**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 7 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 09/14/2025 and was located by facility staff approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death. Findings included: Record review of Resident #1's electronic facility face sheet dated 09/17/ 2025, indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis of cognitive communication deficit generalized anxiety disorder, unspecified symptoms and signs involving cognitive functions. Record review of Resident #1's quarterly MDS assessment, dated 08/10/2025 indicated a BIMS score of 06 indicating Resident #1 was severely cognitive impaired. Resident #1 ambulated independently with no mobilities devices needed. MDS indicated Resident #1 had behaviors related to rejecting care that typically occurred 1 to 3 days. Record review of Resident #1's care plan dated 08/22/2025 indicated he had a behavior problem (Delusions) related to impaired thought process and impaired cognition following Cerebrovascular accident (stroke). Interventions: Anticipate and meet the resident's needs and if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. On 09/15/2025 the facility added a new focus to Resident #1 care plan indicating he is an elopement risk/wanderer related to his history of attempting to leave the facility unattended and exit seeking. Interventions: Send to the behavior hospital for evaluation and treat. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Monitor location every (15) min. Record review of Resident #1's Wandering Risk Scale dated 08/04/2025 indicated a score of 4- low risk. Record review of Resident #1's NSG: Additional admission Assessments (Braden, Morse, etc.) dated 08/05/2025 indicated a low wander risk. Record review of Resident #1's Wandering Risk Scale dated 09/15/2025 indicated a score of 15- high risk. Record review of Resident #1 nursing note dated 09/14/2025 at 5:24 p.m. indicated LVN A documented the following: Resident noted to be wandering the grounds of facility behind the building near a field with high grass. This nurse and other staff approached the resident to guide this resident back into the facility, Resident became belligerent and aggressive stating that he does not need to be in the nursing facility. The resident begins waving his arms and not allowing staff to hold his hands to guide him back into the building. This nurse explained to the resident it is very hot outdoors and dangerous temperatures to be wandering away from the facility. Resident did not want to hear what this nurse was saying but finally was able to get resident back in facility. Record review of LVN A nursing note dated 09/14/2025 at 6:30 p.m. indicated the following: Resident #1 was placed on 15-minute monitoring checks from the dates of 09/13/2025-09/14/2025 starting at 6:00 p.m. Record review of the fifteen-minute monitoring sheet indicated Resident #1's monitoring was initiated on 09/13/2025 at 6:00 a.m. by LVN A. - On the time slot for 10:45 a.m. - 11:45 a.m. there was no staff initials on the line to confirm Resident #1 was being monitored.- On the time slot for 6:00 p.m.- 11:45 a.m. there was a line from 6:00 p.m. to 11:45 a.m. stating no issues. - On the time slot for 7:45 p.m. stated no issues. - On the time slot for 11:00 p.m. stated no issues.- The monitoring sheets were dated for: 09/13/2025- 09/18/2025. Record review of Resident #1's witness statement completed on 09/19/2025, by LVN A indicated This nurse went to do 15 min check on Resident #1 at about 4:45 p.m. and noted resident was not in his room. I started looking around the halls and other staff did as well. Once nobody could find the resident in the building, several staff went outdoors to look for resident, I was walking down towards the (redacted) on 9th avenue by the fields. I looked by the ditches and trees; I did not see him. LVN A wrote in her statement that Resident #1 was walking back from the field where the ground was uneven and had tall grass. Once staff was able to get him back onto facility grounds and inside, he stated why am I here and he needs to go. Resident did state he does not need to be here, nor does he need to be evaluated for any behaviors. During an interview on 09/16/2025 at 4:00 p.m., the DON said Resident #1 had aggressive behaviors present on admission. On 09/13/2025 he chased staff, cussed at them, tried to hit them, and was very aggressive with staff. The DON said she initially planned to send Resident #1 to a behavioral hospital on [DATE] but decided to cancel the transfer because his behaviors calmed down some. The DON said she initiated 15-minute monitoring checks for Resident #1. The DON did not give specific instructions to staff on how to monitor, nor what behaviors to look for in Resident #1. The DON did not designate a staff member to monitor Resident #1 but said she expected nurses to complete the checks. Resident #1 eloped from the facility on 09/14/2025 while the 15-minute monitoring checks were still in place. The DON said she didn't know the exact location of Resident #1 but hoped he's in his room. The DON said the facility does not have wander guards or any keycodes on any of the doors inside the facility. The DON said the residents can go in and out of the facility freely. During interview on 09/17/2025 at 10:01 a.m. LVN A said she last laid eyes on Resident #1 09/14/2025 at 4:45 p.m. and did not locate him till 5:08 p.m. on 09/14/2025. LVN A said Resident #1 was off facility property. It had taken a minimum of 3 staff members to get him back into the building due to his cussing and combativeness. During interview on 09/17/2025 at 10:15 a.m. Resident #1 said he went out of an unlocked facility door because he did not want to be there. Resident #1 said if the door was locked, he would not have been able to get out of the facility. Resident #1 said he doesn't want to be at the facility and should not be there. During interview on 09/17/2025 at 10:53 a.m., LVN B said on 09/13/2025 Resident #1 came out of his room yelling at her and began chasing her down the hall and around the nurse's station. The LVN B was unable to say why or what triggered Resident #1's aggressive behavior episode. The LVN B said he balled his fist up and attempted to hit her and then began yelling at other staff at the nurse's station. LVN B said the DON and the Administrator were notified. She said the DON told her and LVN A to start 15-minute monitoring checks on Resident #1. The LVN B said the DON did not designate a staff member to oversee the 15-minute monitoring checks nor what behaviors they should be looking for while Resident #1 was on the 15-minute monitoring checks. During interview on 09/17/2025 at 11:05 a.m., LVN A said she started looking for Resident #1 on 09/14/2025 at 4:45 pm because the 15- minute monitoring check was due and noticed he was not in his room nor in the facility. She said she located Resident #1 off facility grounds near (YMCA- redacted) in an uneven ground field with high grass, and cut trees laid everywhere. During interview on 09/17/2025 at 11:53 a.m., LVN B said Resident #1 would attempt to elope again because he states he should not be here, he did not want to be here and wanted to leave. During interview on 09/17/2025 at 11:58 a.m., LVN A said Resident #1 would attempt to elope again because now he knows the laundry and front door are unlocked and knows how to exit the facility. She said there was no way she can monitor all her assigned residents, give medications, and monitor Resident #1 at the same time. LVN A said when she gave medications on hall 300, she was unable to complete the 15- minute monitor checks on Resident #1 all at the same time. She said she already missed the 12- noon 15-minute monitor check because she was doing medication pass on her second assigned hall (hall-300). LVN A said while she was on her hour lunch break there was not another nurse watching Resident #1. During interview on 09/17/2025 at 12:12 p.m., CNA C said on 09/13/2025 she was not made aware Resident #1 was on 15-mintute monitoring checks. CNA C said she did not see any staff checking on him during her shift on 09/13/2025 from 6 a.m.- 6 p.m. During interview on 09/17/2025 at 12:30 p.m., CNA D said Resident #1 was wandering inside the facility on 09/13/2025. She said once Resident #1 was located by staff he kept saying the city hired him to pick up all the cut down trees in the field. She said she was not made aware Resident #1 was on 15-mintute monitoring checks. During interview on 09/17/2025 at 12:45 p.m., the CNA Supervisor said on 09/13/2025 Resident #1 was very aggressive stating I don't want to f***ing be here. She said Resident #1 had been saying he did not want to be at the facility since admission. She said she reported Resident #1 behaviors to the DON. She said she was not made aware Resident #1 was on 15-mintute monitoring checks. During interview on 09/17/2025 at 2:40 p.m., the DON said Resident #1 was admitted with behaviors and was very confused. The DON said Resident #1's behavior was reported to her on 09/13/2025 approximately 11:30 a.m. The DON said she along with the Administrator made the decision to place Resident #1 on 15-mintue monitor checks. She said the 15-mintue monitor checks were supposed to start approximately at 11:30a.m. She said the corporate nurse agreed to place him on 15-mintue monitor checks. The DON said she expected the nurses to do 15-mintue monitor checks, know where Resident #1 was at, and report to her any changes. The DON said she was responsible for following up on the 15-mintue monitor checks to ensure they are completed accurately. She said a high elopement risk was someone saying they want to leave the facility and start having exit seeking behaviors. She said a low elopement risk was someone wandering around the facility but not exit seeking. The DON said LVN A notified the Physician about Resident #1s behavior on 09/13/2025. The DON was unable to provide documentation of the physician being notified because the nurse did not document her calling. The DON said they do not have an assigned staff member to sit at the receptionist desk. During interview on 09/17/2025 at 4:05 p.m., the Administrator said Resident #1 had no payor source and stated, who's going to pay for a 1:1 sitter? During observation on 09/17/2025 at 11:15 a.m. Resident #1 was in his room sitting on the bed. Resident #1 had no wander guard on. The facility does not have nor use the wander guard system. During an observation on 09/17/2025 at 11:18 a.m. indicated the facility was located on a busy commercial 4 lane road with a speed limit of 45 mph. LVN A walked outside of facility and showed surveyor where Resident #1 was found when he eloped. LVN A showed surveyor location approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. During an observation on 09/17/2025 at 11:20 a.m. LVN B showed surveyor an exit door on hall 200 was not locked and had no keycode or alarming sound on door. She said Resident #1 could also go out of the entrance door of the facility. LVN B said both doors lead to were Resident #1 was located off facility premise. Record review of website www.wunderground.com accessed 09/17/2025 indicated the outside temperature at the time of the elopement 09/14/2025 was approximately 96 degrees.Record review of an Elopement Policy with revision date of March 2019, indicated, Policy: 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 other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:1. Determine if the resident is out on an authorized leave or pass;2. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and3. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall:1. examine the resident for injuries;2. contact the attending physician and report findings and conditions of the resident;3. notify the resident's legal representative (sponsor);4. notify search teams that the resident has been located; 5. complete and file an incident report; and document relevant information in the resident's medical record. The Administrator and DON were notified on 09/17/2025 at 4:10 p.m., that a noncompliance Immediate Jeopardy situation had been identified due to the above failures and were given a copy of the Immediate Jeopardy template and a Plan of Removal (POR) was requested. The facility's POR for the Immediate Jeopardy was accepted on 09/18/2025 at 6:34 a.m. and reflected the following: 1.Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:Action: Resident #1 placed on 1:1 monitoring to be in place until Interdisciplinary team determines that monitoring can be decreased or alternate placement is found in a secure environment. The 1:1 will be 24 hours per day. Resident #1 will be within direct visual observation to ensure safety and immediate response. The person doing the 1:1 monitoring will only have that responsibility. Currently staff are signing up for 2-hour intervals and will not require a meal break. Staff will be required to document the 1:1 on the monitoring form.Person(s) Responsible: Director of Nursing, and/or Designee.Date: By 09/17/2025. Action: Facility audit of all residents to ensure a wander risk assessment was completed within the last quarter. Any resident who has not had a wandering assessment completed will have an updated one completed by 9/17/2025. Person(s) Responsible: Director of Nursing, and/or Designee Date: By 09/17/2025. Action: Ad-Hoc QAPI was conducted on 9/17/2025 with the Medical Director present by telephone. Person(s) Responsible: Administrator and Director of Nursing.Date: 09/17/2025. Action: Referrals to be sent for alternate placement.Person(s) Responsible: Director of Nursing or Assistant Director of Nursing.Date: 09/17/2025. Action: Education provided to the Director of Nursing on 9/17/25 related to interventions when a resident at risk for elopement expresses desires to elope, or an actual elopement occurs. Person(s) Responsible: Regional Nurse.Date: 09/17/2025. Action: Education to be initiated with all staff related to monitoring and safety of residents as well as appropriate steps to take when a resident expresses desire to leave or an actual elopement occurs. This training for all staff will be validated by completion of a post-training test, to be dated and signed by each staff member. Person(s) Responsible: Director of Nursing, and or/ Designee.Date:09/17/2025. Action: Residents requiring 1:1 monitoring or 15-minute checks will be relayed to staff on the daily assignment sheet.Person(s) Responsible: Updated by Nursing Management.Date: 09/17/2025. Action: Staff will be re-educated on the elopement policy and elopement drills will be performed by policy.Date: OngoingPerson(s) Responsible: Director of Nursing, and or/ Designee. Action: Education to be completed with all nursing staff working. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training.Person(s) Responsible: Director of Nursing, and or/ Designee.Date:09/17/2025. Action: Door chimes will be installed on the laundry door and front door to alert staff when someone is coming in or going out. The staff will re-direct any resident that has been deemed at risk for elopement.Date: To be completed by 09/18/2025 at 12:00 p.m. The facility's verification of the POR was as follows: During observation 09/17/2025 at 4:30 p.m. Resident #1 was placed on 1:1 monitoring with assigned staff. Resident #1 had a staff member outside of his room. During observation on 09/18/2025 at 10:00 a.m. door chimes were on the laundry door and front door. Door chimes sounded every time it was opened. Record review on 09/18/2025 of wander risk audit dated 09/17/2025 indicated a facility audit was conducted on all residents ensuring a wander risk assessment had been completed within the last quarter. Record review of the QAPI sign-in roster dated 09/17/2025 indicated an in-person attendance at the meeting from the Administrator, Assistant director of nursing, regional nurse, DON, and attendance by telephone from the Physician. Record review on 09/18/2025 at 10:00 a.m. of the DON training indicated the DON was trained 9/17/2025 on What is Elopement and Wandering and Elopements policy revised date: March 2019 and took a Elopement in Long- Term Care Quiz on 09/17/2025, by the Regional nurse. The Regional nurse educated the DON on the interventions when a resident at risk for elopement expresses desires to elope, or an actual elopement occurs. Record review on 09/18/2025 at 11:15 a.m. of an Employee In- service Record indicated 20 CNAs, 8 nurses (DON & ADON) included), 7 housekeepers, 2 dietary, 2 cooks, 2 admission staff, and 2 transport staff were educated on the elopement binder, residents at high risk for elopement, (interventions when a resident is exit seeking or attempting to elope.) communication of residents that are requiring 1:1 or 15 minute monitoring (will be indicated on the daily assignment sheet.) Record review on 09/18/2025 at 12:10 p.m. of A Mock elopement drill sign-in sheet and elopement drill observer checklist dated 09/18/2025 indicated 7 CNA's, 6 housekeepers, 1 transport staff, 5 nurses (DON & ADON included) 1 admissions staff, Administrator, and the MDS Coordinator participated in a mock elopement drill with Regional nurse, as the drill observer. Record review on 09/18/2025 2:00 p.m. of facility staff schedules dated 09/18/2025 indicated new rotate staff were all educated on the elopement policy, the elopement binder, and which residents are at high risk for elopement. All staff and took a post test on elopement. Record review of elopement assessments completed on 09/18/2025 reflected 75 assessments were completed. In an interview with the Maintenance Director on 09/18/2025 at 2:13 p.m. indicated he had received an in-service regarding elopement and learned how to identify exit seeking behaviors, look for missing residents, and redirecting exit seeking residents. took a post test on elopement. He said he added chimes to the laundry door and front door so everyone would know whose going in and out of the facility. In an interview with the Administrator on 09/18/2025 at 3:00 p.m., he stated he performed an education in-service with all department heads regarding elopement. He said he would follow up with the DON to ensure compliance with their elopement policy. In an interview with the Administrator on 09/18/2025 at 3:30 p.m., he said all residents who had positive elopement screenings had re-evaluations of their care plans. Staff interviews conducted on 09/18/2025 from 12:00 p.m. to 2:30 p.m., representing staff from (6:00 a.m.- 6:00 p.m.) and (6:00 p.m.- 6:00 a.m.) included: Administrator, DON,ADON, LVN A, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, CNA Supervisor, OT #1, PT #1, LVN F, LVN G, LVN H, LVN J, LVN K, LVN L, LVN P, LVN O, Housekeeper AA, Housekeeper BB, Housekeeper CC, Housekeeper DD, Housekeeper EE, Housekeeper Supervisor, [NAME] FF, [NAME] GG, [NAME] HH, [NAME] LL, Dietary aide, Dietary Supervisor, Business Office Manager, Admissions Director, Activities Director, Maintenance Director, Transportation Director. All staff were able to identify what Elopement is, who to report any residents displaying exit seeking behaviors and steps for staff to take to de-escalate resident behaviors. Staff indicated they were to be aware of resident behaviors, monitor for exit seeking behaviors. Staff were able to state elopement risk factors, elopement prevention strategies, required staff response if an elopement occurs, and keys points to remember. All staff were able to identify the responsibilities for supervision and monitoring residents with any exit seeking behaviors. During these interviews, staff stated they had received in-service training about the facility's elopement policies and procedures, including the charge nurse's responsibility and ensure they checked the elopement binder to know who's at risk for elopement. The staff stated they felt confident in identifying exit seeking behaviors. Record review of the 1:1 monitoring document dated 09/17/2025 indicated the documentation was not completed accurately. The 1:1 monitoring document reflected the following:On the time slot for 10:45 a.m. - 11:45 a.m. there was no staff initials on the line to confirm Resident #1 was being monitored.- On the time slot for 6:00 p.m.- 11:45 a.m. there was a line from 6:00 p.m. to 11:45 a.m. stating no issues. - On the time slot for 7:45 p.m. stated no issues. - On the time slot for 11:00 p.m. stated no issues. During an interview on 09/17/2025 at 2:00 p.m. the DON said it was her responsibility to ensure the 1:1 monitoring sheet was being filled out accurately. Resident #1 was transferred to another facility 09/18/2025 at 5:15 p.m. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement.

**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 #2) of four residents reviewed for pharmaceutical services.The facility failed to ensure Resident #2's hospital discharged medication regimen was accurately reviewed and implemented. Resident #2 was readmitted to the hospital with respiratory failure and COPD. The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. 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 #2's PPS MDS assessment dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), COPD (a group of lung diseases that block airflow and make it difficult to breathe). The MDS also indicated a BIMS score of 14 (suggested no cognitive impairment).Record review of Resident #2's baseline care plan dated 02/07/2025 indicated Resident #2 used oxygen continuously due to COPD. Record review of Resident #2's hospital H&P dated 02/04/2025 (prior to facility admission) indicated Resident #2 was admitted to the hospital on [DATE] for complaints of a 2-3-week history of gradual worsening shortness of breath, cough, and wheezing. Resident #2 was hypoxic (an inadequate supply of oxygen o the body's tissues) and was placed on BIPAP (a non-invasive ventilation therapy that uses 2 different levels of air pressure to assist breathing). Record review of Resident #2's hospital Discharge summary dated [DATE] indicated 3 new medications upon discharge: -budesonide 0.5 mg/2 ml (breathing treatment) per nebulizer twice daily;-prednisone 20 mg(anti-inflammatory) by mouth before breakfast; and-levalbuterol HCL 0.63mg/3 ml (breathing treatment) every 6 hours via nebulizer. Additionally, Resident #2 was to continue previous home medications:-omeprazole 20 (reduces stomach acid) mg daily;-Levothyroxine 100 mcg (used to treat underactive thyroid) daily;-Memantine 10 mg (used to treat moderate to severe Alzheimer's) daily;-hydrochlorothiazide 12.5 mg (used to treat high blood pressure and fluid retention) daily;-Magnesium oxide 400 mg (supplement used to regulate muscle and nerve function) daily;-Duloxetine 30 mg (used to treat mood disorders and chronic pain) twice daily;-Ibuprofen 600 mg (anti0inflammatory) twice daily as needed;-losartan 25 mg (for blood pressure) daily; -atorvastatin 40 mg (used to reduce cholesterol levels) every evening; and -tramadol 50 mg (for pain) four times daily. Record review of Resident #2's admission orders and MAR dated 02/07/2025 indicated the facility ordered and administered 11 medications that were not Resident #2's discharge medications with multiple doses to Resident #2 from 02/07/25-02/10/25. Resident #2 was administered the following: *Amiodarone 200 mg 5 doses (blood pressure) -Plavix 75 mg 3 doses (blood thinner), -Eliquis 5 mg 5 doses (blood thinner), -Lexapro 5 mg 3 doses (anti-depressant), -Lasix 40 mg 3 doses (diuretic), -Metolazone 5 mg 3 doses (diuretic), - Gemtesa 75 mg 3 doses (for bladder spasms), -Valsartan 320 mg 3 doses (blood pressure) ,-Levothyroxine 137 mcg 2 doses(for thyroid - receives 100 mcg at home), -Docusate 100 mg 2 doses (stool softener) and,-Melatonin 5 mg 2 doses (helps sleep).Record review of Resident #2's nurses notes written by LVN P indicated Resident #2 experienced shortness of breath and anxiety within 72 hours of admission to facility, resulting in decreasing oxygen saturation levels and Resident #2 being transferred to hospital for evaluation. She was admitted to the hospital on [DATE] with an exacerbation of COPD and anxiety. Record review of a Medication Error form completed by the corporate nurse and dated 02/10/2025 for Resident #2 indicated the following: . Family brought to the facilities attention that the medications that [Resident #2] was receiving at the facility did not match their understanding of what medications the resident should be on. Upon investigation, it was discovered that the 2 pages (pages 33 and 34) of the hospital paperwork containing the discharge medications that the family brought to the facility with the resident had a different resident's name on them. This resulted in [Resident #2] being placed on the wrong medications from 2/7 through 2/10. During an interview on 09/17/2025 at 09:30 a.m., the regional nurse said Resident #2's family member came to the facility and had asked if Resident #2 had been given her breathing treatment over the weekend. The corporate nurse said upon review of Resident #2's medical record, she had noticed the diagnoses, and the medication list did not look right. Upon further reviewing, the corporate nurse said out of the 60+ pages, she found that the medication list provided by the discharging hospital had a different person's medication list and discovered the facility had inadvertently missed and had written the wrong medications for Resident #2. In addition, the 3 new medications upon discharge from hospital had been overlooked and were omitted. She said the staff nurses were in-serviced on medication errors, ensuring correct residents were listed on their discharge papers, verifying correctness of orders, etc. She said they did an audit of all admission within the 30 days prior and there were no new identifiable errors. She said they did QAPI and monitored all new admissions for 3 months with no errors. During a phone interview on 09/19/2025 at 10:45 a.m., Physician H, who was the attending physician for Resident #2's most recent hospital visit, said it was difficult to say if Resident #2 having received the wrong medications would have contributed to her hospital stay. He said it was very important for facilities to provide accurate medication lists when transferring residents to the hospital. During an interview on 09/19/2025 at 10:50 a.m., LVN E reported she completed Resident #2's admission Assessment, but denied transcription of the medication orders that were included in the discharge paperwork from the hospital. LVN E said she had noticed Resident #2 crying at times, and felt it was due to being a new admission to the facility. During a phone interview on 09/19/2025 at 11:00 a.m., NP J said he was employed as Physician K's NP (who was also the facility Medical Director). He said he had not seen Resident #2 while she was in the facility, and he recalled receiving a call from nursing staff saying Resident #2 was having shortness of breath. He said he gave orders to send to ER for evaluation. NP J said in his opinion, Resident #2's shortness of breath could have been contributed to having been administered the wrong medications, and added the error should have been caught on admission. He said he and physician attend monthly QA meetings at facility and he vaguely recalled the entire incident. During an interview on 09/19/2025 at 11:50 a.m., the DON said the admitting nurse was responsible for reconciling the medications with the physician, and the ADON was to ensure the medications were accurately transcribed. The DON said she was not employed at the facility at the time of this incident. She was hired one month later. The DON said the facility had a Standards of Care meeting weekly at which time new admissions, wounds, change in conditions were discussed and acted upon. The DON said this failure could negatively affect the residents as the wrong medications could cause harm, allergic reactions, or adverse reactions. She said her expectations were for nursing staff to make sure the correct resident's names and date of birth were on all paperwork from the hospital or physician offices. During an interview on 09/19/2025 at 12:20 p.m., the regional nurse said the staff had failed to transcribe and administer Resident #2's breathing treatments as prescribed upon discharge from hospital on [DATE]. She said staff failed to verify the names on Resident #2's discharge papers from the hospital. She said the admitting nurse was responsible for transcribing physician orders, and the ADON was responsible to ensure correctness. If a resident was admitted over the weekend, the orders were to be checked on the next workday. During a joint interview on 09/19/2025 at 12:55 p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions. She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician. Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the investigation:-Record review of an Employee In-service Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff. Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

**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 of 19 residents reviewed for significant medication errors. (Resident #2)The facility must ensure that its residents are free of any significant medication errors. Resident #2 received multiple doses of medications that were not prescribed to her to include 2 blood thinners and blood pressure medications. Also, Resident #2 did not receive prescribed breathing treatments and anti-inflammatory medications and was re-hospitalized with COPD.The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. 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 #2's PPS MDS assessment dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), COPD (a group of lung diseases that block airflow and make it difficult to breathe). The MDS also indicated a BIMS score of 14 (suggested no cognitive impairment).Record review of Resident #2's baseline care plan dated 02/07/2025 indicated Resident #2 used oxygen continuously due to COPD.Record review of Resident #2's hospital H&P dated 02/04/2025 (prior to facility admission) indicated Resident #2 was admitted to the hospital on [DATE] for complaints of a 2-3-week history of gradual worsening shortness of breath, cough, and wheezing. Resident #2 was hypoxic (an inadequate supply of oxygen o the body's tissues) and was placed on BIPAP (a non-invasive ventilation therapy that uses 2 different levels of air pressure to assist breathing). Record review of Resident #2's hospital Discharge summary dated [DATE] indicated 3 new medications upon discharge: -budesonide 0.5 mg/2 ml (breathing treatment) per nebulizer twice daily;-prednisone 20 mg(anti-inflammatory) by mouth before breakfast; and-levalbuterol HCL 0.63mg/3 ml (breathing treatment) every 6 hours via nebulizer.Additionally, Resident #2 was to continue previous home medications:-omeprazole 20 (reduces stomach acid) mg daily;-Levothyroxine 100 mcg (used to treat underactive thyroid) daily;-Memantine 10 mg (used to treat moderate to severe Alzheimer's) daily;-hydrochlorothiazide 12.5 mg (used to treat high blood pressure and fluid retention) daily;-Magnesium oxide 400 mg (supplement used to regulate muscle and nerve function) daily;-Duloxetine 30 mg (used to treat mood disorders and chronic pain) twice daily;-Ibuprofen 600 mg (anti0inflammatory) twice daily as needed;-losartan 25 mg (for blood pressure) daily;-atorvastatin 40 mg (used to reduce cholesterol levels) every evening; and-tramadol 50 mg (for pain) four times daily. Record review of Resident #2's admission orders and MAR dated 02/07/2025 indicated the facility ordered and administered 11 medications that were not Resident #2's discharge medications with multiple doses to Resident #2 from 02/07/25-02/10/25. Resident #2 was administered the following: *Amiodarone 200 mg 5 doses (blood pressure) -Plavix 75 mg 3 doses (blood thinner),-Eliquis 5 mg 5 doses (blood thinner),-Lexapro 5 mg 3 doses (anti-depressant),-Lasix 40 mg 3 doses (diuretic), -Metolazone 5 mg 3 doses (diuretic),- Gemtesa 75 mg 3 doses (for bladder spasms),-Valsartan 320 mg 3 doses (blood pressure) ,-Levothyroxine 137 mcg 2 doses(for thyroid - receives 100 mcg at home),-Docusate 100 mg 2 doses (stool softener) and,-Melatonin 5 mg 2 doses (helps sleep).Record review of Resident #2's nurses notes written by LVN P indicated Resident #2 experienced shortness of breath and anxiety within 72 hours of admission to facility, resulting in decreasing oxygen saturation levels and Resident #2 being transferred to hospital for evaluation. She was admitted to the hospital on [DATE] with an exacerbation of COPD and anxiety. Record review of a Medication Error form completed by the corporate nurse and dated 02/10/2025 for Resident #2 indicated the following: . Family brought to the facilities attention that the medications that [Resident #2] was receiving at the facility did not match their understanding of what medications the resident should be on. Upon investigation, it was discovered that the 2 pages (pages 33 and 34) of the hospital paperwork containing the discharge medications that the family brought to the facility with the resident had a different resident's name on them. This resulted in [Resident #2] being placed on the wrong medications from 2/7 through 2/10. During an interview on 09/17/2025 at 09:30 a.m., the regional nurse said Resident #2's family member came to the facility and had asked if Resident #2 had been given her breathing treatment over the weekend. The corporate nurse said upon review of Resident #2's medical record, she had noticed the diagnoses, and the medication list did not look right. Upon further reviewing, the corporate nurse said out of the 60+ pages, she found that the medication list provided by the discharging hospital had a different person's medication list and discovered the facility had inadvertently missed and had written the wrong medications for Resident #2. In addition, the 3 new medications upon discharge from hospital had been overlooked and were omitted. She said the staff nurses were in-serviced on medication errors, ensuring correct residents were listed on their discharge papers, verifying correctness of orders, etc. She said they did an audit of all admission within the 30 days prior and there were no new identifiable errors. She said they did QAPI and monitored all new admissions for 3 months with no errors. During a phone interview on 09/19/2025 at 10:45 a.m., Physician H, who was the attending physician for Resident #2's most recent hospital visit, said it was difficult to say if Resident #2 having received the wrong medications would have contributed to her hospital stay. He said it was very important for facilities to provide accurate medication lists when transferring residents to the hospital.During an interview on 09/19/2025 at 10:50 a.m., LVN E reported she completed Resident #2's admission Assessment, but denied transcription of the medication orders that were included in the discharge paperwork from the hospital. LVN E said she had noticed Resident #2 crying at times, and felt it was due to being a new admission to the facility. During a phone interview on 09/19/2025 at 11:00 a.m., NP J said he was employed as Physician K's NP (who was also the facility Medical Director). He said he had not seen Resident #2 while she was in the facility, and he recalled receiving a call from nursing staff saying Resident #2 was having shortness of breath. He said he gave orders to send to ER for evaluation. NP J said in his opinion, Resident #2's shortness of breath could have been contributed to having been administered the wrong medications, and added the error should have been caught on admission. He said he and physician attend monthly QA meetings at facility and he vaguely recalled the entire incident.During an interview on 09/19/2025 at 11:50 a.m., the DON said the admitting nurse was responsible for reconciling the medications with the physician, and the ADON was to ensure the medications were accurately transcribed. The DON said she was not employed at the facility at the time of this incident. She was hired one month later. The DON said the facility had a Standards of Care meeting weekly at which time new admissions, wounds, change in conditions were discussed and acted upon. The DON said this failure could negatively affect the residents as the wrong medications could cause harm, allergic reactions, or adverse reactions. She said her expectations were for nursing staff to make sure the correct resident's names and date of birth were on all paperwork from the hospital or physician offices.During an interview on 09/19/2025 at 12:20 p.m., the regional nurse said the staff had failed to transcribe and administer Resident #2's breathing treatments as prescribed upon discharge from hospital on [DATE]. She said staff failed to verify the names on Resident #2's discharge papers from the hospital. She said the admitting nurse was responsible for transcribing physician orders, and the ADON was responsible to ensure correctness. If a resident was admitted over the weekend, the orders were to be checked on the next workday. During a joint interview on 09/19/2025 at 12:55 p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions. She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician.Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the investigation:-Record review of an Employee In-service Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff. Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse.The facility failed to ensure Resident #1 was free from resident to resident sexual abuse when Resident #2 touched her vaginal area inappropriately on 08/14/2025 and was witnessed by Resident #3.The noncompliance was identified as PNC. The IJ began on 08/14/2025 and ended on 08/14/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse. Findings include:1. Record review of Resident #1's face sheet, dated 08/16/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), adjustment disorder with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), altered mental status (a disorder that affects a person's ability to think, feel, and behave clearly) and auditory and visual hallucinations (seeing and hearing things that are not there).Record review of Resident #1's annual MDS assessment, dated 06/21/2025, indicated she made herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 4. She required supervision or touching assistance with most activities of daily living.Record review of Resident #1's care plan, dated 06/24/2024 and revised on 08/14/2025, indicated Resident #1 had increased risk for anxiety/acute stress reaction r/t unwanted sexual contact from another resident. She was not having any negative effects from history of anxiety/acute stress. Interventions included to encourage resident to verbalize feelings and provide safe and supportive environment. Social Services to provide counseling and provide emotional support in a private setting.Record review of Resident #1's facility incident report, dated 08/15/2025 at 12:08 p.m., documented in the Resident description section .he (Resident #2) came in here and told me to lie back and when I asked him for what and picked up my teddy bear to put in front of me. He (Resident #2) moved my bear out of the way and put it right the foot of the bed and did like this pushing her shoulder back and put his hand in there and I asked him what are you doing and he said you're going to like it and put his hand in there some more. Nursing description section read in part: .resident noted sitting with her feet dangling over the side of the bed leaning sideways to left towards the foot of her bed using her stuffed animal for support and another resident had his hand in her brief digitally penetrating her. Immediate action taken section read in part: . other resident removed from this resident's room resident educated on resident to resident incidents and was ensured of safety, head to toe assessment as well as pain assessment complete no abnormalities noted social worker, psych-counselor, NP and RP notified. Resident #1 was assessed, and no injuries were noted.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:13 p.m., indicated social services was notified of an alleged incident of non-consensual sexual contact between Resident #1 and Resident #2. Upon interview, Resident #1 stated she was seated on her bed when fellow Resident #2, alleged perpetrator, entered her room sat beside her and placed his hands inside her brief despite her telling him to stop. She denied any vaginal penetration and expressed that she did not consent to the contact she reported feeling upset and surprised as she previously considered him Resident #2 a friend. Social services provided emotional support validated Resident #1's feelings and assured her that steps were being taken to ensure her safety. Resident #1 was informed that Resident #2 would be relocated and instructed her to notify staff immediately if he approaches her. Resident #1 verbalized understanding and agreed to report any further concerns. Social services coordinated with nursing, administration and the investigation team to ensure separation of residents. Witnesses' interviews, completion of body skin assessment and initiation of the formal investigation. Ongoing emotional support and monitoring will be provided.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:40 p.m., indicated Resident #1 carries a diagnosis of dementia which impacts her judgement, impulse control and reliability of self-reported information due to her cognitive impairment, statements made by Resident #1 cannot be considered fully reliable without corroborating information. Social services will continue to monitor Resident #1 for safety, provide redirection as needed and collaborate with nursing and the interdisciplinary team to address ongoing behavioral concerns.Record review of Resident #1's social services notes, dated 08/15/2025 at 10:02 a.m., indicated social services met with Resident #1 to review and have her sign the grievance filed regarding the incident with another resident on 8/14/2025. The grievance and actions taken were explained to her and she expressed that she was pleased with how the matter was addressed Resident #1 was observed to be in good spirits when asked about her well-being following the incident she stated that she was fine. Upon inquiry regarding her relationship with Resident #2, Resident #1 denied being in a relationship she indicated that he had been pursuing her, but she reiterated she denies any desires only friendship. She stated one time before, me and the lady up the road went downstairs and when we came back he was laying in the other bed in my room. This statement demonstrates cognitive impairment as there is no downstairs or lady up the road and she has never had passes outside the facility. Resident #1 was engaged in conversation, understood the discussion regarding the grievance and continued to demonstrate cooperative and appropriate behavior throughout the interaction. Plan continue to monitor interactions with other residents, provide ongoing emotional support and education regarding boundaries and appropriate sexual behavior as needed.2. Record review of Resident #2's face sheet, dated 08/16/2025, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included insomnia due to mental disorder (inability to fall asleep), adjustment disorder with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder with severe psychotic symptoms (a severe form of depression where a person experiences symptoms of psychosis, such as hallucinations or delusions, often reflecting depressive themes of worthlessness or guilt). discharge date [DATE] at 6:34 p.m. to psychiatric hospital.Record review of Resident #2's quarterly MDS assessment, dated 05/06/2025, indicated he made himself understood and understood others. He had severe cognitive impairment, identified with a BIMS score of 06. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of Resident #2's care plan, dated 08/14/2025, indicated Resident #2 had potential sexually inappropriate with a resident related to impaired judgement. Intervention was admission to behavioral hospital for evaluation and admission. Place on 1:1 care until transported to behavioral hospital.Record review of Resident #2's facility incident report, dated 08/14/2025 at 12:08 p.m., the Resident description section read in part .when asked Resident #2 about the incident resident stated we are both grown adults, so it is not abnormal for two grown adults to enjoy these types of things, we were both enjoying it. Nursing description section read in part: Resident #2 noted in his wheelchair in another resident's room at her (Resident #1) bedside with his hands in her (Resident #1) brief digitally penetrating the resident (Resident #1). Immediate action taken section read in part: . Resident #2 removed from resident's (Resident #1) room and educated on resident-to-resident incidents, head to toe assessment as well as pain assessment completed no abnormal abnormalities noted. Social worker and psychology counselor made aware nurse practitioner and RP notified. Local Police Department notified 8/14/2025 at 1:23 p.m.Record review of Resident #2's progress notes, dated 08/14/2025 at 12:33 p.m., ( authored by LVN A) indicated Resident was in a female room resident (Resident #2) was sitting in his wheelchair with his fingers inside of the female (Resident #1) vagina going in and out of her vagina with his fingers another resident (Resident #3) was coming down the hall to see what the resident was doing and he called the staff to come down there. This nurse entered the room the female resident (Resident #1) was lying on the bed and the male resident (Resident #2) had his fingers in her vagina I told the resident (Resident #2) he can't be doing that he stated I don't see why not it's nothing wrong with that. This nurse escorted the resident (Resident #2) out the room this nurse and ADON and CNA interviewed the female resident (Resident #1) to ask her did she give the resident (Resident #2) permission to do that to her, she stated no she wanted him (Resident #2) to stop she (Resident #1) asked him (Resident #2) twice to stop and he (Resident #2) kept going and told her, she was going to like it. Notified DON, social worker, administrator and RP. Record review of Resident #2's progress note, dated 08/14/2025 at 12:36 p.m. and authored by ADON, indicated NP made aware of incident and gave the ok to send resident (Resident #2) out to the behavioral hospital.Record review of Resident #2's social services note, dated 08/14/2025, indicated interview investigation completed by social services Resident #2 acknowledged physical contact occurred describing it as consensual and mutually enjoyable. He (Resident #2) stated Resident #1 laid her head back and appeared to enjoy it and denied being told to stop he (Resident #2) expressed that if she (Resident #1) had told him to stop he would have done so immediately. Social services notes Resident #2 demonstrates lapses in memory which may impact the accuracy and consistency of his statements due to these cognitive limitations self-reported information should be interpreted with caution and corroborated with additional sources when possible. Social services will continue to monitor cognitive status collaborate with nursing and therapy staff and provide supportive interventions as appropriate.Record review of Resident #2's progress note, dated 08/14/2025 at 3:35 p.m. and authored by DON, indicated Resident #2 currently isolated on one to one sitting until behavior hospital is here to transport.3. Record review of Resident #3's face sheet, dated 08/16/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #3 had diagnoses which included insomnia (inability to fall asleep), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder (a severe form of depression where a person experiences symptoms of reflecting depressive themes of worthlessness or guilt).Record review of Resident #3's quarterly MDS assessment, dated 07/17/2025, indicated he made himself understood and understood others. He had no cognitive impairment, identified with a BIMS score of 15. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of the facility's PIR (Provider Investigation Report), report to HHSC, dated 08/14/2025, incident category as abuse, Resident #2 with his hand touching Resident #1 in her brief, confirmed and signed by the Administrator. PIR indicated the incident occurred on 08/14/2025 at 12:08 p.m. in Resident #1 room.During an interview on 08/15/2025 at 2:00 p.m. with Resident #3 said he was the one who reported and saw what had happened to Resident #1. Resident #3 said he was rolling down the hall in his wheelchair around noon yesterday (08/14/2025) headed to the dining room for lunch. Resident #3 said he was looking from side to side both ways in rooms and when he got to Resident #1's room he saw Resident #2 pushing his fingers, going in and out of Resident #1's vagina area. Resident #3 said Resident #1 had no underwear on and Resident #2 was holding one leg of Resident #1 with his right hand and using his left hand going in and out of Resident #1's vagina. Resident #3 said he was angry because that could have been his mom or his grandmother. Resident #3 said he started yelling help help stop. Resident #3 said it looked like Resident #1 couldn't move and thought Resident #1 was saying no. Resident #3 said Resident #2 had a smile on his face that looked like an evil laugh. Resident #3 said LVN A arrived, got resident #2 by the wheelchair and took him completely off the hall. Resident #3 said he didn't know what happened after that, but he thought Resident #2 went to a behavior hospital because he hadn't seen him again since then. Resident #3 said Resident #2 usually sat out on the front porch and fed the birds. Resident #3 said he had no concerns of anyone harming him and if someone were too, he'd report it to the Administrator.During an observation and interview on 08/15/2025 at 2:00 p.m., Resident #1 she was sitting on the edge of her bed and said, it all went crazy as far as she was concerned, and she was ok with it. Resident #1 said Resident #2 tried but didn't get into her pants because her dad was a police officer and she knew how to handle men like that. Resident #1 said when Resident #2 stopped touching her vagina she asked him to start again because she did not want him to hurt that young girl. Resident #1 said the young girl was around the age of 12-[AGE] years old. She said Resident #2 only wanted to touch my body because it was so soft and so good. She said she was pregnant and did not want to mess her body up, so she just let Resident #2 touch her legs. Resident #1 stated she felt safe living at the facility and Resident #2 was a friend who was not dangerous. Resident #1 said if she was in danger or hurt she would report it to the office. Resident #1 said there were no witnesses to the incident because no one was on the porch.During an interview on 08/15/2025 at 09:30 a.m., the Administrator said he was the abuse coordinator and was responsible for investigating the incident that occurred yesterday (08/14/2025) between Resident #1 and Resident #2. The Administrator said Resident #2 was not in the facility and was sent to a behavioral hospital the same day of the incident. The Administrator said Residents #1 and #2 were not a couple or in a romantic relationship. The Administrator said Resident #2 liked to go outside and feed the birds and was often seen alone. The Administrator said Resident #3 witnessed the incident and alerted nursing staff and nursing staff immediately separated the two residents. Resident #2 was immediately taken to another hall for 1:1 and interviewed and cleaned up. The Administrator said Resident #2 was seen with his fingers inside of Resident #1's vagina by LVN A and CNA B. The Administrator said when Resident #1 was initially interviewed right after the incident she said she told Resident #2 no, and Resident #2 said Resident #1 did not tell him no or to stop so he thought she was enjoying it. The Administrator said the incident had been reported to the police and they had taken written statements from Residents #1, #2, #3 and LVN A, CNA B and ADON. The Administrator said he started the investigation and reported it to HHSC.During an interview on 08/15/2025 at 5:10 p.m., CNA B said she was also the CNA Supervisor which was like a lead CNA. CNA B said around 12 noon, on 8/14/2025, she was in the dining room passing trays and heard Resident #3 yelling for help. CNA B said when she got to Resident #1's room she saw Resident #1 lying on the bed with her head to the foot of the bed, legs opened and Resident #2 was in his wheelchair between Resident # 1's legs, his right hand on his wheelchair arm, his left hand was twisting inside of Resident #1's vagina. CNA B said Resident #1 looked scared, holding her teddy bear on her chest. CNA B said Resident #1 said she didn't want Resident #2 there. CNA B said this was her first time seeing Resident #2 do something like this and she had never seen Resident #2 naked but he liked to sleep naked. CNA B said she was shocked, Resident #2 was not perverted. CNA B said she saw Residents #1 and #2 talking before in the front foyer, but nothing sexual or romantic with each other or with any other female. CNA B said Resident #2 said he just wanted to make Resident #1 feel good because he knew he would feel good. CNA B said Resident #2 said Resident #1 didn't say he couldn't do it. CNA B said she didn't think Resident #2 knew Resident #1 was confused. CNA B said she and LVN A were the first to show up and that LVN A told Resident #2 to stop and he stopped. LVN A took Resident #2 out of Resident #1's room. CNA B said she really thought Resident #2 didn't think he was doing anything wrong; he was not confused and had his right mind. CNA B said she thought Resident #2 didn't know Resident #1 didn't want him to touch her vaginal area. CNA B said CNA C sat with Resident #2 until CNA D arrived to relieve him. CNA B said after LVN A removed Resident #2 from the room and interviewed Resident #1, she continued with her assignments she didn't know what happened after that. CNA B said she was in-serviced on abuse and neglect and on how to recognize consensual versus non-consensual touching and to report immediately to the Administrator who was the abuse coordinator.During an interview on 08/15/2025 at 5:10 p.m., CNA C said he worked the 2p-10p shift and sat 1:1 with Resident #2 from 2:30 p.m. to about 3:30 p.m. when CNA D arrived and took over the 1:1 until Resident #2 left the building. CNA C said Resident #2 was agitated because he couldn't go back to his hall. CNA C said he and Resident #2 were on hall 100. CNA C said he never worked with Resident #2 before, and Resident #2 kept saying I didn't do anything wrong. CNA C said Resident #2 said he felt like he was being prosecuted because he couldn't go to his room. CNA C said Resident #2 was usually quiet and not get into arguments. CNA C said CNA A instructed him to do 1:1 because of the incident and they were keeping Residents' #1 and #2 separated. CNA C said he washed the resident's hands. CNA C said he did not see the female resident. CNA C said he did not do any documentation because he only had him for an hour to 45 minutes and the Resident didn't go anywhere or do anything. CNA C said he was trained on abuse and neglect, to report immediately to the abuse coordinator who was the Administrator and how to identify signs and symptoms of inappropriate sexual behaviors such as crying, saying no or moving away and what it looks like when someone is consenting versus not consenting to sexual activity such as kissing back or touching back. CNA C said he would report all sexual behavior inappropriate and consenting and non-consenting to the DON and Administrator.During an interview on 08/15/2025 at 5:50 p.m., CNA D said she got to the facility about 3:00 p.m., because CNA B called and asked if she could sit 1:1 with Resident #2. CNA D said when she got to the facility around 3:00 p.m. CNA B told her it was for allegations of inappropriate behavior with Resident #2. CNA D said she didn't document anything because she stayed with Resident #2 the whole time on hall 100 because the residents were to be kept apart until he was transferred to a behavior hospital. CNA D said Resident #2 would say I did not do anything wrong. CNA D said she provided care for Resident #2 before, and she never saw him make any sexual advances towards Resident #1 or towards any other female resident. CNA D said she didn't think they were a couple because she never saw them together and Resident #1 needed constant redirection to where her room was because she had some confusion. CNA D said Resident #2 had very good understanding, but had said he and Resident #1 were in a relationship for a couple of months and in his mind he thought they were in a relationship. CNA D said she didn't think Resident #2 was a danger to anyone else. CNA D said she was in-serviced on and verbalized knowledge of abuse and neglect, resident to resident abuse, sexual encounters and how to recognize consensual and non-consensual sexual advances. CNA D said Resident #2 didn't understand why he had to leave but she overheard the Social Worker explaining to Resident #2 about it being protocol and precautions for both the resident's safety.During an interview on 08/16/2025 at 10:00 a.m., LVN A said Resident #3 alerted him to come to Resident #1's room and when she got to Resident #1's door, it was wide open, and she could see Resident #2 was in his wheelchair in front of Resident #1 who was lying in bed holding her teddy bear tight on her chest. LVN A said Resident #2 had his left hand, three fingers inside Resident #1's vagina moving in a back, forth and circle motion. LVN A said she could see the vaginal hair on Resident #1. LVN A said Resident #1 was lying there doing nothing with a blank stare on her face and it didn't look like Resident #1 was enjoying it. LVN A said Resident #2 looked like he enjoyed it because he had a smile on his face. LVN A said she separated the residents, escorted Resident #2 out of the room to get to safety and to get interviews. LVN A said Resident #2 told her as she was pushing him down to 100 hall, that they both were enjoying it. LVN C said she took Resident #2 to hall 100 to be on 1:1 with CNA C who was also a male. LVN C said she went back to Resident #1's room to assess and interview her with the ADON and CNA B. LVN A said she completed the assessment on Resident #1 and there was no bruising, no blood and no complaints of pain. LVN A said she assessed Resident #1 vaginal area and there was no blood or discharge, no bruising and no open areas. LVN A said Resident #1 said she told Resident #2 to stop twice. LVN A said Resident #2 was more alert than Resident #1. LVN A said she called both the residents RP and left a message for them to call back and notified the DON and the Administrator. LVN A said she was in-service on and was knowledgeable of abuse and neglect, abuse coordinator is the administrator, immediately report abuse and neglect, signs and symptoms on how to identify inappropriate sexual behaviors, how to redirect and residents' rights as it related to consensual and non-consensual sex or intimacy. LVN A said the Police were called and she was interviewed along with ADON, CNA B and the two residents involved.During an interview on 08/16/2025 at 4:08 p.m., the ADON said she was in the conference room and CNA B came and got her. The ADON said she did not see the actual act, but she was headed to the room. She said she saw LVN A was taking Resident #2 out of Resident #1's room by the wheelchair and Resident #2 was asking what's wrong saying he didn't do nothing wrong; we were two consenting adults. The ADON said Residents #1 and #2 were immediately separated. Resident #2 was taken to hall 100 to do 1:1 and she interviewed Resident #1 along with LVN A and CNA B. The ADON said when she saw Resident #1, she did not seem afraid and was not crying and said she did not give consent, he (Resident #2) came into her room and told her to lay back. The ADON said Resident #1 said she grabbed her baby which was a bear and put it on her lap and then he (Resident #2) asked her (Resident #1) to lay back again, and Resident #2 started touching her vaginal area. The ADON said Resident #1 said she wasn't OK with that, when Resident #2 first started touching her vaginal area and she didn't enjoy it at first but then later she said she did start to enjoy it. The ADON said Resident #1 also told her they were friends, and she was not OK at first with him digging in her brief. The ADON she said she interviewed Resident #2 within 10 minutes of the incident. She said Resident #2 told her Resident #1 was fine with him touching her vaginal area and Resident #1 didn't tell him to stop, he didn't ask her if he could touch her, they were two consenting adults, Resident #1 didn't stop me, he figured it was OK because she never told him no and Resident #2 said Resident #1 was his friend. The ADON said the assessment of the resident, the female resident, was done by LVN A and CNA B washed Resident #2's hands. The 1:1 sitter said Resident #1 said she wasn't hurt and didn't want to go to the hospital. They called the RP and at first they had to leave a message but then he showed up the next day and he was notified and didn't want to send Resident #1 to the hospital. The ADON said she called the doctor, and new orders were to send Resident #2 to the behavior hospital. The ADON said the Police were called and she was interviewed along with LVN A, CNA B and the two Residents involved. The facility implemented the following interventions prior to the state surveyors entrance:Interviews conducted on 08/16/2025 from 3:30 p.m. through 08/16/2025 at 5:30 p.m., with the following staff through various shifts (6a-6p, 6p-6a, 6a-2p, 2p-10p, and 10p-6a) the DON, the ADON, LVN A, CNA B, Dietary O, CNA C, CNA D, Admissions, BOM, HR, CNA E, Dietary F, CNA G, CNA H, laundry I, CNA J, Rehab K, CNA L, LVN M, Dietary N, Dietary P, LVN Q, CNA R, LVN S, CNA T, Laundry U, LVN V, CNA W, LVN Y, CNA Z, Rehab AA, LVN X, CNA BB, LVN CC, CNA DD, Housekeeper EE, CS FF, Housekeeper GG, and LVN HH the staff said they were trained on abuse/neglect, abuse reporting, resident rights on hire and at least annually. The staff said they were retrained following the incidents that occurred on 08/14/2025. They were able to voice what to do first such as separate the residents and get help as needed. They said they would report to the Administrator who was the abuse coordinator. They were able to identify different types of abuse (examples of verbal, sexual and physical). Staff said they were trained to be alert to intimate acts between residents and to report to the nurse or management immediately. Staff understood residents had rights to sexual expression if it was consensual and identify those with capacity to consent and to report all acts of sexual expressions to nursing management for review for safety of both residents.Record review indicated on 08/14/2025, the DON held an in-service on the following with 54 employees in attendance:-resident rights,-abuse, neglect, and abuse reporting, -alert to intimate acts between residents, - resident safety and both residents able to give consent, recognizing concerns and,-identifying sexual abuse and capacity to consent.Attendees included 15 licensed nurses, 18 CNAs, 3 rehabilitation staff, 7 dietary staff, 4 housekeepers, 1 SW, 1 laundry, and 5 office personnel.The noncompliance was identified as PNC. The IJ began on 08/14/2025 at 12:08 p.m. and ended on 08/14/2025 at 6:34 p.m. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders dated 04/08/24 and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented to include her Rivaroxaban (Xarelto-used to prevent blood clots). Resident #1 was not administered Rivaroxaban (Xarelto) for 38 days. Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24, 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's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of naïve coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat). Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants. Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. Handwriting on this list by an unidentified staff indicated there was no documentation on the Discharge Home Medication List of the medication clarification. Record review of text message dated 04/11/24 at 11:42 a.m. sent by LVN E to NP A included Resident #1's Discharge Home Medication List indicated Resident #1's Discharge Home Medication List needed clarification of frequency. NP A texted back (time not visible) and responded she would be there in a bit. Record review of Resident #1's medication order summary dated 04/08/24 was reconciled on 04/11/24 without Xarelto by MD B. Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued. Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24. Record review of Resident #1's physician progress notes dated 04/10/24 at 8:15 a.m., completed by NP E indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/11/24 5:30 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/16/24 at 2:05 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/17/24 at 10:00 a.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto Record review of Resident #1's physician progress notes dated 04/18/24 at 4:09 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/23/24 9:15 a.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/25/24 4:04 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/30/24 at 3:54 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation. Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested. Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg related to atherosclerotic heart disease of native coronary with unspecified angina pectoris. Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related to coffee ground emesis (vomit that looks like coffee grounds)). The DON and MD were notified. RP was at bedside. Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs have become mottled and cool. She was diagnosed with Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24. Record review of Resident #1's hospice records dated 05/23/24 indicated resident passed away on 05/23/24 of heart failure. During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on [DATE]. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto. She said the hospital records were uploaded in Resident #1's EHR on 04/08/24 and available for the MD or NP to review. During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness and discoloration to her right foot . She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on [DATE] due to vomiting. During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. During an interview on 06/14/24 at 10:18 a.m., the DON said she was unable to locate the 24 hour reports and subsequent reviews of Resident #1's admission and medications. During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA and cardiologist appointment. She said NP A never wrote orders for the Eliquis or ASA or cardiologist follow-up. During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism (blood clot in the lung that creates a blockage) or a blood clot due to DVT. During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes. He said he was trained to document communication with the MD or NP in the progress notes. LVN C was no longer employed with the facility and was not available for an interview. Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. Record review of the facility's Medication Reconciliation Policy dated 2001 (revised 2017) indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: 1. Discharge summary from referring facility; 2. admission order sheet; 3. All prescription and supplement information obtained from the resident/family during the medication history; and 4. Most recent medication administration record (MAR), if this is a readmission. 2. Find a quiet place that is free from distractions. General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 1. If a medication history has not been obtained from the resident or family, complete this first. Information from the medication history should include: 1. Prescription medications, including those taken only as needed; 2. Non-prescription/over-the-counter medications, including those taken only as needed; 3. Herbal or dietary supplements, including vitamins and minerals; 4. Patches, eye drops, creams, inhalers, shots, sample medications; 5. Dose, route, frequency and last dose taken for all items; and 6. Reason(s) for taking each medication/supplement. 2. Ask the resident to list all physicians and pharmacies from which he or she has obtained medications. 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. For example: 1. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 2. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or 3. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: 1. Contact the nurse from the referring facility; 2. Contact the physician from the referring facility; 3. Discuss with the resident or family; 4. Contact the resident's primary physician in the community; 5. Contact the resident's secondary physician(s) in the community; 6. Contact the community pharmacy used by the resident; or 7. Contact the admitting and/or Attending Physician. 7. Document findings and actions (see Documentation below). 8. When a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented. Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. 3. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. 4. If the discrepancy was resolved, document how the discrepancy was resolved. This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m. The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following: Resident #1 was discharged to the hospital on 5/17/24 and no longer resides in the facility. A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. Facility will implement system changes requiring the admitting nurse to put in a progress note indicating that they have reviewed the admission orders with the MD. Facility will implement a system requiring the primary care physicians to put in a progress note indicating that they have reviewed and reconciled hospital discharge orders with admission orders within 72 hours of admission. PCP's will be made aware of the new system today on 6/14/2024. The DON/Administrator and, or designee will notify all facility PCPs of the new system. If the physician cannot reconcile the orders then the patient will be sent out to the hospital. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director. All other licensed staff will be in-serviced prior to working next shift. Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director. *Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 06/16/24, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the EHR. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly. Record review of the resident census dated 06/16/24 indicated there was no new admissions to the facility. Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m., included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m.-6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the MD or NP and then documented in the progress notes. During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. An IJ was identified on 06/14/24. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., 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's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on [DATE] and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., 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's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving their medications as ordered, illness, hospitalizations, exacerbation of their disease processes, and death. Findings included: Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of naïve coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat). Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants. Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. An unidentified staff indicated the order needed clarification. There was no documentation on the Discharge Home Medication List of the medication clarification. Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued. Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24. Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation. Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested. Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg. related to atherosclerotic heart disease of native coronary with unspecified angina pectoris. Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related coffee ground emesis (vomit). The DON and MD were notified. RP was at bedside. Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs had become mottled and cool. She was diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24. Record review of Resident #1's hospice records dated 05/23/24 indicated passed away on 05/23/24 of heart failure. During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on [DATE]. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto. During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness. She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on [DATE] due to vomiting. During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA. She said NP A never wrote orders for the Eliquis or ASA or Xarelto. During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism or a blood clot due to DVT. During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes. LVN C was no longer employed with the facility and was not available for an interview. Record review of the facility's Medication Therapy policy dated 2001 (revised 2007) indicated 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. 3. All medication orders will be supported by appropriate care processes and practices. Policy Interpretation and Implementation 1. The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident. 2. All decisions related to medications shall include appropriate elements of the care process, such as: a. Adequately detailed assessment; b. Review of causes of symptoms; c. Consideration of the clinical relevance of symptoms and abnormal diagnostic test results; d. Principles of prescribing for the elderly; and e. Each resident's wishes, values, goals, condition, and prognosis. Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m. The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following: Resident #1 was discharged to the hospital on 5/17 24 and no longer resides in the facility. A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director - All other licensed staff will be in-serviced prior to working next shift. Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director. *Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 06/16/24, the surveyor confirmed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the HER. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly. Record review of the resident census dated 06/16/24 indicated here were no new admissions to the facility. Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m. and included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m. to 6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the practitioner and documented in the progress notes. During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. On 06/16/24 at 1:20 p.m., the Administrator was informed the IJ was removed; however, 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'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 immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); for 1 of 4 residents reviewed for notification. (Resident #1) The facility failed to consult with Resident #1's physician, when Resident #1's HIV (a virus that attacks the human immune system) medication Triumeq (a medication used to treat HIV; discontinuation or interruption of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and/or clinical progression) was not available for administration in August 2023 for 11 doses and September 2023 for 3 doses. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of a pattern due the facility's nned to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and could cause, or likely continue to cause, harm, impairment, or death. Findings included : Record review of physician's orders dated 10/02/23 indicated Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE]. Her diagnoses included HIV, diabetes (a disease in which the body's ability to produce or respond to the insulin hormone is impaired resulting in abnormal metabolism) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). The orders indicated the resident was to receive Triumeq (antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body) 600-50-300 mg one tablet every day for antiviral. Record review of the quarterly MDS dated [DATE] indicated Resident #1 was usually able to make herself understood, usually understood others, had moderately impaired cognitive skills and required supervision and set up for transfers and ambulation. She utilized a walker for mobility and had no impairment to upper and lower extremities. Record review of the care plan dated 08/21/23 indicated Resident #1 was at risk for infections related to HIV. The goal indicated the resident would not display any complications related to immunodeficiency. Interventions included to administer medications as ordered and monitor/document and report signs and symptoms. Record review of the August 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 08/04/23 the date was coded a 6 and indicated the resident was in the hospital documented by the DON, *on the following dates there was a code 9 on the date indicating other see progress note: 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/10:23 documented by agency staff, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A,08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A. *on 08/22/23, the date was coded a 6 and indicated the resident was in the hospital. Record review of the September 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 09/23/23 the date was coded a 1 and indicated the resident was absent from home without meds *on 9/24/23 the date was coded a 3 and indicated the resident was absent from home with meds *on 09/25/23, 9/26/23 documented by LVN E the date was coded a 9 and on 9/28/23 the date was coded a 9 documented by LVN B and indicated other see progress note Record review of the nurses' progress notes for Resident #1 indicated the following: *on 08/04/23 the resident was at the hospital. Resident #1 returned from hospital with a new antibiotic for pneumonia, *on 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A, 08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A the Triumeq was on order, *on 08/10/23 signed by LVN D, the documentation for Triumeq did not indicate the medication was not administered, *on 08/22/23, the documentation indicated the resident was in the hospital. *on 09/01/23, documentation indicated the resident was readmitted from the LTAC hospital. *on 09/22/23 to 09/24/23, the resident was out of the facility with family *on 09/25/23 documented by LVN E, 09/26/23 documented by LVN E and 09/28/23 documented by LVN B, the documentation indicated the medication was not available. There was no documentation on the nurses' progress notes to indicate the physician was notified the Triumeq medication was not available or not administered. Record review of a LTAC hospital Interdisciplinary Notes for Resident #1 dated 08/23/23 indicated, History of Present Illness: The patient is an [AGE] year-old female who resides at a nursing home, who presented to the emergency room on [DATE] and was found to have urinary tract infection and pneumonia. She was prescribed Lovenox (a medication used to thin the blood) and Rocephin (an antibiotic to treat infection) and sent back to the nursing home, where she continued to have functional decline. The patient has had increased weakness and falls since her emergency room visit. The patient was transferred to LTAC on 08/21/2023 for continuation of antibiotic medical management of above symptoms and strengthening. The patient is currently not able to participate in activities of daily living and mobility as she was prior to her emergency room visit. A consult was performed by Physical Medicine and Rehabilitation physician, who determined the patient was suffering from exacerbation of her Parkinson's disease. The patient wants to come to acute inpatient rehabilitation for aggressive physical and occupational therapy. medication. An order dated 8/24/23 indicated Resident #1's Triumeq medication was ordered for administration. The order indicated the resident could use own home supply. There was no documentation to indicate the resident did not have the Triumeq available upon admission to the LTAC. During interview on 09/30 23 at 8:45 a.m., the DON said Resident #1 had gone out to the hospital on 08/0423 and returned the same day a diagnosis of pneumonia. She said when the resident returned, she was placed on skilled services. The Triumeq medication was a high-cost medication and was not covered on the insurance once the resident became skilled. She said as soon as the facility received the request for approval by the administrator, the approval was signed, faxed back and the resident received the medication. She said she was unaware the resident missed any doses of the Triumeq. During an observation, interview and record review on 09/30/23 at 12:51 a.m., LVN A said she was the nurse who worked Hall 300, where Resident #1 resided. During a record review of Resident #1's August 2023 MAR with LVN A, she said Resident #1 was out of her Triumeq medication on 08/08/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23 08/15/23, 08/18/23, 08/19/23, 08/20/23 and 08/21/23 where she documented the code 9. She said the resident had gone to the hospital on 8/4/23 but returned the same day and was diagnosed with pneumonia. She said the resident was weak because of the diagnoses of pneumonia and did continue to get weaker and was sent out to the LTAC for rehabilitation services on 08/22/23. She said it was her responsibility to administer the medications on Hall 300. She said she should have notified the DON and the physician when the Triumeq medication was not available. She said she did not know why she did not notify them, but she did not. She said she remembered Resident #1 was out of the Triumeq but did not remember notifying the pharmacy it was out. Observation of the bottle of Resident #1's Triumeq 30 count in the medication cart indicated the bottle was ¾ full of medication. The bottle was dated 9/28/23. LVN A said it had been refilled on 9/28/23 and only a few pills had been administered out of the bottle. She said she should have notified the pharmacy when there were approximately 10 tablets left. LVN A said the possible negative outcome of not notifying the physician would be the resident's condition could worsen and the physician would not know the resident had missed her medication. During an interview on 9/30 23 at 1:20 p.m., the DON said she was unaware Resident #1 did not have the Triumeq medication for 11 days during August 2023. She said the Triumeq was to treat her diagnosis of HIV. She said she and the physician should have been notified the medication was not available. She said she and the physician required notification, so interventions could be put in place to have the medication available for administration to the resident. She denied the resident could suffer increased symptoms by not having the medication available and said the medication was to keep the resident's HIV undetectable. During an interview on 09/30/23 at 1:52 p.m., LVN B said she started orientation on Hall 300 on 09/27/23 last week. She said Resident #1's Triumeq was not available on Wednesday 09/27/23 and Thursday 9/28/23. She said she was in training and did medication pass with LVN C. She said she watched LVN C pass medications on Wednesday 09/27/23 and passed the medications herself on Thursday 09/28/23. She said LVN C told her the Triumeq was a medication that required approval from the administrator and it was not available. LVN B said if a medication was not available the physician should be notified. She said she did not notify the physician the medication was not available because she was in training and LVN B had faxed the pharmacy. She said the medication was for Resident #1's HIV. She said the possible negative outcome of not notifying the physician could be the physician would not be aware the resident did not receive the medication and the resident's HIV symptoms could exacerbate. During a confidential interview on 9/30/23 at 2:04 p.m., an individual said the facility did not have Resident #1's Triumeq medication available when the resident went out on pass 9/22/23 to 09/24/23. The individual said the ADON was notified the resident did not have her medication. During an interview on 09/30/23 at 2:22 p.m., the ADON said she was unaware Resident #1 did not have the Triumeq medication with her when she went out on pass 09/22/23 to 09/24/23. She denied staff had informed her the resident's medication was not available. She said Resident #1 should not miss a dose of the Triumeq medication and she was unaware that she did. She said staff should have called the pharmacy if the medication was not available. She said herself, the DON and the physician should be notified. During an interview on 09/30/23 at 2:34 p.m., an attempt was made to call LVN D, who documented a code 9 on the August 2023 MAR on 08/10/23, with no answer and the mailbox was full; unable to leave message for call back. During an interview on 09/30/23 at 2:48 p.m., the DON said she was unaware Resident #1 had not received the Triumeq until 09/28/23, when the administrator approved the medication for the pharmacy to refill it and he sent the approval to her, and she ordered the medication stat. She denied knowing the resident also did not have the medication in August 2023. She said she was unaware and did not notify the physician. During an interview and record review on 09/30/23 at 3:12 p.m., LVN C said she worked two days last week on Hall 300, Wednesday 09/27/23 and Thursday 9/28/23, training LVN B. She said Resident #1's medication Triumeq was not available for administration either day. She said she did mark the MAR on 09/27/23 with a check which indicated she had administered the Triumeq, but she did not administer the medication because it was not available. She said she ordered the medication on 9/21/23 and there were pills left in the bottle but when she came back on 9/27/23 there were none left. During an interview and record review of a pharmacy Long Term Care Reorder Form dated 09/21/23, LVN C said she ordered the Triumeq on 09/21/23 and faxed it to the pharmacy and did not receive the fax back until the next day and noticed it said the Triumeq did not have an active order. The pharmacy Long Term Care Reorder form dated 09/21/23 had the Triumeq order request circled and had a label indicating No active order. Please send new order. She said she faxed an order for the Triumeq back to the pharmacy on 9/22/23 and was off the next few days. LVN C then provided an order dated 09/22/23 that indicated the Triumeq was ordered. Written across the bottom of the order was Please Refill. She said when she returned to work on 09/27/23 the resident was out of the Triumeq medication, so she called the pharmacy and asked them why it was not in the facility. She said the pharmacy told her it was a high-cost medication and was not covered and they had faxed over a high- cost medication approval request to the administrator but did not receive an approval and the medication could not be refilled until it was approved. She said she did not remember if she reported what the pharmacy said. She said she did not notify Resident #1's physician that the resident did not have the medication available for administration. She said the physician should have been notified. She said the physician would not have known the resident was out of her medication and could not intervene to make sure she received it. During an interview on 09/30/23 at 3:45 p.m., LVN E, who worked Hall 300 on 9/25/23 and 9/26/23, said Resident #1's Triumeq medication was not available for administration. She said she did not usually work Hall 300 and was filling in, so she assumed someone had already ordered the medication and notified the physician. She said she did not notify the physician the medication was not available to administer. She said she told the ADON and the ADON told her to call the LTAC and make sure they did not have it. She said she knew LVN C had reordered the medication, but the pharmacy sent back the refill request saying it was a high-cost medication and had to be approved before it could be filled. During an interview on 09/30/23 at 3:48 p.m., the ADON said the facility had sent Resident #1's Triumeq medication with her to the LTAC hospital on [DATE] because the hospital called and said they could not provide the medication. She said when the resident returned on 09/01/23, the facility had to go pick the medication up from the LTAC because the hospital did not send it back with her . She said she was unaware the resident did not have the Triumeq medication for 11 days in August 2023 or the last week of September 2023. She said no one notified her on 09/25/23 or 09/26/23 that Resident #1 did not have the Triumeq medication available for administration. During an interview on 09/30/23 at 4:01 p.m., Pharmacist F said he pulled all of Resident #1's transactions off of the computer and the pharmacy had refilled Resident #1's Triumeq and had a signed receipt for 6/29/23 and 8/19/23, but did not find a signed receipt for July 2023. He said they had also sent 30 Triumeq tablets to the nursing facility on 09/28/23 . He said he had a note the pharmacy had communicated with the facility on 09/22/23 that the medication was a high dollar medication and could not be refilled without approval, but the Administrator , DON and ADON were out of the facility. He said the pharmacy then refaxed and emailed the information again on 9/25/23, 09/26/23, 09/27/23, and 09/28/23. He said the administrator signed the approval and returned it on 9/28/23 and it was refilled. Pharmacist F was asked why the facility would have possibly not had the Triumeq medication available in August 2023 and he said there was a refill request for the Triumeq from the facility on 07/05/23 but the medication had already been filled on 6/29/23 and it was too soon. He said there were no other communications found between the pharmacy and the facility regarding Resident #1's Triumeq medication requesting a refill for July 2023 and he did not have a signed receipt for July 2023. During an interview on 10/02/23 at 10:09 a.m., the Administrator said he did not receive an approval request from the pharmacy until 09/28/23 and he immediately sent it back that day with his approval to be filled stat and Resident #1 received the medication the same day. He said he checked his emails daily and did not receive an approval request from the pharmacy until 09/28/23. He said on 09/28/23 he explained to the family member of Resident #1 the Triumeq was not covered because the resident was on skilled services, and it required his approval. He said he was not aware the resident did not receive her medication in August 2023 or the last week of September 2023. He said the resident should receive her medication as ordered. He said he notified his medical director, and the medical director told him there would be no negative outcome of missing the Triumeq medication. During an interview and record review on 10/02/23 at 10:10 a.m., the DON provided a document, which she said was the July 2023 receipt for Resident #1's Triumeq. The top of the document had the words on order and Triumeq tablet cut in half indicating the page had been snipped. A pharmacy notes column indicated dispensed 7/26 updated to insurance-BA, 7/25 emailed facility-RR, 7/19 High $ emailed. There was no signature on the document. The DON said she did not have a signed receipt for the Triumeq for July 2023. During an interview on 10/02/23 at 11:15 a.m., the NP said she nor Resident #1's physician was notified the resident did not receive the doses of Triumeq in August 2023 and September 2023. She said the resident had to have the Triumeq medication or it would exacerbate her HIV if she did not receive it. She said it was herself that would need to be notified and she did not receive a call and the records did not indicate the facility called the office to report the resident had missed the Triumeq doses. She said the facility had her personal cell phone number to call her. She said the records indicated the office was notified on 08/21/23 of lab work for Resident #1 and the office was notified when the resident fell, but there were no notifications about the resident missing her Triumeq doses. The NP said her notes indicated a family member called and wanted her to go to hospital on 8/21/23 and a family member called the office on 09/28/23 to report the resident did not receive her Triumeq medication last week from 9/22/23 to 9/28/23. She said her nurse called the ADON on 09/28/23 and spoke with her about Resident #1 not receiving the medication. During an interview on 10/02/23 at 11:20 a.m., the ADON said no one from Resident #1's physician's office notified her that the resident's Triumeq medication was not available, and she was not aware of it. During an interview on 10/02/23 at 1:02 p.m., the DON said she realized the emails from the pharmacy, requesting approval for Resident #1's medications on 09/25/23, 09/26/23, 09/27/23 and 09/28/23, were going to the other box and not the in box of her emails. She said she had just looked and the emails from the pharmacy were in the other box, and she had not checked the other box for incoming emails. During an interview on 10/03/23 at 3:08 p.m., the MD said the ADM had called him either Saturday 9/30/23 or Sunday 10/01/23 and notified him Resident #1 did not receive her Triumeq medication. He said he had not previously been notified. He said it was his understanding that Resident #1 only missed 3 days of the Triumeq medication and that would not be a problem, but he did not understand the resident missed multiple doses in August 2023. He said approximately 15 doses could potentially cause a problem for the resident. Record review of https://www.drugs.com/triumeq.html, last updated June 9, 2022, accessed on 10/03/23 indicated: Triumeq contains a combination of abacavir, dolutegravir, and lamivudine. Abacavir, dolutegravir, and lamivudine are antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body. Triumeq is used to treat human immunodeficiency virus (HIV), the virus that can cause acquired immunodeficiency syndrome (AIDS). Take Triumeq exactly as prescribed by your doctor. Use all HIV medications as directed and read all medication guides you receive. Do not change your dose or stop using a medicine without your doctor's advice. Every person with HIV should remain under the care of a doctor. Usual Adult Dose for HIV Infection: 1 tablet orally once a day. Use: For the treatment of HIV-1 infection. Get your prescription refilled before you run out of medicine completely. If you miss several doses, you may have a dangerous or even fatal allergic reaction once you start taking this medication again. Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. The IJ template was provided to the Administrator on 10/02/23 at 4:30 p.m and the POR was requested. The facility's POR dated 10/02/23 and accepted on 10/03/23 at 3:00 p.m. indicated: [Resident #1] medication was ordered and received by the facility on 9/28/2023. Primary care physician notified of the identified missed doses of medication on 10/2/23. The Medical Director also notified. There were not consequences associated or directly correlated with missed doses of the resident's medication. A viral load test has been ordered STAT for the resident. A facility audit to be completed by the Director of Nursing/Designee by 10/2/2023 of all residents with missed doses of medication in the past 7 days to assure that the medication was not held due to unavailability. For any medication identified as not given due to not available, the MD will be notified, and pharmacy will be contacted if the medication continues to not be available in the facility. If trends established, then we will QAPI the trend and in-service staff on root cause to prevent in the future. No other issues have been identified. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. All other licensed staff will be in-serviced prior to working the next shift. The regional nurse consultant in serviced the DON and Administrator on checking all email folders for notifications of high-cost medications or refills from the pharmacy. Ad Hoc QAPI meeting completed with IDT and Medical Director on 10/2/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Audit to be completed 10/2/23 by DON/Designee to identify any residents that did not receive medications due to availability, pharmacy was contacted, and MD notified. This audit included the med cart, med room and MARS. There were no other residents identified that missed doses due to medication unavailability. We did identify new admits on the weekend were at a risk due to pharmacy hours of operation and ordering cut off time at 6PM. These orders will be sent to the local pharmacy and then delivered to the facility. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed medication administrations on 9/30/23. This includes checking all eFax's, and fax machines at the nurse's station. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. Staff will be responsible for contacting the MD/PCP for any missed doses. The DON and or designee will follow up in the morning clinical meeting to ensure compliance. LVN A has been given disciplinary action and trained one on one by the DON. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by 10/3/2023 at 2 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. On 10/03/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observation on 09/30/23 at 12:51 p.m., Resident #1's Triumeq medication was dated 09/28/23 and available in the Hall 300 nurses' medication cart. During interviews on 10/03/23 from 3:18 p.m. to 3:28 p.m., Resident #1's NP and the MD said they were notified of Resident #1's missed doses of Triumeq. Record review of the audit tool completed by the DON indicated residents were identified that did not have their medications available. The medications were unavailable for 9 residents and the physicians were notified on 09/30/23, 10/02/23 and 10/03/23. No new orders were implemented. Record review of signed in-services to LVNs indicated the LVNs were trained on documenting missed doses of medications, who to notify, and notification of the physician with posttests taken and dated 10/02/23 and 10/03/23. Record review of in-services dated 09/30/23 to 10/03/23 indicated the LVNs were trained on supervision to prevent missed medication administration. Record review of the Regional Nurse Consultant's in-service to the DON and ADM dated 10/03/23 indicated the DON and ADM were trained to check all email folders for notifications of high cost medications or refills from the pharmacy. Record review of a counseling note dated 10/03/23 indicated LVN A was counseled on documentation, notification, and medications not being available. During an interview on 10/03/23 at 3:53 p.m., the DON was able to verbalize how to check emails for pharmacy notifications. During interviews on 10/03/23 from 4:20 p.m. to 5:20 p.m., three day shift LVNs, 3 evening shift LVNs and 2 night shift LVNs were able to verbalize the appropriate interventions to put in place to ensure the medications were available, refilled timely, weekend admits received their medications, the physician and DON were notified timely if medications were not available for administration and when to notify the pharmacy. On 10/03/23 at 5:40 p.m., the Administrator was informed the IJ was removed; however; the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 4 residents reviewed for significant medication errors. (Resident #1) The facility failed to ensure Resident #1's HIV ([human immunodeficiency virus] a virus that attacks the human immune system) medication was available for administration in August 2023 for 11 doses and September 2023 for 3 doses. Resident #1 had a diagnosis of HIV. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, impairment, or death from not receiving a significant medication. Findings included: Record review of physician orders dated 10/02/23 indicated Resident #1 was an [AGE] year-old female re-admitted on [DATE]. Her diagnoses included HIV, diabetes (a disease in which the body's ability to produce or respond to the insulin hormone is impaired resulting in abnormal metabolism) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). The orders indicated the resident was to receive Triumeq (antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body) 600-50-300 mg one tablet every day for antiviral. Record review of a quarterly MDS dated [DATE] indicated Resident #1 was usually able to make herself understood, usually understood others, had moderately impaired cognitive skills and required supervision and set up for transfers and ambulation. She utilized a walker for mobility and had no impairment to upper and lower extremities. Record review of a care plan dated 08/21/23 indicated Resident #1 was at risk for infections related to HIV. The goal indicated the resident would not display any complications related to immunodeficiency. Interventions included to administer medications as ordered and monitor/document and report signs and symptoms. Record review of the August 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 08/04/23 the date was coded a 6 and indicated the resident was in the hospital documented by the DON, *on the following dates there was a code 9 on the date indicating other see progress note: 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/10:23 docuemnted by agency staff, 08/12/23 documented by LVN A , 08/13/23 documented by LVN A , 08/14/23 documented by LVN A,08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A , 08/20/23 documented by LVN A and 08/21/23 documented by LVN A. *on 08/22/23, the date was coded a 6 and indicated the resident was in the hospital documented by LVN G Record review of the September 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 09/23/23 the date was coded a 1 and indicated the resident was absent from home without meds., *on 9/24/23 the date was coded a 3 and indicated the resident was absent from home with meds, *on 09/25/23, 9/26/23 documented by LVN E the date was coded a 9 and on 9/28/23 the date was coded a 9 and documented by LVN B and indicated other see progress note. Record review of the nurses' progress notes for Resident #1 indicated the following: *on 08/04/23 the resident was at the hospital. Resident #1 returned from hospital with a new antibiotic for pneumonia, *on 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A, 08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A the Triumeq was on order, *on 08/10/23 signed by LVN D, the documentation for Triumeq did not indicate the medication was not administered, *on 08/22/23, the documentation indicated the resident was in the hospital. *on 09/01/23, documentation indicated the resident was readmitted from the LTAC hospital. *on 09/22/23 to 09/24/23, the resident was out of the facility with family *on 09/25/23 documented by LVN E, 09/26/23 documented by LVN E and 09/28/23 documented by LVN B, the documentation indicated the medication was not available. There was no documentation on the nurses' progress notes to indicate the physician was notified the Triumeq medication was not available or not administered. Record review of a LTAC hospital Interdisciplinary Notes dated 08/23/23 indicated History of Present Ilness: The patient is an [AGE] year-old female who resides at a nursing home, who presented to the emergency room on [DATE] and was found to have urinary tract infection and pneumonia. She was prescribed Lovenox (a medication used to thin the blood) and Rocephin (an antibiotic medication used to treat infection) and sent back to the nursing home, where she continued to have functional decline. The patient has had increased weakness and falls since her emergency room visit. The patient was transferred to [LTAC] on 08/21/2023 for continuation of antibiotic medical management of above symptoms and strengthening. The patient is currently not able to participate in activities of daily living and mobility as she was prior to her emergency room visit. A consult was performed by Physical Medicine and Rehabilitation physician, who determined the patient was suffering from exacerbation of her Parkinson's disease. The patient wants to come to acute inpatient rehabilitation for aggressive physical and occupational therapy.medication. A LTAC order dated 8/24/23 indicated Resident #1's Triumeq medication was ordered for administration. The order indicated the resident could use own home supply. There was no documentation to indicate the resident did not have the Triumeq available upon admission to the LTAC. During interview on 09/30 23 at 8:45 a.m., the DON said Resident #1 was sent out to the hospital on 08/0423 and returned the same day a diagnosis of pneumonia. She said when the resident returned, she was placed on skilled services. The Triumeq medication was a high-cost medication and was not covered on the insurance once the resident became skilled. She said as soon as the facility received the request for approval for the Triumeq by the administrator, the approval was signed, faxed back and the resident received the medication. She said she was unaware the resident missed doses of the Triumeq. During an observation, interview, and record review on 09/30/23 at 12:51 a.m., LVN A said she was the nurse who worked Hall 300, where Resident #1 resided. During record review of Resident #1's August 2023 MAR with LVN A, she said Resident #1 was out of her Triumeq medication on 08/08/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23 08/15/23, 08/18/23, 08/19/23, 08/20/23 and 08/21/23 where she documented the code 9. She said the resident had gone out to hospital on 8/4/23 but returned the same day and was diagnosed with pneumonia. She said the resident was weak because the diagnoses of pneumonia and did continue to get weaker and was sent out to the LTAC for rehabilitation services on 08/22/23. She said it was her responsibility to administer the medications on Hall 300. She said she should have notified the DON and the physician, when the Triumeq medication was not available. She said she did not know why she did not notify them, but she did not. She said she remembered Resident #1 was out of the Triumeq but did not remember notifying the pharmacy it was out. Observation of the bottle of Resident #1's Triumeq 30 count in the medication cart indicated the bottle was ¾ full of medication. The bottle was dated 9/28/23. LVN A said it had been refilled on 9/28/23 and only a few tablets had been administered out ot the bottle. She said she should have notified the pharmacy when there were approximately 10 tablets left. LVN A said the possible negative outcome of Resident #1 not receiving her medication would be the resident's HIV could worsen. During an interview on 9/30/23 at 1:20 p.m., the DON said she was unaware Resident #1 did not have the Triumeq medication for 11 days during August 2023. She said the Triumeq was to treat her diagnosis of HIV. She said she and the physician should have been notified the medication was not available. She said she expected the nurses to make sure the residents' medications were available for administration. She denied the resident could suffer increased symptoms by not having the medication available and said the medication was to keep the resident's HIV undetectable. During an interview on 09/30/23 at 1:52 p.m., LVN B said she started orientation on Hall 300 on 09/27/23 last week. She said Resident #1's Triumeq was not available on Wednesday 09/27/23 and Thursday 9/28/23. She said she was in training and did medication pass with LVN C. She said she watched LVN C pass medications on Wednesday 09/27/23 and passed the medications herself on Thursday 09/28/23. She said LVN C told her the Triumeq was a medication that required approval and it was not available. LVN B said if a medication was not available, the physician should be notified. She said she did not notify the physician the medication was not available because she was in training and LVN B had faxed the pharmacy. She said the medication was for Resident #1's HIV. She said the possible negative outcome if the resident did not receive the medication, would be the resident's HIV symptoms could exacerbate. During a confidential interview on 9/30/23 at 2:04 p.m., an individual said the facility did not have Resident #1's Triumeq medication available when the resident went out on pass 9/22/23 to 09/24/23. The individual said the ADON was notified the resident did not have her medication. During an interview on 09/30/23 at 2:22 p.m., the ADON said she was unaware Resident #1 did not have the Triumeq medication with her when she went out on pass 09/22/23 to 09/24/23. She denied staff had informed her the resident's medication was not available. She said Resident #1 should not miss a dose of the Triumeq medication because her HIV could worsen, and she was unaware that she missed doses. During an interview on 09/30/23 at 2:34 p.m., an attempted was made to call LVN D, who documented a code 9 on the August 2023 MAR on 08/10/23, with no answer and the mailbox was full; unable to leave message for call back. During an interview on 09/30/23 at 2:48 p.m., the DON said she was unaware Resident #1 had not received the Triumeq until 09/28/23, when the administrator approved the medication for the pharmacy to refill it and he sent the approval to her, and she ordered the medication stat. She denied knowing the resident also did not have the medication in August 2023. She said she was unaware and did not notify the physician. During an interview and record review on 09/30/23 at 3:12 p.m., LVN C said she worked two days last week on Hall 300, Wednesday 09/27/23 and Thursday 9/28/23, training LVN B. She said Resident #1's medication Triumeq was not available for administration either day. She said she did mark the MAR on 09/27/23 with a check which indicated she had administered the Triumeq, but she did not administer the medication because it was not available. She said she ordered the medication on 9/21/23 and there were pills left in the bottle but when she came back on 9/27/23 there were none left. During an interview and record review of a pharmacy Long Term Care Reorder Form dated 09/21/23, LVN C said she ordered the Triumeq on 09/21/23 and faxed it to the pharmacy and did not receive the fax back until the next day and noticed it said the Triumeq did not have an active order. The pharmacy Long Term Care Reorder form dated 09/21/23 had the Triumeq order request circled and had a label indicating No active order. Please send new order. She said she faxed an order for the Triumeq back to the pharmacy on 9/22/23 and was off the next few days. LVN C then provided an order dated 09/22/23 that indicated the Triumeq was ordered. Written across the bottom of the order was Please Refill. She said when she returned to work on 09/27/23 the resident was out of the Triumeq medication, so she called the pharmacy and asked them why it was not in the facility. She said the pharmacy told her it was a high-cost medication and was not covered and they had faxed over a high cost medication approval request to the administrator but did not receive an approval and the medication could not be refilled until it was approved. She said she did not remember if she reported what the pharmacy said. She said she did not notify Resident #1's physician that the resident did not have the medication available for administration. She said the physician should have been notified. She said the possible negative outcome of the resident not receiving her HIV medication could be the resident's HIV symptoms could worsen. During an interview on 09/30/23 at 3:45 p.m., LVN E, who worked Hall 300 on 9/25/23 and 9/26/23, said Resident #1's Triumeq medication was not available for administration. She said she did not usually work Hall 300 and was filling in, so she assumed someone had already ordered the medication and notified the physician. She said she did not notify the physician the medication was not available to administer. She said she told the ADON and the ADON told her to call the LTAC hospital and make sure they did not have it. She said she knew LVN C had reordered the medication, but the pharmacy sent back the refill request saying it was a high-cost medication and had to be approved before it could be filled. She said the resident's condition could get worse if she did not receive her medication as ordered. During an interview on 09/30/23 at 3:48 p.m., the ADON said the facility had sent Resident #1's Triumeq medication with her to the LTAC on 08/22/23 because the hospital called and said they could not provide the medication. She said when the resident returned on 09/01/23, the facility had to go pick the medication up from the LTAC because the hospital did not send it back with her. She said she was unaware the resident did not have the Triumeq medication for 11 days in August 2023 or the last week of September 2023. She said no one notified her on 09/25/23 or 09/26/23 that Resident #1 did not have the Triumeq medication available for administration. During an interview on 09/30/23 at 4:01 p.m., Pharmacist F said he pulled all of Resident #1's transactions offthe computer and the pharmacy had filled Resident #1's Triumeq and had a signed receipt for 6/29/23 and 8/19/23 but did not find a signed receipt for July 2023. He said they had also sent 30 Triumeq tablets on 09/28/23. He said he had a note that the pharmacy had communicated with the facility on 09/22/23 that the medication was a high dollar medication and could not be refilled without approval, but the administrator, DON and ADON were out of the facility. The pharmacy then refaxed and emailed the information again on 9/25/23, 09/26/23, 09/27/23, and 09/28/23. He said the administrator signed the approval and returned it on 9/28/23 and it was refilled. Pharmacist F was asked why the facility would have possibly not had the Triumeq medication available in August 2023 and he said there was a request from the facility on 07/05/23 for a refill but the medication had already been filled on 6/29/23 and it was too soon. He said there were no other communications found between the pharmacy and the facility regarding Resident #1's Triumeq medication requesting a refill for July 2023 and he did not have a signed receipt for July 2023. The During an interview on 10/02/23 at 10:09 a.m., the Administrator said he did not receive an approval request from the pharmacy until 09/28/23 and he immediately sent it back with his approval to be filled stat as soon as he received the request and Resident #1 received the medication the same day. He said he checked his emails daily and did not receive an approval request from the pharmacy until 09/28/23. He said on 09/28/23 he explained to the daughter of Resident #1 the Triumeq was not covered because the resident was on skilled services, and it required his approval. He said he was not aware the resident did not receive her medication in August 2023 or the last week of September 2023. He said the resident should receive her medication as ordered. He said he notified his medical director, and the medical director told him there would be no negative outcome of missing the Triumeq medication. During an interview and record review on 10/02/23 at 10:10 a.m., the DON provided a document, which she said was the July 2023 receipt for Resident #1's Triumeq. The top of the document had the words on order and Triumeq tablet cut in half indicating the page had been snipped. A pharmacy notes column indicated dispensed 7/26 updated to insurance-BA, 7/25 emailed facility-RR, 7/19 High $ emailed. There was no signature on the document and no year indicated on the document. The DON said she did not have a signed receipt for the Triumeq for July 2023. During an interview on 10/02/23 at 10:35 a.m., a phone call was initiated to the MD. The MD did not answer with a voice message left for callback. No call back was returned. During an interview on 10/02/23 at 11:15 a.m., the NP said she nor Resident #1's physician was notified the resident did not receive the doses of Triumeq in August 2023 and September 2023. She said the resident had to have the Triumeq medication or it would exacerbate her HIV if she did not receive it. She said it was herself that would need to be notified and she did not receive a call and the records did not indicate the facility called the office to report the resident had missed the Triumeq doses. She said the facility had her personal cell phone number to call her. She said the records indicated the office was notified on 08/21/23 of lab work for Resident #1 and the office was notified when the resident fell, but there were no notifications about the resident missing her Triumeq doses. The NP said her notes indicated a family member called and wanted her to go to hospital on 8/21/23 and a family member called the office on 09/28/23 to report the resident did not receive her Triumeq medication last week from 9/22/23 to 9/28/23. She said her nurse called the ADON on 09/28/23 and spoke with her about Resident #1 not receiving the medication. During an interview on 10/02/23 at 11:20 a.m., the ADON said no one from Resident #1's physician's office notified her that the resident's Triumeq medication was not available, and she was not aware of it. During an interview on 10/02/23 at 1:02 p.m., the DON said she realized the emails from the pharmacy, requesting approval for Resident #1's medications on 09/25/23, 09/26/23, 09/27/23 and 09/28/23, were going to the other box and not the in box of her emails. She said she had just looked and the emails from the pharmacy were in the other box and she had not checked the other box for incoming emails. During an interview on 10/03/23 at 3:08 p.m., the MD said the ADM had called him either Saturday 9/30/23 or Sunday 10/01/23 and notified him Resident #1 did not receive her Triumeq medication. He said he had not previously been notified. He said it was his understanding that Resident #1 only missed 3 days of the Triumeq medication and that would not be a problem, but he did not understand the resident missed multiple doses in August 2023. He said approximately 15 doses could potentially cause a problem for the resident. Record review of https://www.drugs.com/triumeq.html, updated June 9, 2022, accessed on 10/03/23 indicated: Triumeq contains a combination of abacavir, dolutegravir, and lamivudine. Abacavir, dolutegravir, and lamivudine are antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body. Triumeq is used to treat human immunodeficiency virus (HIV), the virus that can cause acquired immunodeficiency syndrome (AIDS). Take Triumeq exactly as prescribed by your doctor. Use all HIV medications as directed and read all medication guides you receive. Do not change your dose or stop using a medicine without your doctor's advice. Every person with HIV should remain under the care of a doctor. Usual Adult Dose for HIV Infection: 1 tablet orally once a day. Use: For the treatment of HIV-1 infection. Get your prescription refilled before you run out of medicine completely. If you miss several doses, you may have a dangerous or even fatal allergic reaction once you start taking this medication again. Record review of the Administering Medications policy revised April 2019 indicated: Medications are administered in a safe and timely manner. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication errors are documented, reported and reviewed by the QAPI committee. Record review of the Pharmacy Services policy revised April 2019 indicated: Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. 2. The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. The IJ template was provided to the Administrator on 10/02/23 at 4:30 p.m. The facility's POR dated 10/02/23 and accepted 10/03/23 at 3:00 p.m. indicated: Resident #1 medication was ordered and received by the facility on 9/28/2023. Primary care physician notified of the identified missed doses of medication on 10/2/23. The Medical Director also notified. There were not consequences associated or directly correlated with missed doses of the resident's medication. A viral load test has been ordered STAT for the resident. A facility audit to be completed by the Director of Nursing/Designee by 10/2/2023 of all residents with missed doses of medication in the past 7 days to assure that the medication was not held due to unavailability. For any medication identified as not given due to not available, the MD will be notified, and pharmacy will be contacted if the medication continues to not be available in the facility. If trends established, then we will QAPI the trend and in-service staff on root cause to prevent in the future. No other issues have been identified. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. All other licensed staff will be in-serviced prior to working the next shift. The regional nurse consultant in serviced the DON and Administrator on checking all email folders for notifications of high-cost medications or refills from the pharmacy. Ad Hoc QAPI meeting completed with IDT and Medical Director on 10/2/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Audit to be completed 10/2/23 by DON/Designee to identify any residents that did not receive medications due to availability, pharmacy was contacted, and MD notified. This audit included the med cart, med room and MARS. There were no other residents identified that missed doses due to medication unavailability. We did identify new admits on the weekend were at a risk due to pharmacy hours of operation and ordering cut off time at 6PM. These orders will be sent to the local pharmacy and then delivered to the facility. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed medication administrations on 9/30/23. This includes checking all eFax's, and fax machines at the nurse's station. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. Staff will be responsible for contacting the MD/PCP for any missed doses. The DON and or designee will follow up in the morning clinical meeting to ensure compliance. LVN A has been given disciplinary action and trained one on one by the DON. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by 10/3/2023 at 2 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. On 10/03/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observation on 09/30/23 at 12:51 p.m., Resident #1's Triumeq medication was dated 09/28/23 and available in the Hall 300 nurses' medication cart. During interviews on 10/03/23 from 3:18 p.m. to 3:28 p.m., Resident #1's NP and the MD said they were notified of Resident #1's missed doses of Triumeq. Record review of the audit tool completed by the DON indicated residents were identified that did not have their medications available in the last 7 days. The medications were unavailable for 9 residents and the physician was notified on 09/30/23, 10/02/23 and 10/03/23. No new orders were implemented. Record review of signed in-services dated 10/02/23 and 10/03/23 to LVNs indicated the LVNs were trained on documenting missed doses of medications, who to notify, and notification of the physician with posttests taken and dated 10/02/23 and 10/03/23. Record review of in-services dated 09/30/23 to 10/03/23 indicated LVNs were trained on supervision to prevent missed medication administration. Record review of the regional nurse consultant's in-service to the DON and ADM dated 10/03/23 indicated the DON and ADM were trained to check all email folders for notifications of high-cost medications or refills from the pharmacy. Record review of a counseling note dated 10/03/23 indicated LVN A was counseled on documentation, notification, and medications not available. During an interview on 10/03/23 at 3:53 p.m., the DON was able to verbalize how to check emails for pharmacy notifications. During Interviews on 10/03/23 from 4:20 p.m. to 5:20 p.m., three day shift LVNs, 3 evening shift LVNs and 2 night shift LVNs were able to verbalize the appropriate interventions to put in place to ensure the medications were available, refilled timely, weekend admits received their medications, the physician and DON were notified timely if medications were not available for administration and when to notify the pharmacy. On 10/03/23 at 5:40 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse and neglect for 2 of 11 residents (Resident #5 and #4) reviewed for abuse and neglect. 1. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2. Resident #4 sustained a laceration to his left eyebrow and had blood in his mouth. Resident #4 indicated he fought with an unidentified staff. He was sent to the ER and received sutures. The facility identified the staff as CNA K. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of face sheet dated [DATE], indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away). Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). Record review of Resident #5's current care plan initiated [DATE] and revised on [DATE] indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene. Record review of Kardex (electronic care needs) printed on [DATE] indicated Resident #5 required extensive assistance by two staff for bed mobility. Record review of an incident report dated [DATE], completed by LVN A indicated CNA C was providing incontinent care for Resident #5. CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of progress note dated [DATE] completed by LVN A, indicated CNA C was changing Resident #5 and she rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of hospital records dated [DATE] indicated Resident #5 sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur (thigh bone) metadiaphysis (the diaphysis (shaft or primary ossification centre), metaphysis (where the bone flares), right knee-minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella a flat, inverted triangular bone, situated on the front of the knee-joint proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla the space below the shoulder through which vessels and nerves enter and leave the upper arm; a person's armpit hematoma (A pool of clotted blood that forms in an organ, tissue, or body space). Her diagnoses included diffuse osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) and osteopenia (a condition that begins as you lose bone mass and your bones get weaker). Record review of hospital Discharge summary dated [DATE] indicated the fractures of Resident #5's left and right thigh bones were both repaired surgically. During an interview on [DATE] at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on [DATE] after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries. During an interview on [DATE] at 2:47 p.m., LVN A said on [DATE] at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said at the time of the incident, Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital at 12:00 p.m. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist when required it could result in injury or death of a resident. During an interview on [DATE] at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on [DATE]. She said the Administrator said it was not reportable because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there were two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff were required to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. She said the nurses were expected to monitor the aides to ensure care was provided per the care plans. During an interview on [DATE] at 3:26 p.m., CNA C said on [DATE] at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 laid down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the Kardex indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the Kardex the day after the fall. She said the DON said it was not her fault because the Kardex was not updated. During an interview on [DATE] at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the Kardex was not updated. She said the Kardex was populated by the care plan. She said Resident #5's care plan was in place from [DATE] and the Kardex was not changed. During an interview on [DATE] at 3:45 p.m., the Administrator said Resident #5's fall off the bed on [DATE] was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware the DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the Kardex. He said CNA C was terminated on [DATE] for not calling and not showing for shifts. During an observation and interview on [DATE] at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said she had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. During an interview on [DATE] at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the Kardex and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. He said the same situation could happen again if the facility did not recognize abuse or neglect. During an interview on [DATE] at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the Kardex for a resident's level of care. She said she received retraining on [DATE] after the incident on the Kardex system and bed mobility prior to [DATE] and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the Kardex and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not follow the Kardex for care needs the resident could have serious injuries or die. During an interview and record review on [DATE] at 1:04 p.m., the DON said they believed all staff were trained on [DATE] and [DATE] to check the Kardex for level of resident assistance required. She said she and the ADON monitored the care plans and Kardex weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. During an interview on [DATE] at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the Kardex. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side before the fall on [DATE]. She said Resident #5 was not able to use her legs. She said resident care information was in the Kardex system. She said she was retrained on the Kardex system and bed mobility after the incident. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the Kardex system and bed mobility but forgot to sign. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 2:45 p.m., the RNC said she received an anonymous call from a blocked number. She said she was told of Resident #5's fall. She said she looked at Resident #5's clinical record and the hospital record. She said she called the CNO who told her the incident was reportable. She said she called the Administrator and told him the incident was reportable. She said the Administrator wanted the COO to review the incident. She said the COO agreed the incident was reportable as an allegation of neglect. During an interview on [DATE] at 2:50 p.m., the DON said the incident of Resident #5's fall and injuries on [DATE] was neglect and reportable. During an interview on [DATE] at 2:50 p.m. the ADON said incident of Resident #5's fall and injuries on [DATE] was neglect and reportable. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated: The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review of the facility Resident Rights policy revised 02/21 indicated Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and implementation 1. Federal Law state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation; . The Administrator and the DON as notified of the Immediate Jeopardy on [DATE] at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 12:35 p.m. and reflected the following: 1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. 2* Corrective Action Nursing administration will review care plans and Kardex's for all residents to ensure they match with the resident's level of assistance required. This process began [DATE] and will be complete by 10 AM on [DATE]. All areas of concerns have been addressed and all care plans match all Kardex's for all residents. All nursing staff will be in-service on where to find a resident's level of assistance in the Kardex. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. All nursing staff will be in-service on abuse and neglect. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the Kardex/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM. The Kardex showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the Kardex. The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of [DATE] 4:30 PM. 3* Identification of Others The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by [DATE] of all facility residents' administrative nurses. Assessment will compare care plans to Kardex. The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. A facility record audit of residents Kardex and care plans will be completed by Director of Nursing/Designee by [DATE] 10 AM. 4* Plan to prevent from recurring Intervention for Neglect: DON/designee to evaluate care plan and Kardex for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on Kardex and levels of assistance prior to working the first shift. This is to be completed during orientation. Training Plan Initial Trainings: Facility to Initiate Training by [DATE] 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working [DATE], and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by [DATE] 10AM via in person on telephone training. All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM. Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations. 5* Ongoing Monitoring Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate Kardex knowledge during rounds. 6* QAPI In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed [DATE] by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on [DATE] from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the Kardex system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the Kardex system for resident care needs. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Kardex for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the Kardex. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the Kardex. Review of staff training indicated nursing staff were in-serviced on where to find a resident's level of assistance in the Kardex. The training was completed on [DATE]. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on [DATE]. The 5-question quiz of Kardex knowledge given to all tested staff indicated all staff scored 100%. The Kardex showed that Resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on [DATE]. The administrator was in-service on [DATE] by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter. There were no additional allegations of neglect or abuse identified during the investigation. During an interview on [DATE] at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. During an interview on [DATE] at 2:50 p.m., The DON said the audit of all residents' care plans and Kardex revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents. A facility record audit dated [DATE] of residents' Kardex and care plans revealed no issues or concerns. Staffing was reviewed for the previous two weeks and for [DATE]. There was no concerns noted. Five residents said they were not afraid during care or had complaints of their care. The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. On [DATE] at 3:12 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2. Record review of face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included vascular dementia, diabetes, cognitive communication deficit, muscle weakness, muscle wasting and atrophy, and need for assistance with personal care. Record review of MDS dated [DATE] indicated Resident #4 was usually able to express ideas and wants and able to understand others, had severe cognitive impairment, and required extensive assist of 1 persons for bed mobility and toilet use, 2+ person for transfers and personal hygiene. He was incontinent of bladder and bowel. There were no noted behaviors. Record review of Resident #4's care plan indicated no care plans developed for aggression or behaviors. Record review of incident report dated [DATE] and completed by LVN J indicated CNA K came to the nurse station and reported the resident had blood on his forehead. LVN J observed Resident #4 lying in bed with an open wound over his left eye with dried blood around the wound. When Resident #4 was asked what happened, Resident #4 said he said he had a fight with a nurse. Resident #4 was transported to the hospital. Record review of Resident #4's hospital record dated [DATE] indicated Resident #4 said someone punched him.here for a fall according to (facility). Someone put Resident #4 back to bed, but no one knows who. Something happened last night that went unreported per EMS. 2 cm wound sutured with 4 sutures . Clinical impression: assault, facial laceration .SW was called to the ER to assist Resident #4 with possible NH abuse. Apparently the EMS staff advised LVN L that I (Resident #4) kicked a nurse and she hit me' . Communicating with Resident #4 is very difficult due to him being hard of hearing. The SW found Resident #4 to be awake and alert, just slow to respond. (In fact, he told the SW to please slow down. I might be old, but if I take my time I can get it all out. Resident #4 stated, I kicked my nurse and she hit me. I guess I made her mad. Resident #4 stated he was embarrassed that he kicked a woman and was remorseful for the event even occurring. Record review of the facility investigation dated [DATE] indicated LVN J said CNA K came to the nurse station on [DATE] 15 minutes prior to the end of shift and reported Resident #4 had blood on his forehead. CNA K left the facility the immediately after she reported the blood on Resident #4. LVN O (day shift nurse) assisted with assessment. Resident #4 was lying in bed neatly tucked in bed. LVN O stated it looked staged how neatly Resident #4 was tucked in. Resident #4 sustained a laceration to his left eye and hematoma. There appeared to be blood in his mouth. There was a large amount of fresh blood on the privacy curtain adjacent to Resident #4's bed. When asked what happened, Resident #4 said he got in a fight with the nurse. Resident #4 was sent to the hospital for evaluation and assessment. CNA K was the only aide to provide care for Resident #4 on the night shift. The Administrator received a call from the SW at the hospital who reported Resident #4's injuries seemed suspicious to the hospital staff and Resident #4 told the EMS staff he got in a fight with the nurse. SW N interviewed Resident #4 and asked what happened. Resident #4 said he got in a fight with a nurse and said he had kicked the nurse as she hurt him when she moved him and she did not like that he kicked her. Resident #4 was not able to give a name or description. He received sutures above his eye and returned to the facility the same day. The night nurse and all CNAs were suspended. It was noted Resident #4 refers to all staff as nurse and did not differentiate between aides and nurses. The administrator observed a large amount of blood on the privacy curtain. It was bright red and appeared fresh. CNA K was the only staff identified to provide care for Resident #4 on [DATE]. CNA K returned to the facility to give her statement. She appeared nervous and fidgeted during the interview. She had black bandages on the middle and ring finger of her right hand. The ADON noted scratches on the fingers. CNA K indicated she was right-handed. CNA K refused to remove the bandages. CNA K said she did not know what happened to Resident #4. CNA K changed her statement to reporting the incident to the nurse early in the shift and then changed it back to the end of her shift. She denied Resident #4 had a fall or if there was an argument or a scuffle. Progress note dated [DATE] indicated Resident #4 expired after testing positive for Covid-19 on [DATE] (unrelated to the abuse). The investigator attempted to call CNA K on [DATE] at 12:27 p.m. The person who answered the phone said no when the investigator asked to speak to CNA K and disconnected the call. The investigator left a text message at 12:31 p.m. for CNA K at the same number and received no response. Record review of CNA K's statement (undated) indicated she checked on Resident #4 and noticed dried up blood on his face and reported to the charge nurse. She checked on him a second time with CNA N, there was still blood on Resident #4 but she assumed LVN J had reported it. Record review of LVN O's statement dated [DATE] indicated she arrived at the facility on [DATE] at approximately 5:45 a.m. She started rounds and observed Resident #4 lying in bed with blood and hematoma noted above his left eye. Blood was also noted in Resident #4's mouth with no visual laceration noted to his mouth. Resident #4 was sent to the ER for evaluation and treatment. Record review of CNA M's statement

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 11 residents (Resident #5) reviewed for accidents. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization. Findings included: Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away). Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). Record review of Resident #5's most current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene. Record review of [NAME] (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility. During an observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. LVN A did not indicate Resident #5 was a 2-person assist. Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia. Record review of hospital Discharge summary dated [DATE] indicated Resident #5 bilateral femoral fractures were repaired surgically. During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries. During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the [NAME]. She said if staff did not use 2-person assist when required it could result in injury or death of a resident. During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff are required to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the [NAME] indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the [NAME] the day after the fall. She said the DON said it was not her fault because the [NAME] was not updated. During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the [NAME] was not updated. She said the [NAME] was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the [NAME] was not changed. During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the [NAME]. During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell. He said the incident was mentioned in QAPI that they conducted training and continued to monitor the [NAME] and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the [NAME] for a resident's level of care. She said she received retraining after the incident on the [NAME] system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the [NAME] and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the [NAME]. She said if staff did not follow the [NAME] for care needs the resident could have serious injuries or die. During record review and interview on 04/12/23 at 1:04 p.m., the DON said they believed all staff were re-trained to check the [NAME] for level of resident assistance required after Resident #5's fall. She said she and the ADON monitored the care plans and [NAME] weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the [NAME] system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the [NAME]. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS before the fall. She said Resident #5 was weak on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the [NAME] system. She said she was retrained on the [NAME] system and bed mobility after the incident. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS before her fall. She said the information was in the [NAME] system. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the [NAME] system and bed mobility but forgot to sign. She said if staff did not follow the [NAME] for care needs then residents could get seriously injured. Record review of the facility's Falls-Clinical Protocol revised 03/2018 indicated: .2. In addition, the nurse shall assess and document/report the following: .h. Precipitating factors, details on how fall occurred; . Falls Prevention-Potential Interventions - Nursing Measures . proper positioning . Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. The Administrator and DON were notified of the Immediate Jeopardy on 04/12/23 at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/13/23 at 12:35 p.m. and reflected the following: 1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. 2* Corrective Action Nursing administration will review care plans and [NAME]'s for all residents to ensure they match with the resident's level of assistance required. This process began 4/12/23 and will be complete by 10 AM on 4/13/23. All areas of concerns have been addressed and all care plans match all [NAME]'s for all residents. All nursing staff will be in-service on where to find a resident's level of assistance in the [NAME]. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. All nursing staff will be in-service on abuse and neglect. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the [NAME]/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM. The [NAME] showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the [NAME]. The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of 4/12/23 4:30 PM. 3* Identification of Others The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by 4/13/23 of all facility residents' administrative nurses. Assessment will compare care plans to [NAME]. The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. A facility record audit of residents [NAME] and care plans will be completed by Director of Nursing/Designee by 4/13/2023 10 AM. 4* Plan to prevent from recurring Intervention for Neglect: DON/designee to evaluate care plan and [NAME] for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on [NAME] and levels of assistance prior to working the first shift. This is to be completed during orientation. Training Plan Initial Trainings: Facility to Initiate Training by 4/12/2023 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working 4/12/2023, and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by 4/13/23 10AM via in person on telephone training. All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of [NAME] knowledge. This will be completed by 4/13/23 at 12 PM. Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations. 5* Ongoing Monitoring Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate [NAME] knowledge during rounds. 6* QAPI In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed 4/12/23 by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On 04/13/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 04/13/23 from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the [NAME] system for resident care needs. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. [NAME] for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME]. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME]. Nursing staff were in-serviced on where to find a resident's level of assistance in the [NAME]. The training was completed on 04/13/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on 04/13/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The 5-question quiz of [NAME] knowledge given to all tested staff indicated all staff scored 100%. The [NAME] showed that resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on 01/17/23. The administrator was in-service on 04/12/23 by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter. There were no additional allegations of neglect or abuse identified during the investigation. During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. During an interview on 04/13/23 at 2:50 p.m., The DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents. A facility record audit dated 04/13/23 of residents' [NAME] and care plans revealed no issues or concerns. Staffing was reviewed for the previous two weeks and for 01/16/23. There was no concerns noted. Five residents indicated they were afraid during care or had complaints of their care. The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on 04/12/23. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.