documentation r/t Resident #1's return to the building with Family Member on 05/01/2025, she did not mention he had eloped from the facility but did not give a reason for not including the elopement in documentation. She stated the elopement book was put in place on 05/01/2025. The staff were instructed to document daily on each shift. She stated that the facility was no longer going to accept residents with Wander Guards. The resident would have to qualify for the memory care unit to be admitted to facility should that resident be an elopement risk. In an interview on 08/12/2025 at 2:37 p.m. with the ADM revealed she was on vacation the week of May 5th for 2 weeks. She stated Resident #1 left the building and was found by the gate on the property. He had no injuries. The cameras showed that he was still on property. She stated she would not be able to provide the camera footage. She stated that the receptionist would not have known if the resident was a possible visitor or an independent living resident. Resident #1 did not use a walker to ambulate. He looked like an ordinary person. She stated that Elopement Drills were now implemented. Notebooks were placed at each nurse's station in pink notebooks r/t residents who were at risk for elopement. Resident #1 was the only resident with a Wander Guard in the building. In an interview on 08/12/2025 at 3:25 p.m. with Family Member #3 revealed that Family Member #4 was the one who found Resident #1 at the stop light in front of the property outside the gate. She stated she just happened to be coming to visit him and drove up to the traffic light to turn into the facility property and spotted Resident #1 standing at the traffic light. She stated they were not satisfied with the facility while he was there. They placed Resident #1 on the secured unit which depressed him. The staff requested Family Member #3 to sit with resident at night because of not enough staff to watch him. She stated that was the facility's job. In an interview on 08/12/2025 at 3:36 p.m. with Family Member #4 revealed that she was the Family Member who found Resident #1 at the traffic light outside the property of the facility. She drove up to visit resident at the facility. When she came up to the light, she noticed resident standing at the curb. The traffic light was red. She rolled down her car window and asked him what he was doing, and he replied he was going home to his apartment. She told him to get in the car, and he did. She took him back in the building and the alarm went off when he walked through the front door. She proceeded down the hall with him towards the nurse's station and alarm continued to sound. A housekeeper passed them in the hallway and turned off the alarm. No nursing staff came to meet them. She told them where she found him. They had no idea he was missing. She stated it was after 2:00 PM when she arrived at the facility, but she was not certain of the exact time. In an interview on 08/13/2025 at 10:13 a.m. with Receptionist revealed she was at the desk when the alarm sounded. She stated the alarm went off at the entry door going out to the parking lot. The alarm does not go off near the receptionist desk. She admitted she was not familiar with the residents, but more familiar with Family Members. She was familiar with Resident #1's Family Member #3 and family member #4. Family Member #4 came in that day on 05/01/2025 with Resident #1. She stated when she heard the alarm, she walked down towards the front entrance door to look to see if there was a resident outside. Receptionist stated she did not see anyone. There was a gentleman from Assisted Living, who would walk pass the reception desk and down pass the breezeway and set off the alarm. She stated she would reset the alarm. She looked up walked down the breezeway and cut alarm off. She did not see a resident anywhere outside. She stated that staff would respond to door alarm when they go off. They can see from the staff entrance on [NAME], named for the 2100 Hall. She stated she did not inform the nurses that she cut off the alarm. In an interview on 08/13/2025 at 12:00 p.m. with RN A revealed he was working on [NAME], named for the 2100 Hall for the 6:00 a.m. - 3:00 p.m. shift on 05/01/2025. He stated he was familiar with Resident #1. RN A was scheduled to work the hall on 05/01/2025. He was not the nurse providing direct care for Resident #1 that day. Resident #1 would watch TV and was usually calm. He stated Resident #1 had dementia and was ambulatory. He would use a walker or a wheelchair at times but usually would ambulate throughout the building. Wander Guard was in place around resident's ankle daily. He stated that if Resident #1 would go near an exit door the panel indicates which exit door was set off. He stated that the alarm only indicates which door for a few seconds. The nurses would go the door that was triggered by Wander Guard to search for resident, begin a head count of all the residents on the halls, check all the rooms, shower rooms, and other places residents may wander to. He stated that he was not sure if any staff responded to door alarm, because he was completing a discharge on another resident at the time. He stated he did not stop what he was doing to search for Resident #1. He stated when Family Member brought resident back to the hall is when he realized Resident #1 was missing. He states that all staff have been in-serviced and trained on elopements and the steps to follow. Staff were in-serviced recently. There are pink notebooks at nurse's station with pictures and names of residents, face sheets, and other pertinent information about residents who are high elopement risk. The code for an eloped resident is Code Pink. He states the negative outcome that could have occurred because of Resident #1's elopement was Resident #1 could have gotten really hurt. In an interview on 08/13/2025 at 12:20 p.m. the ADON revealed that she was familiar with Resident #1. Resident #1 was forgetful and would at times would go to the exit doors. She stated she could not remember if he was ever aggressive toward the staff. Resident #1 was ambulatory and would wander throughout the facility. ADON not aware if he had a history of elopement before admission to facility. She stated she was aware that Resident #1 had eloped from the building but did not how long he had been gone. She knew that he did not have any injuries. She stated she knew that Resident #1's Family Member found him when she was arriving at the facility to visit him. She stated she was not sure if any of the staff on the 2100 hall knew Resident #1 was missing because she was conducting an in-service on another hall with staff. She stated on 05/01/2025, she heard the alarm sound and then heard it cut off within a second or two. She stated she thought staff went to look for resident and a CNA brought him back in. She stated that staff are to look at panel at the nurse's station to see what door the alarm was set off at. Some staff are to report to that area and begin looking for resident. Other staff are to get a head count of all the residents on each hall and account for their residents. When staff determine which resident is missing, go to Pink Binder at that nurse's station and retrieve the information on the missing resident. Contact the ADM, DON, MD, Police, and Family Members. Continue looking in the building and surrounding area outside the building until resident is found. Management has provided recent trainings and in-services r/t elopement and how to prevent this from happening again. She stated the negative outcome that might have occurred with this elopement with Resident #1 could have been detrimental to the resident. In an interview on 08/13/2025 at 3:30 p.m. with RN B revealed that he was familiar with Resident #1. He stated he had only cared for him for one shift during his time at the facility. The main behavior Resident #1 would exhibit was wandering and restlessness. Resident #1 showed attributes of dementia and confusion. He was ambulatory but would use a wheelchair at times. He stated, because he had a history of elopement, he kept him at the nurse's station with him. He stated he was not working 2100 hall on 05/01/2025 but was working on hall 300 in the memory care unit. He stated that he could not respond to alarm on 05/01/2025 because he was working the memory care unit. He stated he had received trainings and in-services on elopement recently. He stated the panel behind the nurse's station will indicate which door was set off by the Wander Guard. The staff should immediately respond to that area to search for resident who may have eloped. Begin a head count of residents on halls and determine which resident who may be missing. There are notebooks at the nurse's stations with information r/t residents who are at risk for elopement with their picture and a face sheet. Staff search for resident until the resident is located safely. He stated the negative outcome that could have occurred for Resident #1, he could have been hit by a car, or the police could have picked him up. In an interview on 08/13/2025 at 3:50 p.m. with CNA C revealed that she was familiar with Resident #1. She stated she worked on the memory care unit on hall 3. Resident #1 had only been there on Hall 3 for a few hours when he was placed there. He was not adjusting well to the memory care unit. Resident #1 was not exhibiting any behaviors except his Family Members did not want him there in the unit. He was moved off the unit the same day he arrived. She stated she did not remember what date this occurred. Resident #1 had dementia. He was ambulatory but used a wheelchair at times. She stated she was aware that a resident had eloped from the facility on 05/01/2025 but was not aware it was Resident #1. She stated she has been trained and attended in-services r/t elopement recently. She stated that when the alarm goes off, the nurse's look at the panel at the nurse's station which shows which door was set off. Staff are to go to that exit to search for the resident. Staff are to complete a head count to find out which resident is missing. There is an elopement book at the nurse's station with a picture and information about each resident who are an elopement risk. She stated the negative outcome that could have occurred with Resident #1's elopement would have been not too good because cars on the street speed on that street and resident could have been hit. In an interview on 08/13/2025 at 4:08 p.m. with CNA D revealed that she was not sure if she was familiar with Resident #1 because she never cared for him. She stated that she received training and in-services on elopement recently. She stated the steps to take in case a resident elopes from the building. She stated that when a resident with a Wander Guard goes near a door, the alarm will sound if the resident walks out the door. She stated there is a panel on the wall at the nurse's station that tells the nurse which door went off. There is a pink notebook at each nurse's station with the names of the residents who are elopement risk with their information in the book such as their picture and face sheet. She stated the negative outcome that could have occurred with this elopement could have been big trouble for resident and facility. On 08/13/2025, ADM provided the corrective action plan implemented after having an Emergent (QA) Meeting with Members r/t Resident #1. Elopement assessment would be reviewed and deemed still accurate, with care plan update to reflect current wandering issues. Wander Guard would be assessed in place and functioning with no issues. Maintenance performed on doors and Wander Guard checks on all exits. Based on elopement evaluation, elopement binders would be placed on the nurse's stations and front desk. In-services were started with staff on Wander Guard System, Code Pink Alert, Code Alarm System, Emergency Procedures-Missing Resident, Wandering/Elopement with completion with all employees currently working, and prior to their next scheduled workday. Elopement Drill complete on 05/02/2025, labeling system identified as missed labeled, maintenance fixed on 05/02/2025 after identification. On 05/02/2025 at 3:00 p.m. the ADM and DON provided a personal consultation and coachable moment with receptionist involved in incident by turning alarm off that was triggered by Wander Guard on 05/01/2025. Corrective action taken: Coachable Moment & Consultation on 5/2/2025, 1:1 Inservice with ADM and DON on 5/2/2025. In-service included: Wander Guard System, Code Pink Alert, Code Alarm System, Emergency Procedures-Missing Resident, Wandering/Elopement Risk and Alarms Sounding. Following elopement incident in-services were held on 05/01/2025 and 05/02/2025 r/t with staff on, Wander Guard System, Code Pink Alert, Code Alarm System, Emergency Procedures-Missing Resident, Wandering/Elopement Risk and Alarms Sounding. Approximately 73 employees were in attendance held on both days. Record review of facility's Wandering and Elopement Policy (revised March 2019) says in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Observations revealed there were no other residents that were present with Wander Guards and no residents observed with exit-seeking behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision and assistive devices to prevent accidents for one resident (Resident #1) of eight residents reviewed for assistive devices and supervision. - The facility failed to ensure Resident #1 received adequate supervision and care in accordance with professional standards when the resident complained of pain and MA B did not notify the nurse promptly. MA B transferred Resident #1 out of bed using a sit to stand lift without assistance and notified the nurse of Resident #1's pain afterwards. Resident #1 received an X-ray that was positive for an acute spiral fracture of her left femur. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 6/18/25 at 1:00 PM. The Immediate Jeopardy began on 6/12/25 and ended on 6/16/25. The facility had corrected the non-compliance before the state's investigation began. This failure placed residents at risk of a delay in medical evaluation and treatment, which could result in worsening of condition or serious harm. Findings included : Record review of Resident #1's face sheet, dated 6/17/25, reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia ((brain disorder that affects thinking, memory, and behavior), hx of fractured left tibia (long bone in lower leg), hx of fractured left femur neck (hip/thigh bone), age-related osteoporosis (weak bones), unspecified pain, and muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 5/15/25, reflected the resident's BIMS score was 0, which indicated severe cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on staff for all self-care and mobility ADLs, and used a manual wheelchair. Record review of Resident 1's care plan, dated 5/14/25, reflected the resident had ADL self-care performance deficits and required a high-back wheelchair r/t disease process and posturing with interventions that included: assistance with all ADL's and an assist of 2 staff for transfers. Further review of the document revealed it was revised on 6/13/25 to reflect that Resident #1 required safe transfer practices with interventions that included: a transfer status update form sit-to-stand lift (device used to transfer individuals who can bear partial weight from one seated surface to another) to total lift (Hoyer)(device used to transfer individuals who can bear little to no weight) x2 staff members. Record review of Resident #1's consolidated physician's orders, dated 6/17/25, reflected in part the following: -May use mechanical lift device- as needed. Start date: 1/27/25. -May use specialized wheelchair-as needed for posturing and comfort. Start date: 1/28/25. -Acetaminophen tablet 325 mg-give 1 tablet by mouth two times a day for pain. Do not exceed 3 grams in 24 hours. Start date: 6/12/25. -Tramadol HCL oral tablet 50 mg-give 1 tablet by mouth every 12 hours for pain. Start date: 1/28/25. -X-ray of left femur in two weeks 6/27/25-one time only for verbal check fracture healing. Start date: 6/13/25; End date: 6/27/25. Record review of Resident #1's progress notes, dated 6/12/25 at 9:00 AM by LVN A, reflected the following: [Resident #1] c/o left leg pain while up for breakfast. Tramadol and routine Tylenol given for pain. [MD] here and assessed leg and new order given for left leg x-ray from hip to ankle. [Resident #1] was returned to bed and a skin tear was observed on left lower leg. Dressing applied. Record review of Resident #1's progress notes, dated 6/12/25 at 9:50 AM by LVN A, reflected the following: [Hospice RN] here to see [Resident #1]. [Hospice RN] said areas on right buttock and gluteal fold were looking much better. [Hospice RN] is going to order [Resident #1] a new hospital bed with air mattress and another overbed table. [Hospice RN] has seen [Resident #1's] left leg and was informed of new order for left leg x-ray. [Hospice RN] will call [Resident #1's] [RP]and let him know about x-ray order. [Hospice RN] changed routine Tylenol order from one 325 mg Tylenol BIB [sic] to two 325 mg Tylenol BID. A PRN Tylenol 325 mg one tab every 6 hours as needed for pain was added to orders. Record review of Resident #1's progress notes, dated 6/12/25 at 2:36 PM by LVN A, reflected the following: [MD] notified of spiral fracture (a complete bone break that spirals around the bone) of left femur. [MD] ask that [LVN A] call [Resident #1's] [RP] to see if he wanted [Resident #1] sent out to the hospital, or if [Resident #1] would continue to be monitored here by [Hospice]. [Resident #1's] [RP] notified and he said that he would speak to hospice and make a decision. Record review of Resident #1's progress notes, dated 6/12/25 at 4:33 PM by the MD, reflected the following: [Resident #1] seen this am for left lower extremity pain Xray report acute spiral fracture of left femur with displacement (bone moved out of normal position) No falls reported. Skin tear to left shin noted during visit. [Resident #1] usually transferred using sit to stand lift. Xray positive for acute spiral fracture of left femur with displacement. Spoke to [Resident #1's] [RP], pain is currently controlled on APAP and Tramadol. [RP] to decide: continue palliative care in facility on hospice, manage pain and add Lovenox for DVT prophylaxis (action taken to prevent disease). or Revoke hospice and transfer to hospital for management, due to overall condition surgery not recommended, possible bracing if indicated. Record review of Resident #1's progress notes, dated 6/12/25 at 8:48 PM by LVN M, reflected the following: [RP] called facility. Stated do not send [Resident #1] to hospital re: Fx of left femur. Provide care/comfort at facility, [Hospice]. [Resident#1] sleeping no complaints or s/s of pain or discomfort. Cont on routine pain management of Tramadol/APAP. Record review of Resident #1's Xray, dated 6/12/25, reflected in part the following: . LEFT FEMUR X-Ray - 2 view: Findings: AP (front to back) and lateral (one side of the body to the other) views of the left femur demonstrate a diffuse osteoporosis. There is a distal femoral metaphyseal (area of the thigh bone located just above the knee) spiral fracture with mild displacement. No bony erosion or destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body (white or bright objects). IMPRESSION: The bones are osteoporotic. The posteriorly (position at the back, or towards the rear) displaced distal femoral metaphyseal spiral fracture is present. Record review of a statement, dated 6/12/25, submitted by MA B reflected in part the following: When I went to get [Resident #1] up, at first she was saying leave me alone I went to another resident then came back. When I came back to get [Resident #1] up for breakfast, I used the sit to stand lift and put her on the chair. [Resident #1] was stating, leave me alone, leave me alone. [Resident #1] was then complaining of pain when she got in the chair, I thought it was regular pain, because I know she gets pain pill. I went and told the nurse that [Resident #1] was complaining of pain and the nurse went to give her medicine. When was [sic] transferring with the sit to stand lift [Resident #1] did not bump her legs or any part of her body she was ok when I transferred her with the lift. In an interview on 6/17/25 at 9:20 AM with the Administrator and DON, the DON stated on 6/12/25 it was reported to her that Resident #1 complained of pain to MA B while she was preparing her for breakfast. The DON stated MA B notified LVN A, who notified the DON and MD. The DON stated Resident #1 was given pain medication and had an Xray that revealed an acute spiral fracture of the femur. She stated Resident #1 was on hospice and her RP chose not to have her sent out to the hospital since hospice was able to adjust her pain medication and keep her comfortable. The DON stated the lab was able to determine that the fracture was acute after comparing the Xray to a previous image. The DON stated this was her first time dealing with a spiral fracture and she could not use her clinical experience to state likely causes of that type of fracture. The DON stated Resident #1 was diagnosed with generalized pain and a hx of a hip fracture, so when she complained of pain, MA B thought it was her usual pain. The DON stated Resident #1 had a hx of falls but was currently non-ambulatory and was not considered a fall risk. The DON stated Resident #1 depended on staff for mobility and required a sit-to-stand mechanical lift to be transferred out of bed. The DON stated there had been no reported incidents or changes in Resident #1's condition in the days leading up to the injury. The DON stated she took statements from staff who worked with Resident #1, and no one stated any incidents or changes with the resident. The DON stated if Resident #1 had fallen out of bed she would have needed assistance getting up, so staff would have been aware if the injury was caused from a fall. The Administrator stated an investigation was conducted and the cause of injury was unfounded. The Administrator stated an emergent QAPI meeting was held, and interventions were put in place that included all staff being in-serviced and completing skills checkoffs on mechanical lift transfers. In an interview on 6/17/25 at 10:05 AM, LVN A stated she worked at the facility for about 9 years. She stated she worked with Resident #1 on 6/12/25. She stated they were passing breakfast trays when Resident #1 looked at her and said [LVN A] my leg hurts. LVN A stated she was shocked that Resident #1 knew her name and was able to be specific about where her pain was because Resident #1 was diagnosed with advanced dementia and was normally confused. LVN A stated Resident #1 was able to express when something was wrong, but she was very specific that day and was able to point to her left leg. LVN A stated she assessed Resident #1 and only found a faint skin tear to her lower left leg. LVN A stated Resident #1 was on routine Tylenol and Tramadol that had already been administered. LVN A stated the MD was already at the facility doing rounds and was notified that Resident #1 was complaining of pain. LVN A stated hospice and Resident #1's RP was also notified. LVN A stated the MD assessed Resident #1 and ordered a STAT Xray. LVN A stated hospice increased Resident #1's pain medication. LVN A stated Resident #1's Xray was positive for a spiral fracture to her hip bone and that was considered a more serious type of fracture. LVN A stated in her experience that type of fracture could be caused by the leg being bent all the way back or a forceful movement. LVN A stated when she arrived on shift that morning, the off-going nurse did not report any incidents or changes in Resident #1's condition. LVN A stated the day started as normal. LVN A stated the usual CNA for that hall did not work that day and MA B was filling in. LVN A stated there were some staff openings on the unit and it was not unusual for staff from other halls to help. LVN A stated Resident #1 was total care and required a sit-to-stand mechanical lift for transfers. LVN A stated MA B did not report any accidents or injuries while transferring Resident #1 to her wheelchair that morning. In an interview on 6/17/25 at 10:05 AM, MA B stated she worked at the facility for about a year. She stated she was a MA but also helped as a CNA when needed. MA B stated she worked on the memory care unit for the past two weeks and was familiar with Resident #1, who complained of pain often. She stated she worked with Resident #1 on 6/12/25 when the injury was found. MA B stated when she entered Resident #1's room to get her out of bed for breakfast, she complained of pain which she thought was her normal pain. MA B stated Resident #1 was complaining of pain before she moved her; however, she proceeded to use the sit-to-stand mechanical lift to get her into the wheelchair. MA B stated mechanical lift transfers were supposed to be done with 2 staff but there was no one else available to help so she did it alone. MA B stated Resident #1 was able to assist some, which made it easier. MA B stated there was not an accident during the transfer. MA B stated once she got Resident # in the wheelchair, she reported to LVN A that Resident #1 was complaining of pain. MA B stated she had been trained on abuse and neglect. She was able to provide examples of abuse and stated she would report any concerns to the Administrator. MA B stated she had also been trained on safe repositioning, mechanical lift transfers, and notifying the nurse if a resident complained of pain before completing any care. In an interview on 6/17/25 at 11:01 AM, Resident #1's RP stated the facility notified him on 6/12/25 that Resident #1 complained of pain in her leg and an Xray showed a spiral fracture of the left femur. The RP stated he did not have any concerns that Resident #1 was abused or neglected, and the facility always notified him of any incidents or changes with the resident. He stated he was not present, but he could see how maybe during a transfer Resident #1's foot was not planted correctly when staff went to transfer her, and the bone twisted. He stated Resident #1 had multiple fractures in the past and had fragile bones. The RP stated he was pleased with the care Resident #1 was receiving at the facility; however, he understood why the State Agency needed to investigate the injury. In an interview and observation on 6/17/25 at 12:00 PM, Resident #1 was observed lying comfortably in bed. The bed was in the lowest position with a fall mat on the floor. Resident #1 was dressed in her gown and was well-groomed with no visible marks or bruises. Resident #1 stated she was fine and denied being in any pain. Resident #1 stated something happened to her hip, but she was not able to recall what happened. Resident #1 stated she did not fall, and no one hurt her. Resident #1 was not a good historian due to her dementia and was not able to complete the interview. In an interview on 6/17/25 at 1:20 PM, CNA C stated she worked at the facility for 8 years. She stated she normally worked on the memory care unit with Resident #1; however, she called out on 6/12/25 and staff who normally did not work with Resident #1 filled in for her that day. CNA C stated she received a call informing her that Resident #1 had a fractured hip and was on bedrest. CNA C stated Resident #1 required a sit-to-stand mechanical lift for transfers but when she returned to work, she received an in-service and was told that Resident #1 now required a total lift for transfers. CNA C stated she was also informed that all mechanical lift transfers had to be performed with 2 staff. CNA C stated they always used 2 staff with total lift transfers, but they would sometimes do sit-to-stand lift transfers alone because the residents could bear some of their weight and assist some. CNA C stated when Resident #1 was transferred, staff had to know to be patient with her and remind her to keep her legs bent. CNA C stated on 6/13/25 she had to do an in-service and skills check-off for mechanical lift transfers. She stated shewas also in-serviced on notifying the nurse of any complaints of pain or change in condition before proceeding with care, and abuse and neglect. CNA C denied having concerns that any residents were being abused or neglected in the facility . In an interview on 6/17/25 at 1:45 PM, the DON stated MA B informed the DON that she used a sit-to-stand mechanical lift to transfer Resident #1 without a second staff. The DON stated Resident #1 required a 2-person assist with transfers and it was also the facility's protocol to use 2 staff during mechanical lift transfers. The DON stated it was important to use 2 staff during mechanical lift transfers to ensure the safety of residents and prevent injuries. Further interview on 6/17/25 at 3:32 PM with the Administrator and DON, the DON stated the expectation was for the aides to notify the nurse if a resident complained of pain before proceeding with any type of care so the resident could be assessed and provided pain management and staff were re-educated on this during in-services regarding the incident. The Administrator stated the aides were not qualified to assess residents or make any determinations, which was why the nurse had to be notified. The DON stated providing care after a resident expressed being in pain, without notifying the nurse, could place the resident at risk of increased pain. The Administrator added that it could place the resident at risk of further injury or cause an injury. In an interview on 6/18/25 at 12:49 PM, the MD stated on 6/12/25, she was making rounds at the facility when LVN A notified her that Resident #1 was complaining of pain in her left leg. The MD stated she went in the room to assess Resident #1 and ordered an Xray of the leg. The MD stated the Xray was positive for an acute spiral fracture of the left femur/hip. The MD stated Resident #1 had memory loss due to dementia; however, she was able to express when she was in pain, she just could not state what caused it. The MD stated Resident #1 was on hospice for terminal diagnoses of dementia and was also diagnosed with osteopenia, which meant that the resident's bones were very fragile. The MD stated a spiral fracture was an injury that would make one think; however, in Resident #1's case it would only take minor trauma to obtain due to her bones being so fragile. The MD stated there were no reports of a fall or other incidents. The MD stated Resident #1's bed was always low to the ground and staff used a sit-to-stand mechanical lift to transfer her. The MD stated she believed the sit-to-stand lift was in the room when she assessed her on 6/12/25. The MD stated Resident #1's injury could have happened during a transfer. Review of the facility's policy titled Lifting Machine, Using a Mechanical, revised July 2017, revealed in part the following: Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. . Steps in the Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: (1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift? b. Cognitive/Emotional: (1) Can the resident understand and follow instructions? (2) Does the resident express fear or appear anxious about the use of a lift? (3) Is the resident agitated, resistant, or combative? . The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 06/18/25 at 1:00 PM. The Immediate Jeopardy began on 06/12/25 and ended on 06/16/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review on 6/17/25 of a document provided by the Administrator titled Emergent Quality Assurance (QA) Form 10, dated 6/13/25, reflected a QAPI meeting was held to discuss failure and interventions put in place to prevent failure from occurring again, which included: assessment and STAT treatment of Resident #1, notifying MD, hospice, family, and ombudsman of incident, in-servicing all staff, skills checkoffs with all staff, skin assessments, chart review and updated care plan. Follow-up included: continued monitoring of pain, two weeks of bedrest, and transfer status changed from sit-to-stand lift to complete lift (Hoyer) for Resident #1, and monitoring of CNAs weekly for proper lift transfers for 4 weeks, then twice monthly, then times 3 quarterly with results of audits provided to QAPI and recommendations reviewed. Record review on 6/17/25 of a document provided by the Administrator titled Teammate Corrective Action Form, dated 6/13/25, reflected CMA B received corrective action via Coachable Moment. CMA B received one on one education regarding proper use of mechanical lifts and notifying the nurse immediately when assistance is needed. Record review on 6/17/25 of documents provided by the DON titled Skin Monitoring Assessment Sheet, dated 6/13/25-6/14/25, reflected 18 residents on the unit received head-to toe- skin assessments with no negative findings. Record review on 6/17/25 of documents provided by the DON titled Competency Assessment: Lifting Machine,, dated 6/14/25-6/17/25 (overnight 6/16-6/17), reflected 28 staff completed skills checkoffs for mechanical lift transfers, which included assessing the resident's current physical and emotional condition before performing the lift and general principles of safe lifting. Record review on 6/17/25 of in-service titled Use of Sit to Stand and Hoyer lifts, dated 6/13/25-6/15/25, reflected 36 staff were educated by the DON on ensuring that all mechanical lifts be performed with a 2-person assist always. Record review on 6/17/25 of in-service titled Abuse, Neglect, Exploitation Policy, dated 6/13/25, reflected 34 staff were educated by the DON regarding the facility's abuse, neglect, and exploitation policy. Record review on 6/17/25 of in-service titled Safety with turning and repositioning, dated 6/14/25, reflected 28 staff were educated by the DON on safe protocol when turning and repositioning residents. Record review on 6/17/25-6/18/25 of Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, EHRs revealed their care plans included interventions to address ADL needs and appropriate transfer requirements. Resident #1's care plan was revised on 6/13/25 with transfer status updated to Hoyer Lift X 2 staff members, Observations on 6/17/25 from 12:00 PM-1:15 PM; 4:00 PM-4:35 PM, with Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, revealed no s/sx of pain or visible marks or bruises. Observation of mechanical lift transfers revealed they were safely completed, following protocol with 2-person assist. Interviews on 6/17/25 from 12:00 PM-1:15 PM; 4:40 PM-5:05 PM, with the RPs and Residents #1, #2, #3, #4, #5, #6, #7, and #8, who all required transfer assistance, revealed no concerns for accidents/injuries during mechanical lift transfers, abuse, or neglect of residents. Interviews from 6/17/25 (varied times between 10:05 AM-5:22 PM) - 6/18/25 (9:40 AM-11:35 AM), conducted with the Administrator, DON, nurses and CMA/CNAs: LVN A (1st shift/weekdays), CMA B (1st shift/rotating days), CNA C (1st shift/rotating days), CNA D (1st shift/rotating days), RN E (2nd shift/weekdays), CNA F (2nd shift/rotating days), CNA G (2nd shift/ rotating days), CNA H (2nd shift/ rotating days), CNA I (2nd shift/ rotating days), LVN J (1st shift/weekdays), CNA K (1st shift/rotating days), CNA L (1st shift/rotating days), LVN M (3rd shift/weekdays), CNA N (3rd shift/rotating days), LVN O (1st/2nd shift/double weekends), CNA P (3rd shift/ rotating days), RN Q (3rd shift/weekends), and CNA R (3rd shift/ rotating days), indicated they all participated in in-services and skill checkoffs prior to starting their shifts. All staff were able to state that the facility used two different type of mechanical lifts (sit-to-stand and total mechanical lift) and transfers with both lifts required a 2-person assist at all times. All staff were able to state that using a draw sheet and pillow would reduce the risk of injuries when turning and repositioning residents. All CMA/CNAs were able to state that the nurses must be notified immediately if a resident had any changes in condition or c/o pain before proceeding with care or transfers . All nurses were able to state they were responsible for assessing any c/o of pain or changes in a resident's condition, report to the MD, and follow any new orders. All nurses were able to state they would be aware of all mechanical lift transfers and would be available to assist if needed. All staff were able to state in their own words the facility's abuse, neglect, and exploitation policy. All staff were able to describe abuse, neglect, and exploitation, when to report it, and who to report it to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (the process of receiving and interpreting prescriber's orders and to provide procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs) to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. The facility failed to ensure the hospital discharge order to continue Eliquis (anticoagulant commonly known as a blood thinner medication) was accurately transcribed and administered to Resident #1 as ordered from 8/26/2024 to 9/26/2024 (30 days). The noncompliance was identified as past noncompliance (PNC). The IJ began on 8/26/2024 and ended on 10/19/2024. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for not receiving medications as ordered by their physician or per manufacturer's directions. Findings included: Record review of Resident #1's PPS MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), displaced intertrochanteric fracture of the left femur (fractured left hip), and encounter for other orthopedic aftercare (care after surgery). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #1's care plan revised on 10/23/2024 revealed Resident #1 was at risk for bleeding due to anticoagulant use and interventions included evaluating the skin for evidence of impaired coagulation (bruising, petechia, bleeding). Record review of Resident #1's MAR for August 2024 revealed Eliquis was ordered and administered to Resident #1 from 8/08/2024 until 8/23/2024. Record review of Resident #1's hospital H&P dated 8/26/2024 revealed Resident #1 was transferred to the hospital on 8/23/2024 and was on Eliquis for atrial fibrillation. Record review of Resident #1's hospital Discharge summary dated [DATE] revealed orders to continue Eliquis after discharge from the hospital. Record review of Resident #1's physician orders revealed there was not an order for Eliquis from 8/26/2024 to 9/26/2024. Record review of Resident #1's MAR for August 2024 revealed Eliquis was not administered or ordered from 8/26/2024 until 8/31/2024. Record review of Resident #1's MAR for September 2024 revealed Eliquis was not administered or ordered from 9/01/2024 until 9/26/2024. In an interview on 12/17/2024 at 10:03 a.m., MA B reported the MAR showed her what medications to administer to each resident and what time to administer the medications. MA B stated she was not able to add or remove medications from the MAR because the nurses had to enter the orders into the EHR. MA B stated only nurses were able to add medications to the MAR. In an interview on 12/17/2024 at 4:03 p.m., LVN A reported she transcribed Resident #1's discharge medication orders when Resident #1 returned from the hospital on 8/26/2024. LVN A stated she reviewed the medications with the physician and entered them into the EHR. LVN A reported she did not know why the order for Eliquis was missing because she thought she entered it into Resident #1's EHR. LVN A reported she was not aware the order was missing at that time and would never intentionally not give the resident her medicine. LVN A was not asked the risk to the resident. In an interview on 12/17/2024 at 9:50 a.m., LVN D stated a resident would be at risk for a blood clot, stroke, or embolism if they were not given Eliquis as ordered. Record review of Resident #1's hospital H&P dated 9/27/2024 revealed Resident #1 was admitted to the hospital on [DATE] and was found to have a non-salvageable limb ischemia (no blood supply to the leg). On 9/26/2024 Resident #1 had a mechanical thrombectomy (removal of blood clot) for an occluded superficial femoral artery (blood vessel) in the left leg. Resident #1 underwent a left above the knee amputation because blood flow was not restored after the thrombectomy (removal of blood clot). Record review of nursing progress note dated 9/30/2024 at 6:53 p.m. revealed Resident #1 returned to the facility with a left above the knee amputation. Record review of Resident #1's MAR for October 2024 revealed Eliquis was ordered and administered to Resident #1 from 10/01/2024 until 10/17/2024. In an interview on 12/17/2024 at 1:17 p.m., the DON reported she was notified on 10/18/2024 by a case worker from the hospital that Resident #1 had not received her Eliquis previously while at the facility. The DON stated the case workers at the hospital reconciled medications on their end but were unable to notify the facility of the discrepancy because they had the wrong DON email address. The DON reported she immediately notified the Medical Director, the family, and the ombudsman of the error. The DON stated that the Medical Director would have to answer if there were any adverse reactions or risks to Resident #1. The DON stated previously the floor nurse reviewed the medications with the doctor and transcribed them to the EHR. The DON stated the admission process was updated to include additional checks by the unit manager and DON to ensure medications were transcribed accurately. The DON stated the floor nurse was responsible for reconciling the medications with the doctor, then the unit manager would verify the medications were accurately transcribed. The DON stated then she would review the medications again and the medication list would be sent to the pharmacy to be reviewed for accuracy. The DON reported a medication reconciliation competency was completed for every nurse. In an interview on 12/17/2024 at 1:48 p.m., the Medical Director reported Resident #1 had multiple things wrong with her and was doing poorly after hip surgery in August 2024. The Medical Director reported Resident #1 had an above the knee amputation on the left leg because Resident #1 had a blood clot. The Medical Director stated the Eliquis was prescribed for atrial fibrillation, and venous (veins) clots were prevented with Eliquis. The Medical Director stated Resident #1 had an arterial (arteries) clot. In an interview on 12/18/2024 at 12:55 p.m., the Medical Director stated the nurses completing admissions were expected to look at all of the discharge orders and review them with the doctor. The Medical Director stated the Eliquis was on the discharge orders for Resident #1 but could not state if the nurse mentioned it or not when she called to reconcile the medications on 8/26/2024. Record review of the Medication Guide Eliquis, revised September 2021, revealed Eliquis is a prescription medicine used to: reduce the risk of stroke and blood clots in people who have atrial fibrillation. Reduce the risk of forming a blood clot in the legs and lungs of people who have just had hip or knee replacement surgery. In an interview on 12/17/2024 at 2:29 p.m., a medical information specialist for Eliquis stated the premature discontinuation of Eliquis increases the risk of thrombotic events (formation of blood clots) and to reduce the risk consider coverage with another anticoagulant (blood thinner). The medical information specialist stated thrombotic events (blood clots) could occur in veins or arteries. In an interview on 12/18/2024 at 8:38 a.m., the ADM stated their back up checks failed, and a mistake was made. The ADM stated on 8/26/2024 that the admission nurse was not working that day (who assisted in checking the medication orders) and that they would have given the medication if the order had been transcribed. The ADM stated at the time that Resident #1's Eliquis was not transcribed, that the facility had an admission checklist, but it was only monitored by the admission nurse and the DON. The ADM stated all discharge orders are expected to be transcribed. The ADM did not state the risk to the resident not receiving the prescribed medication. Record review of admission/discharge report dated 12/17/2024 revealed Resident #1 was transferred to another facility on 10/18/2024. Review of facility policy titled Adverse Consequences and Medication Errors, with a revision date of April 2014, stated The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems. Facility policy for admission orders/transcribing orders not received a the time of exit. The facility took the following actions to correct the noncompliance prior to the investigation: In an interview on 12/18/2024 at 8:38 a.m., the ADM reported the admission checklist was updated and required the floor nurse, nurse manager, and the DON to review medications on all new admissions. The ADM stated the DON was responsible for monitoring the admission checklist and ensuring the medications were transcribed. The ADM stated the facility reviewed all new admissions during meetings on Thursdays, and she monitored the admission checklist to ensure it was completed during monthly meetings. Record Review of new admission checklist revealed section for floor nurse to initial medications were reviewed with the physician and entered into the EHR. The form revealed an area for the floor nurse to sign, the unit manager to sign, and for the DON to sign once reviewed. Record Review of facility's admission binder revealed completed new admission checklist forms for admissions from 10/20/2024 to current. In an interview on 12/17/2024 at 1:17 p.m., the DON stated the admission process was updated to include additional checks by the unit manager and DON to ensure medications were transcribed accurately. The DON stated the floor nurse was responsible for reconciling the medications with the doctor, then the unit manager would verify the medications were accurately transcribed. The DON stated then she would review the medications again and the medication list would be sent to the pharmacy to be reviewed for accuracy. The DON reported a medication reconciliation competency was completed for every nurse. Record Review of Competency Assessment Reconciliation of Medications on admission forms revealed the competency checklist was completed for 28 nurses on 10/19/2024. In an interview on 12/17/2024 at 9:17 a.m., RN C stated they implemented a new protocol and there were three checks now for the medication reconciliation. RN C stated the floor nurse was the first one responsible for transcribing medications when a resident was admitted . RN C stated then the unit manager would perform the second check, and the DON would perform the third check. RN C stated they had an updated checklist that he received training for and for reconciling medications. In an interview on 12/17/2024 at 9:50 a.m., LVN D stated she received training for medication orders and the admission process. LVN D stated the nurse that completed the admission would reconcile the medications from the hospital discharge paperwork with the physician. LVN D stated the nurse manager and DON would check the medications afterwards. In an interview on 12/17/2024 at 10:15 a.m., LVN E stated discharge orders were reviewed with the doctor and then entered into the EHR. LVN E stated the nurse managers check the medications after the floor nurse, and then the DON checks the medications. LVN E stated she received training for medication reconciliation. In an interview on 12/17/2024 at 10:27 a.m., Unit Manager F stated the floor nurse would review medications with the doctor, and the unit manager would do a second check to ensure all medications were entered. Unit manager F stated the DON would review the medications after the unit manager, and the medications would also be checked again by the pharmacy consultant. Unit Manager F reported she received one-to-one training from the DON concerning the medication reconciliation process. In an interview on 12/17/2024 at 12:53 p.m., RN G stated that when a new admit arrived then the medication orders were verified with the doctor and emailed to the pharmacy consultant. RN G stated then a nurse manager would check the orders, and the DON checked them after the nurse manager. RN G stated she received in-person training for medication reconciliation and completed a checkoff list for medication reconciliation competency. In an interview on 12/17/2024 at 4:03 p.m., LVN A stated she received training for the admission process and the medication reconciliation process. LVN A stated she received one-to-one training from the DON. LVN A stated the nurses would review the medications one by one with the doctor and would complete the admission checklist. LVN A stated the nurse manager checked the medications after the nurse entered them, and then the DON would recheck them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents are free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors. The facility failed to ensure Eliquis (anticoagulant commonly known as a blood thinner medication) was administered to Resident #1 as ordered from 08/26/2024 to 09/26/2024 (30 days). The noncompliance was identified as past noncompliance (PNC). The IJ began on 08/26/2024 and ended on 10/19/2024. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for not receiving medications as ordered by their physician or per manufacturer's directions. Findings included: Record review of Resident #1's PPS MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), displaced intertrochanteric fracture of the left femur (fractured left hip), and encounter for other orthopedic aftercare (care after surgery). The MDS also revealed a BIMS score of 15 (suggested no cognitive impairment). Record review of Resident #1's care plan revised on 10/23/2024 revealed Resident #1 was at risk for bleeding due to anticoagulant use and interventions included evaluating the skin for evidence of impaired coagulation (bruising, petechia, bleeding). Record review of Resident #1's MAR for August 2024 revealed Eliquis was ordered and administered to Resident #1 from 8/08/2024 until 8/23/2024. Record review of Resident #1's hospital H&P dated 8/26/2024 revealed Resident #1 was transferred to the hospital on 8/23/2024 and was on Eliquis for atrial fibrillation. Record review of Resident #1's hospital Discharge summary dated [DATE] revealed orders to continue Eliquis after discharge from the hospital. Record review of Resident #1's physician orders revealed there was not an order for Eliquis from 8/26/2024 to 9/26/2024. Record review of Resident #1's MAR for August 2024 revealed Eliquis was not administered or ordered from 8/26/2024 until 8/31/2024. Record review of Resident #1's MAR for September 2024 revealed Eliquis was not administered or ordered from 9/01/2024 until 9/26/2024. In an interview on 12/17/2024 at 10:03 a.m., MA B reported the MAR showed her what medications to administer to each resident and what time to administer the medications. MA B stated she was not able to add or remove medications from the MAR because the nurses had to enter the orders into the EHR. MA B stated only nurses were able to add medications to the MAR. In an interview on 12/17/2024 at 4:03 p.m., LVN A reported she transcribed Resident #1's discharge medication orders when Resident #1 returned from the hospital on 8/26/2024. LVN A stated she reviewed the medications with the physician and entered them into the EHR. LVN A reported she did not know why the order for Eliquis was missing because she thought she entered it into Resident #1's EHR. LVN A reported she was not aware the order was missing at that time and would never intentionally not give the resident her medicine. LVN A was not asked the risk to the resident. In an interview on 12/17/2024 at 9:50 a.m., LVN D stated a resident would be at risk for a blood clot, stroke, or embolism if they were not given Eliquis as ordered. Record review of Resident #1's hospital H&P dated 9/27/2024 revealed Resident #1 was admitted to the hospital on [DATE] and was found to have a non-salvageable limb ischemia (no blood supply to the leg). On 9/26/2024 Resident #1 had a mechanical thrombectomy (removal of blood clot) for an occluded superficial femoral artery (blood vessel) in the left leg. Resident #1 underwent a left above the knee amputation because blood flow was not restored after the thrombectomy (removal of blood clot). Record review of Resident #1's MAR for October 2024 revealed Eliquis was ordered and administered to Resident #1 from 10/01/2024 until 10/17/2024. In an interview on 12/17/2024 at 1:17 p.m., the DON reported she was notified on 10/18/2024 by a case worker from the hospital that Resident #1 had not received her Eliquis previously while at the facility. The DON stated the case workers at the hospital reconciled medications on their end but were unable to notify the facility of the discrepancy because they had the wrong DON email address. The DON reported she immediately notified the Medical Director, the family, and the ombudsman of the error. The DON stated that the Medical Director would have to answer if there were any adverse reactions or risks to Resident #1. The DON stated previously the floor nurse reviewed the medications with the doctor and transcribed them to the EHR. The DON stated the admission process was updated to include additional checks by the unit manager and DON to ensure medications were transcribed accurately. The DON stated the floor nurse was responsible for reconciling the medications with the doctor, then the unit manager would verify the medications were accurately transcribed. The DON stated then she would review the medications again and the medication list would be sent to the pharmacy to be reviewed for accuracy. The DON reported a medication reconciliation competency was completed for every nurse. In an interview on 12/18/2024 at 12:55 p.m., the Medical Director stated the nurses completing admissions were expected to look at all of the discharge orders and review them with the doctor. The Medical Director stated the Eliquis was on the discharge orders for Resident #1 but could not state if the nurse mentioned it or not when she called to reconcile the medications on 8/26/2024. In an interview on 12/18/2024 at 8:38 a.m., the ADM stated their back up checks failed, and a mistake was made. The ADM stated on 8/26/2024 that the admission nurse was not working that day (who assisted in checking the medication orders) and that they would have given the medication if the order had been transcribed. The ADM stated at the time that Resident #1's Eliquis was not transcribed, that the facility had an admission checklist, but it was only monitored by the admission nurse and the DON. The ADM stated all discharge orders are expected to be transcribed. Review of facility policy titled Adverse Consequences and Medication Errors, with a revision date of April 2014, stated The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems. The facility took the following actions to correct the noncompliance prior to the investigation: In an interview on 12/18/2024 at 8:38 a.m., the ADM reported the admission checklist was updated and required the floor nurse, nurse manager, and the DON to review medications on all new admissions. The ADM stated the DON was responsible for monitoring the admission checklist and ensuring the medications were transcribed. The ADM stated the facility reviewed all new admissions during meetings on Thursdays, and she monitored the admission checklist to ensure it was completed during monthly meetings. Record Review of new admission checklist revealed section for floor nurse to initial medications were reviewed with the physician and entered into the EHR. The form revealed an area for the floor nurse to sign, the unit manager to sign, and for the DON to sign once reviewed. Record Review of facility's admission binder revealed completed new admission checklist forms for admissions from 10/20/2024 to current. In an interview on 12/17/2024 at 1:17 p.m., the DON stated the admission process was updated to include additional checks by the unit manager and DON to ensure medications were transcribed accurately. The DON stated the floor nurse was responsible for reconciling the medications with the doctor, then the unit manager would verify the medications were accurately transcribed. The DON stated then she would review the medications again and the medication list would be sent to the pharmacy to be reviewed for accuracy. The DON reported a medication reconciliation competency was completed for every nurse. Record Review of Competency Assessment Reconciliation of Medications on admission forms revealed the competency checklist was completed for 28 nurses on 10/19/2024. In an interview on 12/17/2024 at 9:17 a.m., RN C stated they implemented a new protocol and there were three checks now for the medication reconciliation. RN C stated the floor nurse was the first one responsible for transcribing medications when a resident was admitted . RN C stated then the unit manager would perform the second check, and the DON would perform the third check. RN C stated they had an updated checklist that he received training for and for reconciling medications. In an interview on 12/17/2024 at 9:50 a.m., LVN D stated she received training for medication orders and the admission process. LVN D stated the nurse that completed the admission would reconcile the medications from the hospital discharge paperwork with the physician. LVN D stated the nurse manager and DON would check the medications afterwards. In an interview on 12/17/2024 at 10:15 a.m., LVN E stated discharge orders were reviewed with the doctor and then entered into the EHR. LVN E stated the nurse managers check the medications after the floor nurse, and then the DON checks the medications. LVN E stated she received training for medication reconciliation. In an interview on 12/17/2024 at 10:27 a.m., Unit Manager F stated the floor nurse would review medications with the doctor, and the unit manager would do a second check to ensure all medications were entered. Unit manager F stated the DON would review the medications after the unit manager, and the medications would also be checked again by the pharmacy consultant. Unit Manager F reported she received one-to-one training from the DON concerning the medication reconciliation process. In an interview on 12/17/2024 at 12:53 p.m., RN G stated that when a new admit arrived then the medication orders were verified with the doctor and emailed to the pharmacy consultant. RN G stated then a nurse manager would check the orders, and the DON checked them after the nurse manager. RN G stated she received in-person training for medication reconciliation and completed a checkoff list for medication reconciliation competency. In an interview on 12/17/2024 at 4:03 p.m., LVN A stated she received training for the admission process and the medication reconciliation process. LVN A stated she received one-to-one training from the DON. LVN A stated the nurses would review the medications one by one with the doctor and would complete the admission checklist. LVN A stated the nurse manager checked the medications after the nurse entered them, and then the DON would recheck them.