**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose for 1 (Resident #1) of 4 residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose for 1 (Resident #1) of 4 residents reviewed for unnecessary medications. The facility failed to identify potential hazards and effects of medications and failed to have internal systems in place to prevent Resident #1 from receiving high doses of extended release Morphine and Oxycodone (opioid analgesics used to treat moderate to severe ongoing pain). This resulted in Resident #1's admission to the intensive care unit, on 07/09/2025, in critical condition requiring a Narcan (antidote for opioid overdose) drip to reverse the effects of medication received at the facility. The non-compliance and an Immediate Jeopardy (IJ) situation was identified on 07/13/2025. The IJ was removed on 07/14/2025. The facility remained out of compliance with a scope of pattern with 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. This failure could place residents at risk for serious adverse outcomes including drug toxicity, the need for hospitalization, and/or death. Findings include:Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had diagnoses which included malnutrition (failure of body to absorb nutrients) with TPN (method used to receive nutrients) through an IV (in a person's veins), enterocutaneous fistula (abnormal connection that forms between the intestine and skin on the abdominal wall), and a colostomy (the colon is re-routed to an opening in the abdomen and skin) following surgical repair of a bowel obstruction (blockage).Record review of Resident #1's admission MDS (tool used to assess health status) Assessment, dated 07/03/2025, reflected intact cognition with a BIMS (screening tool to assess cognitive status) score of 13. Section GG (Functional Abilities) indicated Resident #1 required moderate to maximal assistance for most self-care needs and moderate assistance with mobility.Record review of Resident #1's Comprehensive Care Plan, dated 07/04/2025, reflected the focus The resident uses psychotropic (drug that affects behavior and mood) medications was initiated on 07/07/2025. One intervention was to Educate the resident/family/caregivers about risk, benefits, and the side effects and/or toxic symptoms of (SPECIFY: psychotropic medication drugs being given). Record review of Resident #1's Comprehensive Care Plan, dated 07/04/2025, reflected the focus The resident is on pain medication therapy was initiated on 07/11/2025. One intervention was to monitor/document/report PRN adverse reactions to analgesic therapy; altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, respiratory distress/decreased respirations, sedation, urinary retention. Record review of Resident #1's Physician order date 07/03/2025 reflected Oxycodone Hcl (additive for absorption and stability) 10 mg (unit of measurement) oral tablet by mouth every 4 hours as needed for pain - severe. Take 1-1.5 tablet (10-15 mg total). Start date 07/03/2025. Stop date 07/07/2025. Record review of Resident #1's medication administration record reflected the resident received Oxycodone Hcl 10 mg:On 07/03/2025 - at 11:25 PMOn 07/04/2025 - at 5:26 AM and 12:00 PMOn 07/05/2025 - at 2:01 AM, 7:00 AM, 11:30 AM, and 3:30 PMOn 07/06/2025 - at 12:00 AM, 4:45 AM, 11:00 AM, and 3:00 PM On 07/07/2025 - at 1:30 AM and 11:22 AM Record review of Resident #1's Physician Orders, dated 07/07/2025, reflected Oxycodone Hcl 10 mg oral tablet - 1 tablet by mouth every 4 hours as needed for pain - severe. Take 1-1.5 tablet (10-15 mg total). Start date 07/07/2025 at 10:26 PM. Record review of Resident #1's Medication Administration Record reflected the resident received Oxycodone Hcl 15 mg:On 07/08/2025 - at 2:15 AM, 11:00 AM, and 4:05 PM. Record Review of Resident #1's Physician Orders, dated 07/03/2025, reflected Morphine sulfate 15 mg oral tablet - 1 tablet by mouth one time a day for pain - severe. Start date 07/04/2025 at 8:00 AM. Stop date 07/07/2025. Record review of Resident #1's Medication Administration Record reflected the resident received Morphine sulfate 15 mg:On 07/04/2025 - at 8:00 [NAME] 07/05/2025 - at 8:00 [NAME] 07/06/2025 - at 8:00 [NAME] 07/07/2025 - at 8:00 AM Record review of Resident #1's Physician Orders, dated 07/03/2025, reflected Morphine sulfate 15 mg oral tablet - 2 tablets by mouth at bedtime for pain - severe. Start date 07/03/2025 at 9:00 PM. Stop date 07/07/2025. Record review of Resident #1's Medication Administration Record reflected the resident received Morphine sulfate 30 mg:On 07/04/2025 - at 9:00 PMOn 07/05/2025 - at 9:00 PMOn 07/06/2025 - at 9:00 PMOn 07/07/2025 - at 9:00 PM Record review of Resident #1's Physician Orders dated 07/08/2025 reflected Morphine sulfate oral tablet 15 mg - 1 tablet by mouth one time a day for pain - hold for sedation. Start date 07/08/2025 9:00 AM. Stop date 07/08/2025. Record review of Resident #1's Medication Administration Record reflected the resident received Morphine Sulfate 15 mg:On 07/08/2025 - at 9:00 AM Record review of Resident #1's Physician Orders, 07/08/2025, reflected Morphine sulfate 15 mg oral tablet - give 2 tablets by mouth for pain. Start date 07/08/2025 at 8:00 PM. Stop date 07/08/2025. Record review of Resident #1's Medication Administration Record reflected the resident received Morphine sulfate 30 mg:On 07/08/2025 - at 8:00 PM Record review of Resident #1's Physician Orders, dated 07/09/2025, reflected Morphine sulfate 15 mg oral tablet - give 2 tablets two times a day for pain and HOLD FOR SEDATION. Start date 07/09/2025 at 8:00 PM. Stop date 07/09/2025. Record review of Resident #1's Physician Orders dated 07/04/35 reflected Mirtazapine (medication used to treat depression) 30 mg oral tablet - 1 tablet by mouth at bedtime. Start date 07/04/2025 at 9:00 PM. Record review of Resident #1's Medication Administration Record reflected the resident received Mirtazapine 30 mg:On 07/04/2025 - at 9:00 PMOn 07/05/2025 - at 9:00 PMOn 07/06/2025 - at 9:00 PMOn 07/07/2025 - at 9:00 PMOn 07/08/2025 - at 9:00 PM Record review of Resident #1's Physician Orders, dated 07/04/205, reflected Gabapentin (seizure medication used to treat resident's nerve pain) 6 ml=300 mg oral solution by mouth three times a day for neuropathy. Start date 07/04/2025 at 3:00 PM. Record review of Resident #1's Medication Administration Record reflected the resident received Gabapentin oral solution 6 ml = 300 mg: 07/04/2025 - at 3:00 PM and 9:00 PM07/05/2025 - at 9:00 AM, 3:00 PM, and 9:00 PM07/06/2025 - at 9:00 AM, 3:00 PM, and 9:00 PM07/07/2025 - at 9:00 AM, 3:00 PM, and 9:00 PM07/08/2025 - at 9:00 AM, 3:00 PM, and 9:00 PM07/09/2025 - at 9:00 AM Record review of Resident #1's Progress Notes reflected medication orders for Morphine sulfate triggered a warning of a potential drug-to-drug interaction indicating Morphine sulfate may enhance the serotonergic (involves neurotransmitter that affects mood and behavior) effect of Mirtazapine, resulting in serotonin syndrome (potentially life-threatening drug reaction caused by too much serotonin in the body). Record review of Resident #1's Progress Notes reflected medication orders for Oxycodone triggered a warning of a potential drug-to-drug interaction indicating Oxycodone may enhance the serotonergic effect of Mirtazapine, resulting in serotonin syndrome. Record review of Resident #1's Progress Notes reflected LVN B documented on 07/08/2025 8:47 PM Resident in bed appears and oriented, able to respond to all question asked. Family members were present during the administration of her scheduled Morphine and expressed concern that she might be receiving too much pain medications. This nurse explained that pain is assessed based on the patient's report unless there are observable changes. The resident was assessed and stated the pain medication is effectively managing her pain and she does not wish for any changes to the dosage. Record review of Resident #1's Progress Notes reflected on 07/09/2025 at 9:18 AM, LVN A documented the morning dose of morphine was HELD FOR SEDATION. Record review of Resident #1's progress reflected on 07/09/2025 at 12:56 PM, LVN A documented Alert and oriented x 3, denies pain or discomfort during this shift and Morphine 15 mg - 2 tablets by mouth for pain was HELD FOR SEDATION. Record review of Resident #1's Progress Notes reflected the DON documented on 07/09/2025 at 1:13 PM This nurse was notified by facility staff nurse the resident was drowsy. When arriving to the resident room family member at bedside requested resident be sent to the hospital r/t drowsiness. This nurse asked resident and family was anything they wanted the facility to do other than hospital transfer. Family spoke to resident and responded yes to going to hospital via 911. Update was given to nurse to start process to transfer out via 911. Record review of Resident #1's Progress Notes reflected on 07/09/2025 at 1:25 PM, the Treatment Nurse documented This nurse was asked to check on resident. When I entered the room, I noticed that therapy was present and was assisting resident to sit on the side of the bed. She needed ADL care. While sitting on the side of the bed, the resident was unable to hold her head and trunk up on her own. I assisted her to lay back down in the bed. She was lethargic, jerking, altered mental status, alert/orient to last name only. Family member was present and requested that she be sent to hospital. Called 911. Notified doctor. Record review of Resident #1's Progress Notes reflected the DON documented on 07/09/2025 at 3:39 PM Per conversation yesterday with family member concerning her pain medication. Family concerned resident maybe too drowsy to participate in therapy. Family educated that resident spoke to facility pain NP and stated she was still having pain, new orders were given. Educated family and resident if resident is still drowsy facility will send message to pain NP for re-eval. Record review of Resident #1's emergency room hospital record, dated 07/09/2025, reflected acute opioid overdose and acute hypoxic respiratory failure which was noted as likely due to opioid related respiratory depression with an oxygen saturation of 72% on room air. Further review of Resident #1's emergency room hospital records reflected she also was hypotensive ( low blood pressure) upon arrival of 84/47 as a result of the overdose and required IV fluids to stabilize her blood pressure. Record review of Resident #1's hospital record reflected she was admitted to the intensive care unit on 07/09/2025 and was noted to be critically ill requiring high complexity medical interventions and continuous medical evaluation. She required multiple doses of Narcan and ultimately required an IV Narcan drip to reverse the effects of the medications received at the facility. Resident #1's emergency room hospital records indicated the stacking (combination of) of narcotic medications in addition to Gabapentin and Mirtazapine resulted in sedative synergy (toxicity resulting from combining of opioid medications with SSRI (antidepressant that raises serotonin levels) to Resident #1. During a telephone interview on 07/12/2025 at 10:45 AM, Resident #1's family member stated Resident #1 admitted to the facility on [DATE] following an abdominal surgery for a bowel obstruction. The family member stated she came to the facility with another family member to see Resident #1 on 07/08/2025 at about 5:30 PM. She stated, during the visit, she asked Resident #1 to change the channel on the television and noticed the resident's hand was shaking. She stated later Resident #1 stated she needed to go to the restroom and when she tried to get up, she had no strength in her legs and her body was jittery, so they helped her back into bed. The family member stated about 7:30 PM, the nurse came to give Resident #1 medication. The family member stated Resident #1 was taking morphine and oxycodone when she admitted to the facility, but the doses had been increased. She stated she asked the nurse if medication was causing the symptoms Resident #1 was having. She stated she asked the nurse for the doctor's number and was told she could not give it to her. She stated the nurse told her to call social worker, and the social worker could give her number to the doctor. The family member stated she called the social worker the next morning and left a voicemail about the increased medication. She stated the following morning, on 07/09/2025 between 10:00 AM and 11:00 AM, the other family member was at the facility to see Resident #1. She stated the resident was not moving much and when the family member tapped her, she barely opened her eyes. The family member asked the nurse to call for an ambulance and was told it was not necessary. She stated the family member asked if the resident was given too much medication and was told her last dose was at 8:00 PM on 07/08/2025. The family member stated the resident had medication due that morning and wondered why it was not given and if staff had noticed the resident was just sleeping. She stated when the ambulance arrived at the facility on 07/09/2025 between 12:00 PM and 1:00 PM, the resident's oxygen and blood pressure was low, and the resident was taken to the hospital. She stated Narcan was given in the emergency room, and the resident was admitted to the intensive care unit in critical condition. She stated Resident #1 was in the intensive care unit for 2 nights and when the resident was able to transfer to a regular room, the family asked if she could be transferred to the hospital where her doctors and surgeon were for further evaluation. During an interview on 7/12/25 at 1:27 PM, the DON stated Resident #1 admitted with a draining fistula, colostomy (surgical open in abdomen for the colon), and biliary drain (device used to allow blocked bile ducts to drain) after surgery for a bowel obstruction. The DON stated on 07/08/2025, while in Resident #1's room hanging TPN, a family member told her she did not want the resident so drowsy she could not participate with therapy. The DON stated she told the family member she would talk to therapy the following morning. She stated the plan was if the resident were drowsy and unable to participate with therapy, staff would hold the medication and notify the pain management provider to reevaluate the pain medicine. She stated she left the facility about 7:00 PM on 07/08/2025. She stated the nurse contacted her that evening that family did not want Resident #1 to have all her pain medicine. The DON stated the nurse said the resident was fine. The DON stated she told the nurse she would evaluate Resident #1 the following morning to see how the resident was and to hold the pain medication if she was drowsy. She stated the next morning on 07/09/2025, the dose of pain medication was held because the resident refused it, and the pain management doctor was notified. The DON stated at about 1:00 pm on 07/09/2025, the treatment nurse told her Resident #1 had a change of condition and asked the DON to assess the resident. She stated a family member was in the room and told her the resident did not feel right and needed to go to the hospital. The DON stated she asked if there was anything else staff could do. She stated the family did not want the facility to provide any interventions. She stated she unhooked the IV and flushed the line. She stated the resident's vital signs were stable. She stated the resident was lying flat and talking, and she did not observe poor trunk control. She stated Resident #1 did not have signs of overdose or drug toxicity when she transferred to the hospital. She stated Oxycodone was prescribed PRN for breakthrough pain and the resident had the last dose on 07/08/2025 at 4:00 PM. She stated the Morphine was increased to 30 mg twice a day and Resident #1 had the last dose of Morphine on 07/08/2025 at 8:00 PM. She stated Resident #1 had an order to hold the Morphine for sedation. She stated she tried to avoid having residents on oxycodone because, though it had a half-life, it was very potent. The DON stated residents taking pain medication were monitored closely. She stated staff monitored residents for drowsiness and respiratory depression. She stated staff knew what to look for. She stated staff also monitored for effectiveness of medications, especially PRN medications. She stated staff knew to immediately report any change of condition to the DON and also the doctor or nurse practitioner. She stated the facility recently had an in-service about change of condition and notification. During a telephone interview on 07/12/2025 at 5:20 PM, the Medical Director stated Resident #1 admitted to the facility with a high tolerance for pain medication. He stated the pain management provider had seen the resident and slightly increased the dose. He stated he had viewed the hospital record and it looked like stacking. He stated after medication accumulates in the body, it did not take a lot to take a person over the edge. He stated he spoke with the DON and NP the day Resident #1 was transferred to the hospital and was told the facility wanted to give Narcan at the facility, but the family refused. He stated the family should have allowed facility staff to do what they were trained to do, because it could have been a different situation. He stated it was not unusual for a resident to take the amount of medication Resident #1 was prescribed. He stated when a resident was in pain, physicians try to provide comfort. He stated the pain management doctor increased the morphine dose slightly. He stated when Resident #1 arrived at the hospital, family requested for the resident to follow up with her surgeon because of the recent surgery. He stated after the reason for admission was resolved, the surgeon agreed for Resident #1 to be transferred to the hospital where he practiced. During telephone interview on 07/13/25 at 9:50 AM, LVN A stated Resident #1 was in the facility less than a week. He stated he rounded with the night nurse when he came to work on 07/09/2025 at 6:00 AM. He stated there were no changes in Resident #1. He stated he never saw the resident under stress, no shallow breathing, no respiratory change, or signs of overdose. He stated the resident was able to wake up and talk. He stated on 07/09/2025 he held Resident #1's morphine dose that morning because she was sleepy. He stated he took her vital signs which were good. He stated Resident #1 said she was tired and didn't sleep well the night before. He stated a few minutes later he went back asked Resident #1 if she was going to sleep all day, and she just said no, she didn't sleep well. He stated he saw the resident 2 or 3 times before her family arrived. He stated the family member expressed concern about the resident's condition and pain medication. LVN A stated he called the pain management provider and then told the family members the provider could meet them the following morning to discuss the resident's medication. He stated the pain management provider came to the facility the following day, but the resident was at the hospital. LVN A stated on 07/09/2025, when he returned from lunch, the paramedics were in Resident #1's room. He stated the treatment nurse was also in Resident #1's room. He stated he was told when therapy tried to get Resident #1 up, she was shaking. During a telephone interview on 07/13/2025 at 10:06 AM, LVN B stated she was Resident #1's nurse from 2-10 PM on 07/08/2025. She stated family members were in the room when she gave Resident #1 her evening medicine. LVN B stated she asked the resident how she felt, and Resident #1 said the medication was working better. She stated the family member told Resident #1 she was taking a lot of medication and the resident told her no she was not. LVN B stated she told the family members they may feel like it was too much but staff had to go by what residents say. LVN B stated she checked on Resident #1 before she left and she was sleeping. She stated she had no respiratory distress. During an interview on 07/14/2025 at 1:38 PM, the Treatment Nurse stated she did not know what medications Resident #1 was taking. She stated on 07/09/2025 at about 1:25 PM, Resident #1's family member was in the hall looking for a nurse and she went to the room. The Treatment Nurse stated Resident #1 had been at the facility a short time, and she did not have much interaction with her, but noticed Resident #1 was different from the day before. She stated therapy was in the room assisting Resident #1 to sit on the side of the bed. She stated Resident #1 was not holding her head and trunk up on her own. She stated the resident was not alert like the day before and she just knew something was going on. She stated she contacted the DON to let her know about the change of condition and the DON went to the room to assess the resident and speak with the family member and the treatment nurse called 911. During an interview on 07/14/2025 at 2:19 PM, LVN K stated she was Resident #1's nurse during the night shift on 07/08/2025. She stated there were no concerns with Resident #1 during her shift. She stated she gave report and rounded with the morning shift nurse before she left. During a telephone interview at 07/14/2025 at 4:32 PM, the Pain Management Provider stated he was consulted and had seen Resident #1 in the facility. He stated prior to admission to the facility, Resident #1 had an abdominal surgery, which resulted in multiple drains, and the resident was in severe pain. He stated he reviewed her records and Resident #1's Narx score (reflects patient's use of controlled drugs) did not reflect a concern and she had taken pain medication since 2023. He stated Resident #1 had been taking morphine for a few months in combination with oxycodone. He stated after seeing Resident #1, he increased the morning dose of Morphine. He stated it was a mild increase, less than 10-15%. He stated when increasing medication, he increased the minimum dose. He stated the challenge was when a resident takes medication for chronic pain, they also have to look at other medications. He stated some medications worked together to cause more sedation. During a telephone interview on 07/18/2025 at 12:16 PM, CNA R stated she had not taken care of the resident before 07/09/2025. She stated she rotated and worked on different halls. CNA R stated she did not see a CNA on the hall from the previous shift so she went and got information about her residents from LVN A. CNA R stated she rounded on everyone at the beginning of her shift. She stated when she told Resident #1 good morning, she opened her eyes and replied. She stated she turned on the light and told Resident #1 it was about time for breakfast. CNA R stated she went to the dining room for breakfast and rounded on the residents when she returned to the hall. CNA R stated between 10:00 AM and 11:00 AM, she noticed Resident #1 was sluggish. When asked what she meant, CNA R stated Resident #1 was talking but talking slower. CNA R stated she reported it to LVN A. She stated that was only thing she noticed different. She stated family came in between 12:00 PM and 1:00 PM and said that was not usual for the resident. She stated prior to going to the hospital, therapy was working with Resident #1. During a follow up interview on 07/18/2025 at 1:20 PM, LVN A stated he did not remember the time, but during the morning of 07/09/2025, CNA R reported to him Resident #1 was talking slower. LVN A stated he went to the resident's room to check on her and she stated she did not get enough sleep the night before and was just tired. LVN A stated he did not observe any changes in the resident. Review of the facility's policy Adverse Consequences and Medication Errors, revised April 2014, reflected Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported. This was determined to be an Immediate Jeopardy (IJ) on 07/13/2025 at 4:45 PM. The Executive Director, Director of Nurses, Regional Director of Clinical Services, and the Senior Regional Director of Operations were provided with the IJ template on 07/13/2025 at 4:45 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 07/14/2025 at 12:56 PM.Facility: [Facility Name]Date: 07/14/2025Problem: F757 Unnecessary DrugsPlan of RemovalImmediate ActionsResident #1 is no longer in the building. The Medical Director was assigned this resident.1. The Ombudsmen was notified of the content of the immediate jeopardy via email on 07/13/2025.a) On 07/13/2025 The RDCS in-serviced the DON and the Unit Manager with test for competency on reviewing the daily and prn process of:b) Reviewing physicians' orders daily and prn to clarify any uncertainty of dosage/medication (via the mar, the order list report and 24-hour report in Point Click Carec) Monitoring for Signs and symptoms of opioid overdose (i.e . shallow breathing, change in baseline status, decrease in conscientiousness, confusion, cyanotic in color, small pupils.) this will be monitored every shift and prn with the scheduled every shift (qs) pain assessment.d) Usage of Narcan as a reversal for possible opioid overdose to include: dispatching 911, checking for resident response (ask/shake) to ascertain conscientious ; assessing for shallow breathing, pinpoint pupils; actual use of Narcan nasal spray by tilting head back and providing support under the neck, administrating one spray under one nostril and monitoring resident for response; follow up treatment of an additional dosage if no response every 2-3 minutes-- if no change in status, continued monitoring until 911 arrives.e) Dispatching 911 for emergency transferf) Immediate MD and family notificationg) On 07/14/2025 An in-service for all nurses, with competency was initiated on Stacking of Opioids which included the definition of ‘stacking', the cause of stacking (polypharmacy), signs and symptoms, interventions for stacking which include but not limited to nurse assessment physician notification, use of Narcan and recognizing the potential risk for black box warnings and peaks times.2. 0n 07/13/2025 In-services with competency were started with the certified nursing aides utilizing the Stop and Watch tool to assist with identifying changes in condition and immediately reporting those changes.3. On 07/13/2025 The RDCS completed a 100% audit of all residents who are on narcotics and/or opioids, who have the potential to be affected. The results of the audit yielded that no other residents were affected and were at their normal baseline.4. On 07/13/2025 all in-house licensed and registered nurses were re in- serviced with a test to validate competency on:a) Reviewing physicians' orders daily and prn to clarify any uncertainty of dosage/medication (via the mar, the order list report and 24-hour report in Point Click Careb) Monitoring for Signs and symptoms of opioid overdose (i.e . shallow breathing, change in baseline status, decrease in conscientiousness, confusion, cyanotic in color, small pupils.) this will be monitored every shift and prn with the scheduled every shift (qs) pain assessment.c) Usage of Narcan as a reversal for possible opioid overdose to include: dispatching 911, checking for resident response (ask/shake) to ascertain conscientious ; assessing for shallow breathing, pinpoint pupils; actual use of Narcan nasal spray by tilting head back and providing support under the neck, administrating one spray under one nostril and monitoring resident for response; follow up treatment of an additional dosage if no response every 2-3 minutes-- if no change in status, continued monitoring until 911 arrives.d) Dispatching 911 for emergency transfere) Immediate MD and family notificationf) On 07/14/2025 An in-service for all nurses, with competency was initiated on Stacking of Opioids which included the definition of ‘stacking', the cause of stacking (polypharmacy), signs and symptoms, interventions for stacking which include but not limited to nurse assessment physician notification, use of Narcan and recognizing the potential risk for black box warnings and peaks times.Systematic Approach1. On 07/13/2025 A QAPI meeting was held, in attendance were the Medical Director (via TEAMS), Executive Director, DON, the Regional Director of Clinical Services and the Senior Regional Director of Operations. Policy and Procedures on Physician Notification, Medication Administration and Changes in Condition were reviewed and found to be sufficient with company, state, and federal requirements.Monitoring1. DON, UMs were educated by the RDCS on 07/13/25 in the daily process of:a) Reviewing physicians' orders daily and prn to clarify any uncertainty of dosage/medication (via the mar, the order list report and 24-hour report in Point Click Careb) Monitoring for Signs and symptoms of opioid overdose (i.e . shallow breathing, change in baseline status, decrease in conscientiousness, confusion, cyanotic in color, small pupils.) this will be monitored every shift and prn with the scheduled every shift (qs) pain assessment.c) Usage of Narcan as a reversal for possible opioid overdose to include: dispatching 911, checking for resident response (ask/shake) to ascertain conscientious ; assessing for shallow breathing, pinpoint pupils; actual use of Narcan nasal spray by tilting head back and providing support under the neck, administrating one spray under one nostril and monitoring resident for response; follow up treatment of an additional dosage if no response every 2-3 minutes-- if no change in status, continued monitoring until 911 arrives.d) Dispatching 911 for emergency transfere) Immediate MD and family notificationf) On 07/14/2025 An in-service for all nurses, with competency was initiated on Stacking of Opioids which included the definition of ‘stacking', the cause of stacking (polypharmacy), signs and symptoms, interventions for stacking which include but not limited to nurse assessment physician notification, use of Narcan and recognizing the potential risk for black box warnings and peaks times.0n 07/13/2025 In-services with competency were started with the certified nursing aides utilizing the Stop and Watch tool to assist with identifying changes in condition and immediately reporting those changes to the charge nurse.2. The DON and Unit manager were educated by the RDCS on 07/13/25 and will use the Grand Rounds process and 24-hour Summary to identify any and all residents who were started on opioids, had medication dosages and any discontinuation to ensure that appropriate interventions and monitoring is in place. On 07/14/2025 the DON and Unit Manager were educated, with competency by the RDCS on Stacking of Opioids (which included the definition of ‘stacking', the cause of stacking (polypharmacy), signs and symptoms of stacking, interventions for stacking which include but not limited to nurse assessment physician notification, use of Narcan and recognizing the potential risk for black box warnings and peaks times). All of these components will be monitored daily for 2 weeks, weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process.******Any staff (nurses and aides) who are not present to complete the in-service by 7/13/2025 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee.Quality Assurance:Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for [TRUNCAT

**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 one of nine residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was free of significant medication errors when Heparin was administered incorrectly . The noncompliance was identified as PNC. The IJ began on 11/18/2023 and ended 11/18/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by the physician. Findings include: Record review of Resident #1's face sheet, dated 11/19/23, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's relevant diagnoses included embolism and thrombosis of unspecified artery (blood clot.) Record review of the facility Intake Investigation Worksheet, dated 11/18/2023, reflected Incident Details . [Resident #1] received an incorrect Heparin Dose . Description: On the date mentioned above, an incident occurred involving [Resident #1,] who received an incorrect dosage of heparin. The patient's prescribed orders indicated 1 ml every 8 hours. However, [RN F] inadvertently administered 10 ml. The patient was under continuous monitoring following administration. Actions Taken: Upon realizing the error, the patient was closely observed, and as a precautionary measure, she was transferred to the emergency room at [Hospital] for further evaluation and treatment Record review of Resident #1's Physician Orders reflected: Heparin (porcine) 5,000 unit/Ml injection syringe, 1 Subcutaneous with a start date of 11/17/2023. Record review of Resident #1's MAR for November 2023, dated 11/19/2023, at 10:43 AM, reflected Heparin was administered by LVN F at 11/19/2023 at 12:00 AM. Record review of RN F's written statement on 11/18/2023 at 12:43 PM reflected This statement is for [Resident #1]. Resident had an order for Heparin 5,000 units at midnight. This nurse received vial of Heparin in 50,000 units from pharmacy. This nurse went ahead and gave resident 1 vial of 50,000 units instead of 1 ml of 5,000 units from the vial Record review of Resident #1's Hospital Records, dated 11/18/2023, reflected the resident had a diagnosis of heparin overdose and fluid overload. The resident had minor bleeding from the mouth/lip prior to admit. The treatment ordered to treat the heparin overdose was to hold the medication for two days. The resident had fluid overload and required diuretics and monitoring for six days. In an interview with Resident #1's [Hospital] nurse on 11/19/2023 at 10:40 AM, he stated Resident #1 was his patient for that day, and the resident was currently stable, with vital signs within normal limits. An observation and interview on 12/07/2023 at 2:30 PM with Resident #1 revealed she was seated in her wheelchair in her room. She said she was doing well and glad to be back home from the hospital. She said she did not have any concerns about her hospital stay and she did not realize on 11/18/23 she received too much heparin. She said the injection did not hurt. She said she did not have any side effects from the heparin. In interview with RN F on 11/19/2023 at 10:54 AM, he stated he was the residents nurse the evening of the incident. He stated the resident's medication was delivered on 11/18/2023 between 10:00 PM-12:00 AM and he administered Resident #1's medication around midnight. He stated heparin was typically provided in single dose vials and he administered the entire vial to Resident #1. He was aware now the vial was actually 10 doses (50,000 units) and it was inappropriate to administer the medication all at once. He stated the potential outcome could have been resident harm and/or additional illness. He stated the facility suspended him pending the investigation and he was extensively in-serviced on proper medication administration. In an interview with RN S on 11/19/2023 at 10:30 AM, she stated she was the weekend charge nurse during the time of the incident. She stated during her shift, it was discovered Resident #1 received the incorrect dose of heparin, and she reported it to her administrator, DON, and immediately initiated and investigated for the incident. She conducted an assessment on Resident #1 and closely monitored her for any adverse reactions. She stated Resident #1 was sent to [Hospital] for further evaluation and that was where she was currently. It was determined by her investigation that RN F administered a 50,000-unit vial of heparin to Resident #1, and not the 5,000 units as prescribed. She stated the resident's responsible party, physician, and nurse practitioner were informed. After a period of observation, Resident #1 was transferred to the hospital. She then stated she began extensive in-services in response to the incident. In an interview with the DON on 11/19/2023 at 12:00 PM, she stated her expectation was for nursing staff to provide her residents with medications as prescribed. She stated RN F was suspended pending the investigation, leadership in-serviced all relevant staff on medication administration, and nursing leadership conducted skills checkoffs with her staff who administer medications to residents to ensure the safety of her residents. In interview with the Administrator on 11/19/2023 at 12:30 PM, she stated her expectation was for nursing staff to provide residents with medications as prescribed. She stated RN F was suspended and was extensively in-serviced on medication administration. She further stated facility-wide in-services for relevant staff was ongoing to ensure the safety of the residents. She stated if staff did not adhere to proper medication administration of the 6 rights, an incident could happen that affected resident safety. Record review of the facility in-service, Patient rights, Medication policy, Five rights of administering medications, dated 11/18/2023, reflected Administrator educated on the Five Rights of Medication: Right Patient . Proper Medication . Correct Dose . Correct Route . and Fitting Time. Additionally, there are often three more rights that are included in modern medication administration practices Right Documentation . Right Reason . and Right to Refuse. Record review of the facility Employee Coaching and Counseling Record, dated 11/18/2023, reflected RN F was coached and suspended pending investigation due to [RN F] administered an inaccurate dosage of medication to a patient, posing potential harm to the individual. In response, [RN F] has been suspended pending the conclusion of the investigative process . Action To Be Taken . Employees must ensure strict adherence to the five rights of medication at all times. Failure to do so may result in escalated disciplinary measures, up to and including termination. Record review of the facility reference material located within the facility's system, Heparin, rev . 10/2023, reflected Uses: This medication is used to prevent and treat blood clots . Symptoms of overdose may include: easy/unusual bruising, easy/unusual bleeding (such as frequent nosebleeds), blood in urine, black stools. Record review of the facility's, undated, policy provided by the Administrator on 11/19/2023 at 12:30 PM, Medication Administration,, reflected 2. The 6 Rights of Medication Administration . a. Right Patient . b. Right Drug. Verify prescription label to [DATE] time in different ways i. Drug name ii. Drug strength . c. Right Dose. Verify the MAR to label, these MUST MATCH . d. Right Dosage Form. Verify the MAR to label, these MUST MATCH. e. Right Time . f. Right Route . g. Right Indication This was determined to be a PNC IJ from 11/18/2023-11/18/2023. The Administrator was notified of the PNC IJ on 12/07/2023 at 5:25 PM. The facility took the following action to correct the non-compliance on 11/18/2023 : Record review of in-services and actions taken by the facility on 11/18/2023 reflected: An emergency QAPI meeting was conducted on 11/18/2023, and the following performance improvement plan was initiated: Mandatory nurse skills checkoffs were conducted to enhance the proficiency of nursing staff in medication administration, accompanied by comprehensive in-service training on the five/six rights of medication. Additionally, employee survey questions were deployed to solicit feedback and insights into medication administration practices and testing the knowledge and competency of the nursing staff. To maintain adherence to medication administration protocols, routine weekly spot checks were being conducted. Findings from these checks and statements were diligently reported daily during Quality Assurance (QA) meetings for prompt review and necessary action. In-service and return demonstrations had been implemented on correctly entering medication orders on the computer to avoid errors. RN F was suspended pending investigation and was then terminated. RN F did not return to work at the facility after 11/18/23. The facility created a heparin check list that required the nurse to complete before administering a dose of heparin. The facility put in place that heparin doses had to be checked by two nurses prior to administration and if there were any questions about the dose, the nurse had to call the physician. Nurses had to complete a skills competency check-off with nursing administration and pharmacy services. Interviews with 5 nurses from all shifts, (LVN A, LVN B, LVN C, LVN D, and LVN E ) starting at 11:00 AM - 6:00 PM, revealed they were in-serviced regarding Heparin dosages, medication errors, competency skills checkoffs, rights of medications, and to seek clarification from a doctor if needed for a Heparin dose. Heparin had to be checked off with 2 nurses and a heparin check-off list had to be completed. Staff were also provided with a picture of a Heparin vial with 50,000 units/10 ml with an order to administer 5,000 units/1.0 ml. The nurses were able to verbalize the correct dose to give. An interview on 12/07/2023 at 6:10 PM with the DON revealed measures were in place to prevent future heparin overdoses. Currently there were no residents with heparin orders. The DON said she did weekly random monitoring of medication administration and the nurse completed skills checkoffs with administering medications. The DON said Heparin orders had to be double-checked with another nurse and the nurse had to call the physician if order clarification was needed. An interview on 12/07/2023 at 6:15 PM with the Administrator revealed measures were in place to prevent future heparin errors. The Administrator said nurses including new hires had to complete skills checkoffs with administrative staff and pharmacy staff. Additionally, heparin had a separate checklist had to be completed prior to administration. She said monitoring wound continue with facility QAPI meetings. The noncompliance was identified as PNC IJ. The IJ began on 11/18/2023 and ended 11/18/2023. The facility had corrected the noncompliance before the survey began .