**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 1of 6 residents (Resident #1) reviewed for significant medication errors. The facility did not provide Resident #1's physician ordered Potassium Chloride ER Tablet for four days. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #1's face sheet, dated 8/25/23, indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included Dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Stage 3 kidney disease (means your kidneys have moderate damage that impairs their ability to filter waste and toxins from your blood), hyperlipidemia (means your blood has too many lipids (or fats), hypertension (means that your blood is pumping with more force than normal through your arteries), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), lung cancer, heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), and iron deficiency anemia (type of anemia that develops if you do not have enough iron in your body). Record review of Resident #1's lab results, dated 8/11/23, revealed her potassium level was 2.5, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/11/23, revealed the facility received critical labs from the laboratory, that residents K+ was 2.5. Notified doctor of results. Received orders to start Potassium Chloride 20 MEQ BID. Record review of Resident #1's physician order, dated 8/11/23, revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia (a metabolic imbalance characterized by extremely low potassium levels in the blood). Order date 8/11/23, Start date 8/12/23, End date 8/18/23. Record review of Resident' #1's MAR from 8/1/23 to 8/31/23 revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ, give 1 tablet by mouth two times a day for Hypokalemia. Start date 8/12/23 at 6:00 AM, Discontinued date 8/18/23 at 12:56 PM. The MAR indicated Resident #1 received the medication as prescribed from 8/12/23 to 8/15/23. Record review of Resident #1's lab results, dated 8/15/23, revealed her potassium level was 2.1, reference range 3.5 - 5.1. Record review of Resident #1's nurse note, dated 8/15/23, revealed the facility received critical low Potassium lab of 2.1. Also, received order to administer Potassium Chloride ER Tablet Extended Release 20 MEQ (2 tablets) now and 2 tablets after an hour. Record review of Resident #1's nurse note, dated 8/15/23, revealed the ADON wrote she spoke with the doctor regarding new orders for potassium and discussed sending Resident #1 to emergency room for critical lab level of potassium 2.1. Received new order per doctor to send Resident #1 to emergency room for evaluation. Charge nurse notified and instructed to call emergency room to give report and family to notify. Record review of Resident #1's incident report, dated 8/15/23, revealed the DON wrote the following: Nursing Description: Staff notified DON that [Resident #1] Potassium level was still low and now critically low K+ level, The PCP was notified and new orders were placed to give 40 meqs now and 40 meqs in 1 hour. Resident Description: [Resident #1] was alert and oriented with no N/V or chest pain she was unable to remember if she had received the K+ as scheduled. Description: Investigation began, called PCP due to [Resident #1] needing to be closely monitored, out of caution. Called all med aids and asked about administering the potassium they had all documented that it had been given. checked med cart K+ was not on cart. Checked med room, medication was available in medroom; no medications had been punched out of the card. Record review of Resident #1's hospital note, dated 8/15/23, revealed abnormal labs as chief complaint. Also, during emergency room evaluation, Resident #1 was alert and oriented, denied chest pains, palpitations, or shortness of breath. Hypokalemia, potassium was 2.1 on arrival. Potassium lab retaken in emergency room and was 2.1. During an interview with Resident #1's family member on 8/25/23 at 5:03 p.m., she said Resident #1's potassium was seriously low, and she missed at least 3 days of getting potassium medications because it was not given and as a result Resident #1 was admitted into the hospital on 8/15/23. She said Resident #1 told her at the hospital her heart felt like it was beating faster. During an interview on 8/25/23 at 2:30 p.m., the DON said Resident #1 currently had lung cancer and declined all treatments for cancer. She said Resident #1's health declined within the last couple of months and was on Hospice services. The DON stated the complaint visit was regarding Resident #1 due to medication error with potassium, four days was missed, and Resident #1 was sent to the hospital due to critical low potassium level. The DON said CMA B, CMA C, LVN D and CMA E were terminated due to documenting on the MAR they administered Resident #1's Potassium medication when they did not give Resident #1 her potassium medication. She said Resident #1's, 8/11/23, potassium labs came back low 2.5, the doctor ordered potassium and labs were done again on 8/15/23 but potassium results were more critically low, 2.1, which was lower than on 8/11/23. The DON said she was alerted and concerned by the 8/15/23 lab levels because Resident #1 was taking Potassium twice a day from 8/12/23 to 8/15/23 and potassium level should have improved. The DON said she personally went to the med cart and looked for Resident #1's potassium medication and did not find it, she said she found Resident #1's potassium in the medication room unopened and said, it was no way CMAs was giving Resident #1 her potassium medicine. The DON said Resident #1 never received Potassium after receiving the initial dose on 8/11/23. During an interview on 8/25/23 at 7:15 p.m., the DON said Resident #1 missed potassium medication on the following dates: 8/12/23, 8/13/23, 8/14/23 and 8/15/23 and was sent to the hospital on the 15th. During a telephone interview on 8/27/23 at 3:57 p.m., CMA B said she was terminated due to a medication error. She said on 8/14/23 she was rushing and did not see Resident 1's new potassium order and did not realize she marked the MAR which indicated it was given. CMA B said the DON asked for her to get Resident #1's potassium medication off the medication cart and she did not see it. During a telephone interview on 8/27/23 at 4:22 p.m., CMA C said on 8/15/23 she received a call from the DON regarding Resident #1's potassium medication. She said the DON explained Resident #1's potassium was extremely low and the new order for potassium was not given. CMA C said Resident #1's MAR was marked that potassium was given, but it was not. She said she was not aware she marked the medication was given and said she made a mistake because it was not intentional. CMA C said Resident #1's potassium medication was found in the medication room, and she had access to the medication room. She said the steps to administer medications were to first, read the MAR second, look at medication, check the dosage, check the resident name and third, administer the medication. CMA C said on 8/22/23 she received a call from the DON explaining she was terminated due to falsification of documentation on Resident #1's MAR. During a telephone interview on 8/27/23 at 5:21 p.m., LVN D said on 8/15/23 she received a call from the DON and the ADON asking if she gave Resident #1 her potassium medication. LVN D said she did not falsify documentation, because she gave Resident #1 another resident's potassium medication from the med cart. LVN D said she knew what she did was wrong, but she was busy giving meds and did not have time to go track down Resident #1's potassium medication so she borrowed another resident's med. LVN D said she could not recall what resident she borrowed the potassium pill from and did not document she gave another residents medication and did not notify the DON or the ADON on what she did. LVN D said the steps for administering medications were first, look at the MAR second, check dosage, check patient name, make sure order match MAR, check time and route, third, administer medication. She said she was suspended effective 8/15/23 and received another call on 8/22/23 that she was terminated for falsifying documentation. LVN D said the facility would not allow her to return to facility and felt the facility was throwing her and the other three staff under the bus because they were possibly trying to cover up something. During a telephone interview on 8/27/23 at 5:32 p.m., CMA E said on 8/12/23 Resident #1's Potassium order had changed, and she was not aware. She said on 8/19/23 she received a call to return to the facility regarding Resident #1 critical low potassium. CMA E said she never saw Resident #1's potassium on the med cart or listed on the MARs. The DON showed her Resident #1's MAR in question; CMA E said she was busy with 60 residents and tried to give them all their medications, so it was possible that she was rushing and accidently clicked she gave Resident #1 her potassium medication when she did not administer the medicine. CMA E said it was not intentional to falsify Resident #1's MAR. CMA E said when administering medications she first, compared the medication card to MAR; second she looked at the resident name, dosage and medicine to make sure everything was correct and third, she administered the medication. Record review of immediate response plan due to potential medication administration error, dated 8/15/23, indicated Resident #1 was noted with and abnormal K+ level. On 8/15/23 it was noted Resident #1 had an order for Potassium 20 meq by mouth twice a day to start the morning of 8/12/23. Medication was not administered per doctors' orders. Resident was assessed and stable. Immediate Response: As soon as potential medication error was identified nursing immediately assessed the resident. Outcome - Resident #1 presented stable, MD notified of abnormal lab results and potential medication error notification. Out of an abundance of caution MD ordered that resident be sent to the ER for evaluation and treatment as indicated. Risk Response: All residents prescribed a potassium supplement medication were assessed. Outcome - No negative outcomes or changes in condition were identified. Date Completed: 8/15/2023 *DON/ADON interviewed licensed nurse and medication aides responsible for the medication error. *DON/ADON re-educated: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. -What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON conducted an audit to validate all other residents who had an active potassium order had the correct medication available on the carts for administration and to ensure the medication was being administered as ordered. Audit was completed on 8/15/23. Outcome - Results of the potassium order audit revealed no medication administration discrepancies, and all potassium medications were available, on the carts and administered as per physician's orders. Date Completed: 8/15/23. *DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. Systemic Response: DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. In-service training and re-education will be provided to all licensed nurses and medication aides regarding topics by the DON/ADON: *Re-education consisted of the following topics: Proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. What to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Date commenced: 8/15/23; Date completed: 8/15/23. *DON/ADON will ensure all licensed nurses and medication aids (full -time, part - time, newly hired nurses and med aids and any agency staff) will receive the in-service prior to working their next shift. * DON/ADON/Designee conducted interviews and an audit on MARS and medication carts were in order to validate those medications was available and being administered ordered. Outcome - No negative outcomes or changes in condition were identified. Date completed: 8/17/23. *IDT (to include but not limited to: Administrator/DON/ADON) and Medical Director conducted an QAPI to review issue and community's response plan in place. Date of completion: 8/18/23 Monitoring Response: The DON/ADON will conduct random at least weekly (1-7 days per week) audit of physician orders to validate availability of medications on the carts and observations of medication administration to validate medication administration competency. DON/ADON will conduct daily reviews during clinical start - up meeting (1-7days per week) review of new medication orders, pertinent lab results (K+ levels), progress notes, and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next two months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next two months. Interviews and record reviews were conducted on 8/28/23 from 6:00 p.m. through 8:00 p.m. and on 8/29/23 from 1:35 p.m. through 4:00 p.m., and included 3 RNs, 3 LVNs, 3 CMAs, and DON. Staff said they were trained on medication administration, documentation, medication refill process, and what to do if medications were not available. Staff were able to explain the proper medication administration process, community's expected process for proper medication administration process, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration. This included verifying the medication administered record to the actual medication. The Medication Administration policy was established 3/2019. As well as documentation of medication administration, medication availability to include - receiving and accessing new medications and refilled medications in order to ensure that the medications were available on the carts for administration as ordered. Staff had knowledge on what to do if the medication was not on the cart and not available for administration example: check the medication room, check the carts thoroughly and if not located for medication aids, the med aid must notify the nurse, so that the nurse can ensure the needed medication was retrieved from the stat safe (emergency medication cart) so that the medication may be administered as ordered. Nurses should also respond by contacting the dispensing pharmacy in order to order and/or re-order the medication and the nurse are to contact the MD to report status of the medication not being available for administration and following any additional orders provided. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA B; Date of Policy violation: 8/14/23; Summary of violation: Medication administration error - documented meds were given when they were not. Falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice, dated 8/15/23, revealed the following: Staff: CMA C; Dates of policy violation: 8/12/23 and 8/13/23; Summary of violation: Administered medication incorrectly - falsified MAR document stating med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: LVN D; Dates of policy violation: 8/12/23; Summary of violation: Administered medication incorrectly - falsified MAR document and charted med was given when it was not; Suspended effective 8/15/23 pending investigation results. Record review of conduct and workplace expectation notice dated 8/15/23 revealed the following: Staff: CMA E; Dates of policy violation: 8/14/23 and 8/15/23; Summary of violation: Did not administer med as directed - falsified MAR document; Suspended effective 8/15/23 pending investigation results. Record review of Medication administration Policy dated 3/15/19 revealed Resident medications are administered in an accurate, safe, timely, and sanitary manner .Documentation: Initial the electronic administration record after the medication is administered to the resident. The noncompliance was identified as PNC. The IJ began on 8/12/2023 and ended on 8/17/2023. 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 ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #2) reviewed for pressure injuries. The facility failed to ensure Resident #2's did not develop a Stage 4 (a deep wound reaching muscle, ligaments, or bone) pressure ulcer. The facility failed to ensure Resident #2 received necessary treatment and services to promote healing and prevent infection of a Stage 4 pressure ulcer. The facility failed to update Resident #2's care plan to include development of a pressure ulcer and interventions to be taken. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/23/23 at 12:15 p.m. While the IJ was removed on 5/24/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Record review of consolidated physician orders dated 5/24/23 indicated Resident #2 was an [AGE] year-old female, admitted on [DATE] with diagnoses including displaced fracture of the right femur (fracture to the bone in the right thigh where the ends of the bone are not aligned), muscle weakness, lack of coordination, and hypertension (elevated blood pressure). The physician orders indicated Resident #2 had an order to cleanse her coccyx (small triangular bone at the base of the spinal column) with normal saline/wound cleanser, pat dry, apply collagen, and apply dry dressing daily starting 10/02/22. Record review of the Treatment Administration Record (TAR) dated October 2022 indicated Resident #2 only had wound care performed on 10/03/22, 10/04/22, 10/05/22, 10/06/22, 10/07/22, 10/1022, 10/11/22, 10/12/22, and 10/13/22. Record review of the comprehensive MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS score of 05 and had severe cognitive impairment. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, and toileting. The MDS indicated Resident #2 was totally dependent with personal hygiene. The MDS indicated Resident #2 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #2 did not have any pressure ulcers. Record review of the care plan dated 9/27/22 indicated Resident #2 had fragile skin and was at risk for skin injury with no interventions in place. The care plan indicated Resident #2 had incontinence with no interventions in place. Record review of the Braden Scale for Predicting Pressure Sore Risk dated 9/28/22 Resident #2 was at risk for developing pressure sores. Record review of the nursing progress note dated 10/02/22 indicated Resident #2 was noted with a 3.5cm x 4.2cm x 0.1cm open area to the coccyx with red granulation to the wound bed, pink shearing to the outer edges, and a scant amount of drainage. Record review of the progress note from the wound care physician dated 10/07/22 indicated Resident #2 had a stage 4 pressure wound to the sacrum (area of the spine located at the end of the spine just above the coccyx) great than 1 day in duration, measuring 3cm x 6cm x 0.2cm, and 70% slough (yellowish white material in the wound bed). The progress noted indicated recommendations were made including reposition per facility protocol, a group-2 mattress (low air loss mattress), and a prealbumin (protein) level on 10/07/22 for Resident #2. Record review of the progress note from the wound care physician dated 10/10/22 indicated Resident #2 had a stage 4 pressure wound to the sacrum greater than 3 days in duration, measuring 3cm x 6cm x 0.2cm, and 70% slough. The progress noted indicated recommendations were made including reposition per facility protocol and a group-2 mattress (low air loss mattress). Record review of the Skin and Wound Evaluation dated 10/13/22 indicated Resident #2 had a facility acquired, stage 4 pressure wound to her sacrum. The Skin and Wound Evaluation indicated the pressure wound had been present for 1 week. The Skin and Wound Evaluation indicated the pressure wound measured 5.8cm x 3.4cm x 0.2cm with 80% slough. The Skin and Wound Evaluation indicated interventions for Resident #2's wound included wound care as ordered by the physician, positioning wedge, and turn/reposition program. Record review of the nursing progress note dated 10/13/22 indicated Resident #2's wound to the buttocks had a foul-smelling odor along with green slough. Record review of the nursing progress notes indicated Resident #2 discharged home on [DATE]. During an interview on 5/17/23 at 10:44 p.m. the Treatment Nurse said he had been working at the facility for approximately 8 months. The Treatment Nurse said he did not remember Resident #2. During an interview on 5/17/23 at 2:05 pm the DON said she started at the facility on 2/28/23. The DON said the facility had a large turnover with clinical staff. The DON said none of the nurses currently working at the facility were employed at the facility in October 2022 except the Treatment Nurse. During an interview on 5/23/23 at 11:41 p.m. the DON said residents with low air loss mattresses should have an order in the physician orders. The DON said residents with stage 3 (full thickness tissue loss) or stage 4 pressure ulcers were automatically put on a low air loss mattress for prevention. The DON said residents with a stage 1 (pressure injury that is not open) or stage 2 (open wounds) pressure ulcer were not put on low air loss mattresses. During an interview on 5/23/23 at 11:55 a.m. the Corporate Nurse said low air loss mattresses were an intervention and did not require a physician order. The Corporate Nurse said a low air loss mattress could be identified as in intervention on the skin/wound assessment or on the resident's care plan. The Corporate Nurse said she did not believe Resident #2 was on a low air loss mattress. During an interview on 5/24/23 at 11:00 a.m. the Corporate Nurse said there was no way she could verify whether or not Resident #2 had a low air loss mattress when she was in the facility. Record review of the facility's Skin and Wound Management policy dated 3/14/19 indicated, Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. Each resident is assessed to determine his or her risk for their skin integrity being compromised or the presence of wounds and/or pressure injuries. A plan of care should be developed and implemented based on the skin reviews/checks. If skin compromise occurs, the interdisciplinary team notifies the physician for any orders and those appropriate measures and additional interventions are put in place to minimize further compromising the skin and to aid in healing to the extent possible .Residents identified as at risk for development of pressure injuries should have a plan and interventions included in the care plan to address each risk factor individually .Residents with identified pressure injuries should be reviewed by the Interdisciplinary Team and a care plan should be developed, implemented, evaluated, and re-evaluated as clinically indicated . The Administrator was notified on 5/23/23 at 12:30 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 5/23/23 at 12:31 p.m. The facility's Plan of Removal was accepted on 5/23/23 at 6:26 p.m. and included: Resident #2 had an open area to the coccyx identified on 10/2/2022. Treatment orders were obtained on 10/2/2022. On 10/13/2022 a skin and wound evaluation on Resident #2 indicated a facility acquired stage 4 to the sacrum. Resident #2 discharged home on [DATE]. Conducted audit of: o DON/ADON conducted skin assessments were conducted on 100% of 107 residents on 5/23/2023. o All residents at risk of obtaining pressure ulcers have preventive measures in place documented in the care plan. Any discrepancies are addressed by DON/ADON/Wound Nurse. Completed on 5/23/2023. o All residents with pressure ulcers to ensure they are receiving necessary treatment and services to promote healing and prevent infection of pressure ulcer as ordered by physician and documented in care plan. Any discrepancies addressed by DON/ADON/Wound Nurse. Completed 5/23/2023. o All residents with pressure ulcers have person centered plan of care to include development of a pressure ulcer and interventions to be taken. Regional Director of Nurses reviewed the 7 residents with wounds. One resident needed an additional intervention. Wound Nurse/DON/ADON will update care plans and/or interventions upon any decline in pressure injury. Date commenced: 5/23/2023 Date completed: 5/24/2023 at 11:00am DON/ADON in-serviced licensed nurses regarding: o Skin assessment completed upon admission, readmission, weekly and as needed o Implementing the admission plan of care problem, goal, interventions for skin concerns, identified wounds and risk for skin injury. To include following physician orders regarding all wound care and wound care consultations. o Documentation process for identified skin wounds o Proper staging of wounds o Notifications of new wounds, changes, or deterioration of wounds and resolved wounds to MD, resident representative, and DON. o Communication with IDT of all wounds newly identified and/or admitted with o Low air loss mattresses will be used with stage 3 and 4 pressure injuries and/or as clinical indicated. Date commenced: 5/23/2023 Date of completion: 5/24/2023 at 11:00am Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working the next shift. DON/ADON will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires. Risk Response: Residents who are at risk for skin breakdown may have the potential to have been affected by the deficient practice. DON/ADON conducted audit of: DON/ADON conducted skin assessments on 100% of 107 residents. All residents at risk of obtaining pressure ulcer have preventive measures in place. Any discrepancies addressed by DON/ADON/Wound Nurse. All residents with pressure ulcers to ensure they are receiving necessary treatment and services to promote healing and prevent infection of pressure ulcer as ordered by physician and documented in care plan. Any discrepancies addressed by DON/ADON/Wound Nurse. o All residents with pressure ulcers have person centered plan of care to include development of a pressure ulcer and interventions to be taken. Regional Director of Nurses reviewed the 7 residents with wounds. One resident needed an additional intervention. Wound Nurse/DON/ADON will update care plans and/or interventions upon any decline in pressure injury. Date commenced: 5/23/2023 Date completed: 5/24/2023 at 11:00am Systemic Response: DON/ADON in-serviced licensed nurses regarding: o Skin assessment completed upon admission, readmission, weekly and as needed o Implementing the admission plan of care problem, goal, interventions for skin concerns, identified wounds and risk for skin injury. To include following physician orders regarding all wound care and wound care consultations. o Documentation process for identified skin wounds o Proper staging of wounds o Notifications of new wounds, changes, or deterioration of wounds and resolved wounds to MD, resident representative, and DON. o Communication with IDT of all wounds newly identified and/or admitted with o Low air loss mattresses will be used with stage 3 and 4 pressure injuries and/or as clinical indicated. Date Commenced: 5/23/2023 Date Completed: 5/24/2023 at 11:00am Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Director of Nursing / ADON will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Monitoring Response: The Director of Nursing / ADON will conduct random weekly (1-7 days per week) audit of new admissions, readmissions, residents with pressure ulcers, and resident at risk to develop pressure ulcers to ensure appropriate interventions in place to prevent and treat and pressure ulcers. DNS/ADON will conduct daily reviews during clinical start-up meetings (1-7days per week) review of progress notes, SBARs and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months and documented in the QAPI minutes. IDT and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of completion: 5/24/2023 at 11:00am On 5/24/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of all residents indicated skin assessments had been performed on all residents in the facility. Records review of all residents with pressure sores indicated their care plans were up to date with appropriate interventions in place. Observations of all residents with pressure sores indicated interventions were implemented including low air loss mattresses, pressure reducing mattresses, wedge and pillows for positioning, and pressure relieving cushion in wheelchairs. Record review of a sample of residents at risk for pressure sores indicated care plans were up to date with appropriate interventions in place. Interviews of staff (RN Q works 6:00 a.m. to 6:00 p.m., LVN P works 6:00 a.m. to 6:00 p.m., RN S, works 6:00 p.m. to 6:00 a.m., LVN T works 6:00 p.m. to 6:00 a.m., LVN N works 6:00 a.m. to 6:00 p.m., RN U works 8:00 a.m. to 5:00 p.m., LVN R works 8:00 a.m. to 5:00 p.m., LVN V works all shifts, and LVN C works 6:00 a.m. to 6:00 p.m.) on 5/24/23 between 11:50 a.m. and 2:45 p.m. were able to identify when skin assessments should be performed, who can stage a wound, what the different stages of a wound were, what interventions should be in place for wound prevention and healing, and who to notify in the case of a newly identified or worsening wound. Record review of the QAPI sign in sheet indicated a QAPI meeting was held on 5/24/23 indicated all appropriate members if the Interdisciplinary Team were in attendance. While the IJ was removed on 5/24/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and records review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 5ml (100mg) of morphine 20mg/ml when her order was for morphine 20mg/ml give 0.25ml (5mg) every 3 hours as needed resulting in adverse reactions of vomiting, itching, shaking, and twitching of the eyes. 2. The facility failed to monitor Resident #1 after administering 20 times the ordered dose of morphine. 3. The facility failed to ensure Resident #1's morphine order was properly transcribed. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/17/23 at 3:10 p.m. While the IJ was removed on 5/22/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for harm or death relating to being administered too much medication. Finding Include: 1. Record review of the face sheet dated 5/24/23 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, alcohol-induced dementia, and alcohol-induced psychotic disorder. Record review of the physician orders dated 5/01/23 through 3/31/2023 indicated Resident #1 had an order Morphine 20 mg/ml give 5ml by mouth every 3 hours as needed starting 3/30/23 and ending 5/15/23. The physician orders indicated Resident #1 had an order for Morphine 20mg/ml give 0.25 ml by mouth every 3 hours as needed starting 5/15/23. Record review if the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS did not indicated Resident #1 had a BIMS evaluation. The MDS indicated Resident #1 required extensive assistance with toileting and personal hygiene. The MDS indicated Resident #1 required limited assistance with bed mobility, transfers, and dressing. The MDS indicated Resident #1 required supervision with eating. Record review of the care plan last revised 3/17/23 indicted Resident #1 was at risk for experiencing discomfort or pain with interventions including administer medication to relieve pain as recommended by the physician and coordinate with the physician and review medications as indicated to ensure Resident #1 was on the least amount of medication at the lowest dose to treat her pain. Record review of the MAR dated May 2023 indicated Resident #1 had been administered 5ml of Morphine on 5/02/23 and 5/14/23. Record review of the undated Narcotic Count Sheet for Resident #1's Morphine 20mg/ml bottle indicated the dosage was Morphine 20mg/ml give 0.25ml every 3 hours as needed. The Narcotic Count Sheet indicated the initial amount of Morphine received was 30ml. The Narcotic Count Sheet indicated Resident #1 received 0.25ml of Morphine on 5/02/23 leaving 29.75ml in the bottle. The Narcotic Count Sheet indicated Resident #1 received 5ml of Morphine on 5/14/23 leaving 24.75ml in the bottle. Record review of Morphine container for Resident #1 indicated the order for her Morphine was Morphine 20mg/ml 0.25ml (5mg) by mouth every 3 hours as needed. Record review of the Nurse Progress Note dated 5/14/23 at 11:45 a.m. indicated Resident #1 was administered 5ml of Morphine. Record review of the Nurse Progress Note dated 5/14/23 at 3:01 p.m. indicated the Morphine was effective. Record review of the Nurse Progress Notes dated 5/15/23 at 5:20 a.m. written by RN K indicated Resident #1 had vomited all over her floor and down the hallway. The Nurse Progress Note indicated the nurse had taken Resident #1 to the bathroom to clean her up and noticed Resident #1 had scratch marks all over her legs, arms, chest, and shoulders. The Nurse Progress Note indicated Resident #1 was shaking and twitching her eyes. The Nurse Progress Note indicated the nurse sat Resident #1 at the nurse's station and pushed fluids. The Nurse Progress Note indicated the DON and hospice were notified. Record review of the Nurse Progress Note dated 5/15/23 at 8:26 a.m. written by the DON indicated she was notified at 1:00 a.m. by RN K that there may have been a medication error. The Nurse Progress Note indicated RN K was reviewing Resident #1's Narcotic Count Sheet and noticed it looked like the nurse on the previous shift had given 5ml of Morphine to Resident #1, but the bottle appeared to have 27ml instead of 24ml of Morphine in it. The Nursing Progress Note indicated the DON asked if Resident #1 was okay. The Nursing Progress Noted indicated RN K said Resident #1 was okay and was sleeping. The Nursing Progress Noted indicated the DON told RN K it was probably a writing error. The Nursing Progress Noted indicated the DON called back to the facility around 5:00 a.m. and was informed by RN K that Resident #1 was shaking, twitching, and vomited. The Nurse Progress Note indicated RN K told the DON she had notified hospice and the physician and was passing it off to the day shift to notify the family. Record review of Resident #1 vitals signs for May 2023 indicated she had blood pressure checks performed on 5/12/23 at 5:45 p.m., 5/15/23 at 4:25 p.m., and 5/18/23 at 7:08 p.m. The Vital Signs indicated Resident #1's pulse had been checked on 5/13/23 at 10:34 a.m., 5/15/23 at 8:23 a.m., and 5/16/23 at 8:53 a.m. The Vital Signs indicated Resident #1's respirations had been checked on 5/13/23 at 10:34 p.m., 5/15/23 at 8:23 a.m., and 5/17/23 at 12:29 p.m. During an interview on 5/17/23 at 8:55 a.m. the Hospice Director said the hospice company had been notified via message being left on 5/15/23 at 5:53 a.m. that Resident #1 had been administered 100mg (5ml) of Morphine. The Hospice Director said the hospice company did an audit of Resident #1's orders and determined Resident #1's order had been for Morphine 20mg/ml give 0.25ml (5mg) by mouth every 3 hours as needed. The Hospice Director said this order had been the order provided to the facility. The Hospice Director said the normal dose of Morphine they prescribe was 5-10mg, and they started patients on a very low dose. The Hospice Director said signs and symptoms of Morphine overdose included decreased level of consciousness and lethargy. The Hospice Director said the facility reported Resident #1 was itching and had vomited. The Hospice Director said they contacted their pharmacist regarding the overdose and he was shocked. The Hospice Director said their pharmacist had informed the hospice company 5ml (100mg) of morphine could have been a fatal dose. The Hospice Director said that she would expect the facility to monitor vital signs and perform neuro checks in the event of a morphine overdose. During an interview on 5/17/23 at 9:18 am LVN L said he entered the Morphine order on 3/30/23 for Resident #1. LVN L said the order he entered was incorrect and should have read Morphine 20mg/ml 0.25ml (5mg) by mouth every 3 hours as needed instead of Morphine 20mg/ml 5ml by mouth every 3 hours as needed. LVN L said he did not know the procedure for someone verifying orders once they were entered into the EMR. LVN L said when medications were administered the nurse or MA should compare the order on the MAR with the directions on the medication container. LVN L said if there was a discrepancy in the order and medication container it should be verified by the physician or pharmacy. LVN L said the morphine overdose Resident #1 received could have been fatal. LVN L said Resident #1's vital signs should have been monitored following the overdose. During an observation on 5/17/23 at 9:30 am Resident #1 was walking around the facility. Resident #1 had on a long-sleeved cardigan, long pants, and non-skid sicks. Resident #1 was confused and unable to be interviewed. During an interview on 5/17/23 at 9:44 am LVN M said she had been the nurse working on 5/14/23. LVN M said she administered Resident #1 Morphine 20mg/ml 5ml by mouth. LVN M said she compared the order to the order on the morphine box/bottle. LVN M said Resident #1's order was for Morphine 20mg/ml 5ml by mouth and the box/bottle read Morphine 20mg/ml 5mg (0.25ml) by mouth. LVN M said that 5ml and 5mg were the same. LVN M said Resident #1 was sleepy after she administered the morphine. LVN M said the morphine administered to Resident #1 was effective for her pain. LVN M said on 5/15/23 the DON informed her she had administered too much morphine to Resident #1 on 5/14/23. LVN M said the DON had told her she should have administered 0.5ml instead of 5ml of morphine to Resident #1. LVN M said the morphine overdose could have been fatal. LVN M said Resident #1's behaviors and vital signs should have been monitored following the overdose. During an interview on 5/17/23 at 10:02 am the DON said she had started at the facility in February 2023. The DON said she had been in her position since 4/21/23. The DON said the Morphine 20mg/ml 5ml by mouth was not the correct order for Resident #1. The DON said the policy at the facility was for nursing management to check orders after they were entered into the EMR. The DON said the incorrect order had been entered on 3/30/23 and the previous interim DON should have checked the orders. The DON said when administering medications staff should not administered by what the order says only. The DON said when administering medication staff should use the 5 rights of medication administration (Right Resident, Right Medication, Right Dose, Right Route, Right Time). The DON said the morphine overdose could have caused respiratory depression and death. The DON said in the event of a morphine overdose since morphine was a short acting medication vital signs should be monitored every shift for 24 hours. The DON said vital signs would be monitored more often or longer if an order was given by the physician. During an interview at 5/17/23 at 11:08 a.m. MA B said she only looked at the orders to verify medications and dosage when administering medications. MA B said she did not feel like she should have to compare the order to the medication. MA B said the orders on the MAR should be correct. MA B could only name 2 out of 5 (Right Resident and Right Medication) right of medication administration. During an interview on 5/17/23 at 12:09 pm the DON and the Corporate Nurse said the facility did not have a policy regarding medication errors. During an interview on 5/17/23 at 12:21 pm the Medical Director said he did not remember if he was contacted regarding Resident #1's morphine overdose but could not say for sure whether he was notified or not. The Medical Director said if he had been notified of the morphine overdose he would have ordered for an antidote to be administered and to monitor respiration every 5-10 minutes. The Medical Director said he probably would have not given an order for Resident #1 to be sent to the hospital due to her being on hospice. The Medical Director said it was hard to say if the morphine overdose could have been lethal. The Medical Director said it would depend on the patient and their tolerance to the medication. During an interview on 5/17/23 at 1:15 pm LVN N said mg and ml were not the same. LVN N said ml was a liquid measurement and mg was a dosage measurement. LVN N named the 5 rights of medication administration. LVN N said before administering medication the order on the MAR should be checked against the medication package. LVN N said if there was a discrepancy between the order and package the medication should not been give and clarification should be obtained. Record review of the facility's Medication Administration policy dated March 2019 indicated, Resident medications are administered in an accurate, safe, timely, and sanitary manner .If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders shall be checked for the correct dosage schedule. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved . The Administrator was notified on 5/17/2023 at 3:22 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 5/17/2023 at 3:23 p.m. The facility's Plan of Removal was accepted on 5/19/2023 at 3:15 p.m. and included: Resident #1 received morphine 5ml on 5/14/2023 @ 11:45am. On 5/15/2023 @ 5:20am resident noted with a change in her condition. encouraged fluids. The Night Shift LVN changed residents' clothes after resident was vomiting. They then sat her at the nurse's station to observe her. DNS/ADON in-serviced licensed nurses regarding monitoring patients with Changes in Condition and documentation. These are documented in the SBAR. Monitoring changes in condition takes place every shift until monitoring is no longer clinically indicated. Date commenced: 5/15/2023 Date completed: 5/18/2023 Day Shift LVN conducted a visual assessment of resident #1's status, observing and identifying symptoms presented on 5/15/2023. Outcome: On 5/15/2023 @ 5:20 am resident vomited on the floor, had scratch marks on her legs, arms, chest and shoulders. Resident also was shaking and twitching her eyes. Date Completed: 5/15/2023 Night Shift LVN notified Hospice at approximately 5:20am regarding patient's condition noted above. Date completed: 5/15/2023 Day Shift LVN who incorrectly transcribed the morphine order was educated by Director of Nursing on 5/15/2023 @ approximately 8:10am on proper processes for transcribing of physician orders into EMR. Day Shift LVN Nurse was suspended on 5/17/2023 pending results of the investigation. Date completed: 5/17/2023 Day Shift LVN who incorrectly administered resident's morphine order was educated on 5/15/2023 @ approximately 7:36am by the Director of Nursing on the proper process of medication administration, ensuring the correct resident, the correct medication, correct dose, correct route to be administered, correct documentation of administration, correct time, and monitoring of patient post administration of the medication. This includes verifying the medication administered record to the actual medication to be administered. Licensed Nurses were in-serviced regarding appropriate steps to take if medication error occurs, to include assessing resident, completing medication error report, notifying assigned physician and responsible party, and monitoring and/or intervention as indicated. All discrepancies will utilize the community's policy and procedure regarding Medication Administration. The Medication Administration policy was established on 3/2019. Day Shift LVN who incorrectly administered resident #1 morphine order was suspended on 5/17/2023 pending results of the investigation. Day Shift LVN is no longer working for the company as of 5/17/2023. Date completed: 5/17/2023 Director of Nursing / ADON conducted retraining for all licensed nursing staff on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The Narcan has always been available and in the stat safe. There were no orders at the time of the incident to administer Narcan to resident #1. Orders to administer Narcan were received as a result of the incident investigation. All residents who are on morphine have as needed orders for the administration of Narcan as well as monitoring for signs and symptoms of overuse of morphine. Date of commenced by: Director of Nursing / ADON 5/16/2023 Date of completion: 5/17/2023 Director of Nursing / ADON will ensure all licensed nursing staff will be re-educated to include anyone on leave/agency/PRN staff will be in serviced prior to working next shift. DON/ADON will ensure administrative nursing staff in the community will provide in-service/education prior team members working their assigned shift. The trainings will also be conducted with new hires. Risk Response: Residents who are prescribed liquid morphine may have the potential to be affected by the deficient practice. Director of Nursing / ADON conducted re-education to the identified nurses and medication aids regarding: The community's expected process for proper transcription of physician orders, medication administration, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration and monitoring of patient post administration. This includes verifying the medication administered record to the actual medication. Licensed Nurses were in-serviced regarding steps to take if medication error occurs, to include assessing resident, completing medication error report, notifying assigned physician and responsible party. All discrepancies will utilize the community's policy and procedure for Medication Administration. The Medication Administration policy was established on 3 3/2019. The DON/Corporate nurse were educated by SVP Clinical Operations on Accident/Incident Report and Investigation Guidelines established in 2019 and updated 1/2023. All licensed nurses were educated on when to administer Narcan. Morphine audit initiated on 5/17/23, completed on 5/18/23. All residents who have morphine on their administration record have accurate orders, monitoring for signs/symptoms of overdose, and as needed Narcan orders. Results of the morphine audit reveal no medication administration discrepancies. The audit was completed by the DON/ADON. Also, all licensed nurses were educated by the DON/ADON on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The Narcan has always been available and in the stat safe. All residents who are on morphine have as needed orders for the administration of Narcan as well as monitoring for signs and symptoms of overuse of morphine. There were no physician orders at the time of the incident for resident #1 for administration of Narcan. Orders for Narcan were received on 5/17/23 as a result of the incident investigation. DON/ADON conducted an audit for all residents who are on morphine for accuracy. Results of the morphine audit revealed no medication administration discrepancies. Date Commenced: 5/16/2023 Date of completion: 5/18/2023 All licensed nursing and certified medication aides were educated on the difference between milligrams and milliliters. Date commenced: 5/18/2023 Date of completion: 5/19/2023 Community Director of Nursing / ADON will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / ADON will ensure administrative nursing staff will in service licensed nurses prior to working their next assigned shift. These trainings will also be conducted with new hires. Systemic Response: Inservice training & re-education will be provided to all licensed nurses regarding topics: Inservice topics: Director of Nursing / ADON extended re-education to all licensed nurses and medication aids regarding: (nurses or medication aids will not assume next shift until re-education received) The community's expected process for proper transcription of physician orders, medication administration, ensuring the correct resident, the correct medication, correct dose to be administered, correct route to be administered, correct documentation of administration and monitoring of patient post administration. This includes verifying the medication administered record to the actual medication. All discrepancies will utilize the community's policy and procedure for the Medication Administration policy. The medication administration policy was established 3/2019. Also re-educated on the importance of monitoring for signs and symptoms of narcotic medication (morphine) overdose signs/symptoms as well as emergency use of Narcan should a potential drug overdose occur. Narcan is available in the stat safe. The DON/ADON in-serviced all licensed nurses regarding Abuse & Neglect and Medication Administration, transcribing of physician orders, morphine Overdose signs/symptoms and the use of Narcan use. Date Commenced: 5/16/2023 Date Completed 5/17/2023 Community Director of Nursing / ADON will ensure all licensed nurses on leave/agency/PRN staff are in serviced prior to working their shift. Community Director of Nursing / Designee will ensure administrative nursing staff in the community to provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires. Monitoring Response: The Director of Nursing / ADON will conduct random weekly (1-7 days per week) audit of physician orders to validate the accuracy of transcribed orders within the E.H.R., observations of medication administration to validate medication administration competency. DNS/ADON will conduct daily reviews during clinical start-up meeting (1-7days per week) review of progress notes, SBARs and nursing 24-hour report to ensure that appropriate interventions are in place as well as any additional follow up has been assigned. This plan will remain in place for the next 2 months to ensure compliance or to identify any further training needs. Findings of those observations will be reported to the QAPI committee during monthly meeting for the next 2 months. IDT and Medical Director conducted an Ad Hoc QAPI to review issue and community's response plan in place. Date of completion: 5/17/2023 On 5/22/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Records Review of: -Change of Conditions Policy -Medication Administration Policy -Abuse Policy -All evidence of in-services and education per POR Staff interviewed were able to answer questions re: trainings/in-services noted in the Plan of Removals for IJ 1:51pm MA A (3yrs) 6-2 shift 2:00pm MA B (1yr) 6-2 shift 2:34pm LVN C (6.5 yrs.) All Shift 2:48pm LVN D (10 yrs.) 6a-6p Shift 3:02pm LVN E (AGENCY) 6a-2p, 2p-10p, 6a-6p Shift 3:16pm RN F (2.5yrs) 6a-10p Sat/Sun 3:30pm MA G (9mths) 2p-9p Shift 3:41pm LVN H (Med Nurse Only) 3.5yrs All Shift While the IJ was removed on 5/22/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.