Every finding on record at Cibolo Creek

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 2 residents (Resident #70) reviewed for accidents and hazards. The facility failed to ensure Resident #70 received adequate supervision when Resident #70 was missing on 8/28/2025 for approximately 45 minutes and found lying next to her wheelchair outdoors on an enclosed, outdoor patio. An IJ was identified on 9/3/2025. The IJ template was provided to the facility on 9/3/2025 at 12:10 PM. While the IJ was removed on 9/5/2025 at 10:09, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of the new procedures and training. This failure could place residents at risk of inadequate supervision and monitoring leading to an environment that is not free of accidents/hazards. Findings included:Record review of Resident #70's face sheet (dated 9/02/2025) reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease (a progressive neurological disorder affecting reasoning, memory, and cognitive skills), repeated falls, and unspecified dementia (a progressive neurological disorder that causes memory and cognitive decline). Record review of Resident #70's quarterly MDS (submitted 7/08/2025) reflected a BIMS score of 06, indicating moderately impaired cognition. This MDS also reflected in section E Resident #70 exhibited wandering behavior 0 days of the 14-day assessment period. Record review of Resident #70's comprehensive care plan (dated 8/28/2025) reflected the following:The resident is an elopement risk/wanderer r/t impaired safety awareness, resident wanders aimlessly (date initiated 8/28/2025)Record review of Resident #70's progress included the following documentation:This nurse went looking for resident with CNA in order to give her a scheduled shower. When staff was unable to locate resident, Code Green/Missing Resident was activated and all staff searched for resident whereabouts. Resident then was located by PT on an outside patio, lying by her wheelchair. Resident was assessed by nursing staff, hoyered into her wheelchair and taken inside to cool off, rehydrate and for further assessment [sic]. (8/28/2025 7:16 PM by RN A)This nurse was alerted by other staff that resident had been located by PT on a side patio, lying in front of her wheelchair. Resident was assessed for injuries by nursing staff, hoyered back into her wheelchair and taken indoors to cool off, rehydrate and for further assessment. No injuries noted, all notified [sic] (8/28/2025 7:24 PM by RN A)Record review of the facility's incidents log dated 9/2/2025 reflected an elopement incident for Resident #70 on 8/28/2025 at 2:30 PM. Record review of the facility's investigation report related to the elopement incident reflected an undated, typed statement from the Dietician that read as follows: I arrived at [the facility] at approximately 2:10 PM and checked in with the DON. I was in the DON's office for approximately 5-10 minutes. After checking in, I went to the private dining room and set down my belongings, then I went into the kitchen and checked in with the Dietary Manager. I was in the kitchen for approximately 5-10 minutes, and then I returned to the private dining room. There was an alarm going off at the door that connects the private dining room to the outdoor area. I looked through the glass door and did not see any person outside or anything that appeared out of the ordinary, then I disabled the alarm. This occurred prior to 2:28 PM when I sent an email to another Dietician who works for [company]. At approximately 3:30 PM, I became aware that staff was trying to locate a resident. I looked out the windows of the private dining room, and this time I observed a wheelchair outside. I informed a staff member that I saw a wheelchair outside of the private dining room, and that I thought there might be a resident outside in the wheelchair [sic]. In an observation on 9/2/2025 at 2:33 PM, the private dining area was observed to be closed to the main dining area and the hallway with unlocked doors. The exit alarm that is activated upon pushing the door handle was functioning, and the survey team initiated the alarm by pushing on the door handle for approximately 15 seconds, at which time the door lock released and the door opened. A continuous alarm then sounded. A secondary alarm was observed to be attached to the exit door but was not alarming. The survey team remained in the closed private dining area, and no staff responded to the alarm. At 2:38 PM, a surveyor exited the private dining area and observed the alarm was difficult to hear in the hallway through the closed doors of the private dining area due to environmental noise. At 2:41 PM, the survey team opened the doors to the private dining area, at which time the AD responded to the alarm. Resident #70 was interviewed on 9/2/2025 at 11:19 AM, but she was unable to recall the incident or participate in the interview in a meaningful way due to cognitive decline. In an interview with RN A on 9/2/2025 at 2:15 PM, she stated Resident #70 was discovered to be missing when the CNA attempted to give the resident her scheduled shower. She had not witnessed wandering or exit seeking behavior from Resident #70 prior to that day. She stated she did not hear a door alarm on the day Resident #70 was missing. She stated she activated the missing resident protocol and the resident was located by a physical therapist shortly after. She then assessed Resident #70 and found her to have a mild sunburn on her face and she provided the resident with a cool shower to decrease her body temperature. She then notified the physician, and the Admin. had notified Resident #70's family. She stated Resident #70 required no additional treatment. In an interview on 9/2/2025 at 2:43 PM, the DOR stated he was verbally notified by a staff member in the therapy gym that Resident #70 was missing. He located Resident #70 after being notified by an unknown staff member that a wheelchair was observed on the patio next to the private dining area. He stated the door alarm was not alerting when he entered the key code and exited the building. He stated Resident #70 was lying next to her wheelchair and using a sling for the mechanical lift to cover her face from the sun. She was awake and alert, and she told the DOR that her hands, head, and back felt hot. In an interview on 9/2/2025 at 3:00 PM, the Admin. stated Resident #70 left the facility unsupervised through the exit door in the private dining room, and the alarm had sounded but had been disabled by a visiting Dietician. She stated the outdoor patio area was not routinely used, and Resident #70 had not exhibited wandering behavior prior to the incident. She stated Resident #70 told staff she was attempting to get outside to view the horses in the stables located across the street from the facility and fell from her wheelchair but was uninjured. She stated Resident #70 was outside for approximately 30 minutes and after being located was put on observation every fifteen minutes by staff for 72 hours and then downgraded to observation every shift. She stated the facility had also added the secondary alarms to the doors on 9/2/2025 as she felt the existing alarms were too quiet, but she was unsure why the Maint. Dir. had not turned the alarms on. CNA B did not respond to an attempted interview via telephone call/voicemail on 9/3/2025 at 8:57 AM. An IJ was identified on 9/3/2025. The Administrator was notified of the IJ on 9/3/2025 at 12:31 PM and was given a copy of the IJ template and a POR was requested. The facility's POR for the IJ was accepted on 9/04/2025 at 8:06 AM and reflected the following:1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address and prevent any additional residents from adverse outcomes. Started on 8/28/25 Completion Date: 9/3/25 Residents directly involved in this deficient practice had their care plan reviewed and updated by the DON or designee and updated to reflect current wandering and elopement risk, dehydration risk completed on all residents. The MDS Coordinator reviewed section E of the MDS and associated CAA for all residents. Care plans were reviewed and updated to ensure they reflect audit findings. Concerns were not identified. The DON, designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for wandering/elopement and dehydration using an elopement risk assessment tool and dehydration risk tool. Dietary Staff will ensure that there are hydration stations at the courtyard exits and rear patio exit to ensure any resident who wants to sit outside has access to hydration that is easily accessible. Any resident that requires supervision will be offered fluid during their supervised visitation outside as needed. All staff in-serviced on all shifts by in person or over the phone education on wandering, elopement, and resident safety, Accidents and Hazards and Hydration from the Administrator/ DON or designee(s). Any staff on leave will receive education on their next scheduled work day. On 8/29/25 facility purchased Stop Alarms for exit door to improve audible tone of dining room exit door. Alarms on exit doors at 8am on 9/2/25 and staff education was conducted on 9/2/25. Hydration carts have been implemented on 9/3/25 at 5:30pm.2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9/3/25) Elopement and wandering residents' policy and Accidents and Supervision and Hydration Policies were reviewed/revised by [NAME], RN. Administrator or Maintenance Director will conduct weekly alarm response drill to ensure timely response for 6 weeks. The DON or designee will audit new admissions for elopement risk and dehydration risk to ensure appropriate interventions are in place for 6 weeks. The DON or designee will audit completed MDS's to ensure the care plan reflects needs/concerns identified in the CAAs for At risk residents for elopement or dehydration. New hires and agency staff will receive education on wandering, elopement, and resident safety as well as Freedom from Accidents and Hazard and hydration by the Administrator or designee(s). Agency staff will be given access to point click care to view residents identified as requiring additional supervision as well the look at me now binder containing high risk residents. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained.Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 9/3/25Action Plan to Ensure Relevant Recommendations Are Followed:Action/TaskPerson(s) AssignedDate CompletedReview/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm.[COO]9/3/25New policies written/implemented when applicable to ensure additional serious harm will be prevented.[COO]9/3/25Checklists and monitoring tools used to verify compliance.[Admin}9/3/25Educate necessary staff on facility procedures with return demonstration, where applicable.[COO, Admin, ADON]9/3/25Document PIP implementation, PIP progress, and QAA Committee Meeting Minutes where PIP is discussed.[Admin, COO]9/3/25 Verification of the facility's POR was as follows: Record review of a document dated 9/3/2025, reflected a signed statement from MDS RN and MDS LVN indicating care plans were updated for residents identified at risk following dehydration and elopement risk assessments.Record review of Resident #70's comprehensive care plan, dated 8/28/2025, reflected the following:The resident is an elopement risk/wanderer r/t impaired safety awareness, resident wanders aimlessly (dated 8/28/2025)Interventions: assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank); document wandering behavior and attempted diversional interventions in behavior log, identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.Record review of a facility documented titled Dehydration Risk Evaluation report dated 9/3/2025 reflected risk for dehydration assessments were documented for 79 residents on 9/3/2025, and 56 of the assessed residents had scores indicating a risk for dehydration.Record review of a facility document titled Elopement Evaluation report dated 9/3/2025 reflected elopement/wandering risk assessments were documented for 79 residents on 9/3/2025, and 4 of the assessed residents had scores indicating a risk for elopement or wandering, including Resident #70. Record review of staff development/in-service attendance sheet dated 8/28/2025 reflected in-service topics of exit alarm response; check on residents every 30 minutes when outside; and review of policies: hydration, accidents/hazards, and elopement. Record review of an invoice dated 9/2/2025 reflected an online order for 7 secondary door alarms placed on 8/29/2025. Record review of the facility policies Hydration (undated, copyright 2023), Accidents and Supervision (undated, copyright 2024), and Elopement and Wandering Residents (undated, copyright 2025) reflected the policies were present at the facility. Record review of the facility document titled Action Plan dated 8/28/2025 signed by the Admin. and MD reflected the areas identified as requiring attention were: wandering/elopement, resident care plan review, MDS review of care plans and new admission risk assessment, hydration stations implementation, in-services, and stop alarms. Record review of document titled Action Plan Monitoring for Week 1 of 6 dated 8/29/2025 through 8/31/2025 reflected the following:The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place 5 days per week for 6 week with no issue identifiedThe DON or designee will audit completed MDS' to ensure the care plan reflects needs/concerns identified in the CAAs 5 days per week for 6 weeks with no issue identifiedRecord review of document titled Action Plan Monitoring for Week 2 of 6 dated 9/1/2025 through 9/7/2025 reflected the following: 9/3/2025 Active IJ change to plan of correctionRecord review of document titled Action Plan Monitoring for Week 1 of 6 dated 9/4/2025 through 9/7/2025 The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place 5 days per week for 6 weeks. 9/4/2025 no new admissionsNew hires will receive education on wandering, elopement, and resident safety and Accidents and Hazards by the DON, Director of Social Services, or designees on hire. 9/4/2025 new hire completedThe Admin. or Maint. Dir. will conduct weekly alarm response drills to ensure timely response for 6 weeks.Record review of the facility documented titled New Team Member Orientation Guide dated 1/5/2021 included education regarding the facility's Look at Me program to educate about residents with known elopement/wandering behaviors, as well as education regarding challenging behaviors, types of dementia, and fall prevention. In an observation on 9/4/2025 at 8:39 AM, ice water dispensers and disposable cups were observed in the central courtyard, the two indoor entrances to the courtyard, and the exit doors leading to the patio. In an observation on 9/5/2025 at 9:22 AM, the survey team activated the door alarm in the private dining area. Upon opening, the primary and secondary door alarms activated. 6 staff members responded to the alarm within 1 minute and commenced a search of the exterior area. Staff inside of the facility were observed performing a headcount of all residents. All residents were accounted for after comparing to census. In an observation on 9/4/2025 at 9:43 AM, a hydration cart was observed at the north nurse's station. In an observation on 9/4/2025 at 10:00 AM, a hydration cart was observed at the south nurse's station. In an interview on 9/4/2025 at 10:14 AM, the DM stated she put the hydration carts and stations in place on 9/3/2025 at 5:30 PM. In an observation on 9/4/2025 at 11:35 AM, Look at me Now binders were observed at both nurse's station and at the reception area. In an interview with RN F on 9/4/2025 at 11:35 AM, she stated the Look at Me Now binders were found at every nurse's station and contained information about residents who were identified as wandering/elopement risks. In an interview on 9/4/2025 at 2:54 PM, the MDS RN and MDS LVN stated they reviewed Section E of all residents' MDS to determine if any wandering behavior had been documented on residents, and they did not identify any concerns. They also stated they updated all care plans based on the risk assessments completed by the other nursing staff, to include ensuring access to water, monitoring for signs/symptoms of dehydration, redirection and distraction, and other personalized interventions. In an interview on 9/4/2025 at 3:12 PM, the DON stated all residents at the facility received dehydration and wandering/elopement risk assessments, and Resident #70 had an update to her care plan after the incident on 8/28/2025 to include interventions for the behaviors, as well as the other residents identified as risks for wandering. She stated quite a few residents were identified as at risk for dehydration, and all had their care plans updated to reflect interventions for the risk of dehydration. She reported sending a mass message to all staff employed by the facility summarizing the required in-services for the POR, and she notified them that they will receive the in-service before their next working shift. She stated she had staff at the time clocks performing in-services as staff members were clocking in for their shifts. She stated she had reviewed the relevant policies, and no edits or adjustments were needed. She stated she also will be reviewing the dehydration and elopement risk assessments for every new admission to ensure accuracy and completeness. In an interview on 9/4/2025 at 3:53 PM, the Admin. stated she would be performing a weekly drill on the door alarms and reporting the findings to the facility quality committee. She stated she would confirm verbally with the Maint. Dir. that he had performed the drill on the weeks in which he was assigned the task. She stated all new hires would receive training on wandering/elopement behaviors and resident safety as part of the new hire orientation. She stated the Weekly Audit checklist had been created by the facility to audit their compliance with their action plan and for review internally. 37 total staff members from all departments and shifts were interviewed on 9/4/2025 to ensure required trainings were received (responding to exit alarms, hydration of residents, wandering/elopement behaviors):Activity DirectorMA (morning shift: 1)CNA/Hospitality Aides/Aides in Training (morning shift: 4, evening shift: 4, overnight shift: 1, PRN: 1)Dietary staff (morning shift: 2, evening shift: 1, overnight shift: 1)Housekeeping (morning shift: 2)MDS RN/LVN (2)RN/LVN (morning shift: 3, evening shift: 3, extended shift: 2, overnight shift: 1)Therapy (full time staff: 3, PRN staff: 4)WC Nurse (1)While the IJ was removed on 9/5/2025 at 10:19 AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to evaluate the effectiveness of the POR and complete required staff training.

Based on interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in refrigerators reviewed for essential equipment. The facility failed to ensure the walk-in refrigerator in the kitchen was functioning properly. This failure could place residents at risk for foodborne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317: morning 4318: morning 4219: morning 4222: morning 4224: morning 4325: morning 4226: morning 43 and evening 4228: morning 4329: morning 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated July 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)1: evening 432: morning 423: morning 444: morning 426: morning 438: morning 429: morning 4311: morning 4212: morning 4313: morning 4314: morning 42 15: morning 4317: evening 4318: morning 43 and evening 4319: morning 43 and evening 4222: evening 4624: morning 4327: morning 43 and evening 4328: morning 42 and evening 4229: morning 43 and evening 4330: morning 43 and evening 4331 evening 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated August 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: evening 444: morning 428: morning 439: morning 4210: morning 4311: evening 4213: morning 43 and evening 4214: morning 43 16: evening 4317: morning 4218: morning 42 and evening 4719: morning 43 20: evening 4324: morning 4325: morning 4227: morning 43 Interview on 09/02/2025 at 10:15 AM, the Dietary Manager (DM) revealed the walk-in refrigerator temperature had been fluctuating and they thought it was because the freezer door would not close all the way. They revealed the refrigerator walk-n refrigerator should not be above 41 degrees Fahrenheit. The Dietary Manager revealed she oversaw ensuring the temperatures in the kitchen were at an appropriate temperature. The DM revealed the only corrective action that was taken was the Maintenance Director coming to fix the freezer but was not doing anything else the meantime. Interview on 09/03/25 at 10:26 AM, the Maintenance Director revealed he did not know about temperatures not being within their proper temperature range until yesterday. He revealed it was the kitchen's duty to let him know if any kitchen equipment needed to be fixed. He revealed he reviewed the temperature logs yesterday and all the temperatures were within the appropriate range that they needed to be (32 to 45 degrees Fahrenheit). He revealed this was the range for state regulations. Interview on 09/03/25 at 01:56 PM, the former Dietary Manager revealed the food temperatures were sometimes out of range. She revealed the maintenance director was told about this but could not remember a specific date and could not remember a specific date when the walk-in refrigerator was giving temperatures above 41 degrees Fahrenheit. She revealed she did not put in a maintenance request in for the refrigerator, but the Maintenance Director was aware. She revealed it was important for the walk-in refrigerator to be within an appropriate temperature so there was no spoiled food, rotten food, or cross contamination. She revealed the RD knew about this and could not remember if they said anything about the temperatures of the walk-in refrigerator. She further revealed the walk-in refrigerator was fine as long as it was below 45 degrees Fahrenheit. Interview on 09/03/25 at 03:41 PM, the Maintenance Director revealed he was not told about the temperatures in the walk-in refrigerator fluctuating. He revealed he contacted someone to inspect the walk-in refrigerator. He revealed it was found that there was a valve that was stuck in the condensing unit outside. He revealed this valve was moved and now there should be colder air blowing in the walk-in refrigerator to make the walk-in refrigerator cooler than what it was at. Record review of the FDA Food Code 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less.Record review of facility's policy, Personal Food Storage, dated 2013, reflected 4. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures.

Based on interviews, and record reviews the facility failed to ensure the medical records. In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and systematically organized for 3 _of 16 (#20, #38, #5) residents reviewed for clinical records in that:1.Resident #20 did not have a current care plan conference meeting documented in her file. 2. Resident #38 did not have a current care plan conference meeting documented in her file. 3. The facility failed to ensure accurate documentation of Resident #5's July MAR per doctor's orders. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings included: Record review of Resident #5's admission record, dated 09/05/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include hypertension (high blood pressure) and congestive heart failure (the heart is unable to pump blood effectively). Record review of Resident #5's admission MDS assessment, dated 06/22/2025, reflected resident had a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #5's comprehensive care plan, last review completed on 09/04/25, reflected “The resident has Congestive Heart Failure”, initiated 06/05/2025, with an intervention “Give cardiac medications as ordered.” Record review of doctor’s orders reflected “Furosemide Oral Tablet 20 MG Give 1 tablet by mouth one time a day for diuretic” with start date 06/05/2025 and “Spironolactone Oral Tablet 25 MG Give 1 tablet by mouth one time a day for diuretic…” with start date 06/05/2025. Record review of Resident #5's July MAR reflected DIURETICS-MONITOR FOR THE FOLLOWING: DECREASED PO INTAKE, ACUTE CONFUSION, AGITATION, DELUSIONS, AGGRESSION, LETHARGY, DECREASED SWEATING, TACHYCARDIA, HYPOTENSION, ORTHOSTASIS, GENERALIZED WEAKNESS, AND/OR SUNKEN EYES. every shift Document N if none of the above observed. Y if any of the above observed, notify physician and note findings in progress note, start date 06/04/2025. It further reflected RN AE documented 0 instead of N on 07/04/25 (2p-10p and 10p-6a), 07/05/25 (2p-10p and 10p-6a), 07/06/25 (2p-10p), 07/09/25 (2p-10p), 07/10/25 (2p-10p and 10p-6a), 07/11/25 (2p-10p), 07/12/25 (2p-10p), and 07/13/25 (2p-10p). Interview on 09/05/25 at 02:30 PM, RN AE revealed for Resident #5’s doctor’s orders for diuretics she should have put an “N” instead of a 0 as the doctor’s orders state. She revealed 0 meant no, and she did not have a good reason as to why she did this, and she should have followed the doctor’s orders. She revealed it was important to follow doctor’s orders for resident care. Interview on 09/05/25 at 5:05 PM, the Interim DON revealed in Resident #5’s July MAR nursing staff put a “0” instead of an “N”. She revealed the staff should put an “N” because it was the doctor’s orders. Record review of facility's policy, copyright 2024, Documentation in Medical Record reflected 4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . 1.Record review of Resident #20s admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Heart Failure, Diabetes II, aphasia and hypertension. Record review of Resident #20's Quarterly MDS dated [DATE] was documented as cognition level was cognitively intact, she mobilized with a wheelchair, had upper/lower impairment on one side, she was set up assistance for eating, oral hygiene and dependent with toileting, upper/lower body dressing and footwear, she had aphasia, hemiplegia/hemiparesis, and cognitive communications deficit. Record review of Resident #20s care plan was dated 8/20/2020 was documented she was a risk for falls, dependent of staff for meeting emotional, intellectual, physical and social needs, she had ADL deficits related to history of occlusion and stenosis of right posterior cerebral artery, wasting atrophy, abnormal posture, unsteady, reduced mobility, and left sided hemiplegia, limited physical mobility, and refuses some showers due to not when she wants it. Record review of Resident #20s care plan conference was not documented on 11/5/2024. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #20s care plan conference meeting was 2/4/2025 and 5/6/2025. 2. Record review of Resident #38's admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnoses of osteoarthritis, chronic obstructive pulmonary disease, chronic kidney disease, mild cognitive impairment and unsteady on feet, Record review of Resident #38's Quarterly MDS dated [DATE] with cognition level was cognitively intact, she was able to mobilize with a walker, for ADLs she was independent with eating, oral hygiene, toileting hygiene, upper/lower body dressing, footwear and personal hygiene, she had mild cognitive impairment, and she was on pain management. Record review of Resident #38's Care Plan dated 6/4/2025 was documented she was a risk for infections, resident independent on staff for meeting emotional, intellectual, physical and social needs, her ADL self-care performance deficit related to fatigue, impaired balance, generalized weakness, she has a potential for communications problem related to mild hearing loss, and risk for falls. Record review of Resident #38s care plan conference was not documented on 5/23/2025. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #38s care plan conference meeting was 5/21/2025. Interview on 9/5/2020 at 12:02 PM with the ADM/SW stated there was a TEAM of managers that were involved in the resident care plan conference. ADM stated she was one of the staff responsible for resident care plan conferences and stated she did have a care plan conference for Resident #20 and #38 was not documented. The ADM/SW stated the importance was to identify captured all issues with resident and goals, and interventions for each resident. ADM/SW stated the care plane conferences to talk with families and educate with any concerns they have with resident care. ADM/SW stated the care plane conferences were for all staff to know everything about that resident. Record review of Resident #20’s admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (neurological conditions that cause weakness or paralysis on one side of the body), Heart Failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), Diabetes II ( a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels. ), aphasia language disorder that affects a person's ability to communicate.) and hypertension high blood pressure). Record review of Resident #20's Quarterly MDS dated [DATE] was documented as cognition level was cognitively intact, she mobilized with a wheelchair, had upper/lower impairment on one side, she was set up assistance for eating, oral hygiene and dependent with toileting, upper/lower body dressing and footwear, she had aphasia, hemiplegia/hemiparesis, and cognitive communications deficit. Record review of Resident #20’s care plan was dated 8/20/2020 was documented she was a risk for falls, dependent of staff for meeting emotional, intellectual, physical and social needs, she had ADL deficits related to history of occlusion and stenosis of right posterior cerebral artery, wasting atrophy, abnormal posture, unsteady, reduced mobility, and left sided hemiplegia, limited physical mobility, and refuses some showers due to not when she wants it. Record review of Resident #20s care plan conference was not documented on 11/5/2024. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW documented, Resident #20s care plan conference meeting was 2/4/2025 and 5/6/2025. 2. Record review of Resident #38's admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnoses of osteoarthritis (degenerative joint disease), chronic obstructive pulmonary disease (a group of lung diseases that cause breathing difficulties), chronic kidney disease (kidneys gradually lose their ability to filter waste products and excess fluid from the blood, leading to long-term damage), mild cognitive impairment and unsteady on feet. Record review of Resident #38's Quarterly MDS dated [DATE] with cognition level was cognitively intact, she was able to mobilize with a walker, for ADLs she was independent with eating, oral hygiene, toileting hygiene, upper/lower body dressing, footwear and personal hygiene, she had mild cognitive impairment, and she was on pain management. Record review of Resident #38's Care Plan dated 6/4/2025 was documented she was a risk for infections, resident independent on staff for meeting emotional, intellectual, physical and social needs, her ADL self-care performance deficit related to fatigue, impaired balance, generalized weakness, she has a potential for communications problem related to mild hearing loss, and risk for falls. Record review of Resident #38s care plan conference was not documented on 5/23/2025. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #38s care plan conference meeting was 5/21/2025. Interview on 9/5/2020 at 12:02 PM the ADM/SW stated there was a TEAM of managers that were involved in the resident care plan conference. ADM stated she was one of the staff responsible for resident care plan conferences and stated she did have a care plan conference for Resident #20 and #38 that was not documented. The ADM/SW stated the importance was to identify captured all issues with resident and goals, and interventions for each resident. The ADM/SW stated the care plan conferences to talk with families and educate with any concerns they have with resident care. The ADM/SW stated the care plane conferences were for all staff to know everything about that resident. 3.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F for the last 3 months2. The facility failed to take temperatures for the cold foods (to include milk for 09/05/25 breakfast and fresh fruit cups for 09/05/25 lunch). 3. The facility failed to ensure food products were labeled with discard dates. These failures could place residents at risk for food borne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317: morning 4318: morning 4219: morning 4222: morning 4224: morning 4325: morning 4226: morning 43 and evening 4228: morning 4329: morning 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated July 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)1: evening 432: morning 423: morning 444: morning 426: morning 438: morning 429: morning 4311: morning 4212: morning 4313: morning 4314: morning 42 15: morning 4317: evening 4318: morning 43 and evening 4319: morning 43 and evening 4222: evening 4624: morning 4327: morning 43 and evening 4328: morning 42 and evening 4229: morning 43 and evening 4330: morning 43 and evening 4331 evening 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated August 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: evening 444: morning 428: morning 439: morning 4210: morning 4311: evening 4213: morning 43 and evening 4214: morning 43 16: evening 4317: morning 4218: morning 42 and evening 4719: morning 43 20: evening 4324: morning 4325: morning 4227: morning 43 Record review of the Resource: Refrigerator/Freezer Temperature Log from June to July 2025 reflected no action was taken after the temperature was above 41 degrees Fahrenheit. Record review of temperature logs for 08/25-08/31 and 09/01 to 09/07, untitled and copyright 2023, reflected the temperature of milk for breakfast was not taken 08/25-08/31 to 09/01-09/03. Record review of the facility's infection surveillance for the last 3 months reflected there were no cases of foodborne illness in the facility. Observation on 09/01/25 at 10:01 AM reflected there were prepared foods that did not have discard dates on them, to include sliced cheese that was dated 08/25, chocolate pudding that was dated 09/02, [Peanut Butter and Jelly] sandwich dated 09/01/25. It was observed that the microwave had brownish stains and brownish particles to the right-hand side of the inside of the microwave. Interview on 09/02/2025 at 10:15 AM, DA AF and Dietary Manager (DM) revealed they sometimes put discard dates on food labels. DA AF revealed he knew to throw prepared food items after 3 days. He revealed if foods were not discarded on the correct date, then food can get spoiled. They revealed the walk-in refrigerator temperature had been fluctuating and they thought it was because the freezer door would not close all the way. They revealed the refrigerator walk-n refrigerator should not be above 41 degrees Fahrenheit. The Dietary Manager revealed she oversaw ensuring the temperatures in the kitchen were at an appropriate temperature. The DM revealed the only corrective action that was taken was the Maintenance Director coming to fix the freezer but was not doing anything else the meantime. DA AF and DM revealed the microwave they used has always been stained and looked dirty, but they insisted it was not dirty. They revealed if it was dirty, this could cause cross contamination. Combined interview on 09/03/25 at 10:04 AM, [NAME] G revealed he took the morning temperatures of the refrigerator at 06:30 AM. The DM revealed this was to capture the overnight temperature. The DM revealed the temperatures had not been consistent and she would notice some vegetables in the walk-in refrigerator would get frozen and then inedible so she would not cook with these when she was a cook and ensured these food products were thrown out. The DM had become a manager for about a month already. She revealed she did not know the temperatures nor took the temperatures because she worked in the evening. Interview on 09/03/25 at 10:26 AM, the Maintenance Director revealed he did not know about temperatures not being within their proper temperature range until yesterday. He revealed it was the kitchen's responsibility to let him know when kitchen equipment needed repair. He revealed he reviewed the temperature logs yesterday and all the temperatures were within the appropriate range that they needed to be (32 to 45 degrees Fahrenheit). He revealed this was the range for state regulations. Combined interview and observation on 09/03/25 at 11:18 AM, the DM revealed it was important for foods to be in the recommended temperature range to prevent foodborne illness. Observation reflected sour cream was on the line for lunch service and in a pan, on ice. [NAME] G took the temperature of this sour cream, and it was 42 degrees Fahrenheit and had to be put in the reach-in refrigerator to cool down to temperature (below 41 degrees Fahrenheit). [NAME] G revealed he had taken the sour cream out of the walk-in refrigerator about 10 minutes ago. The DM revealed she was in charge of educating the kitchen staff about policies and procedures and she oversaw these were being done, taking corrective action as needed. Interview and observation on 09/03/25 at 11:38 AM, the DM took the temperature of a tomato from the walk-in refrigerator. The walk-in refrigerator was observed to read 41 degrees Fahrenheit. The DM checked the temperature of a tomato, and it was 41 degrees Fahrenheit. The DM checked the temperature of Italian dressing, and it was at 42.6 degrees Fahrenheit, which the DM revealed could have been because they were preparing for lunch service and were going in and out of the walk-in refrigerator. The DM revealed when they served milk for meals, the temperature for the milk was not checked because they took it out of the refrigerator right before service so it would be within the range it needed to be. She revealed there was not corrective action taken for temperature above 41 degrees Fahrenheit because the walk-in refrigerator was not consistently over 41 degrees Fahrenheit, and it was never over 45 degrees. She revealed if either of these situations occurred, they would throw the food out. She revealed they also did not do corrective action when temperatures were above 41 degrees Fahrenheit because the walk-in refrigerator was in the process of getting fixed. The DM was not able to provide any proof of taking multiple temperatures to show the refrigerator was back within proper temperature range. Interview and observation on 09/03/2025 at 12 PM, the DM took the temperature of the sour cream being served for lunch because all the other kitchen staff were busy serving lunch. The temperature of the sour cream was 41.4 degrees. The DM took the temperature of the fruit cups that were being served for lunch service and they were 51 degrees Fahrenheit. She revealed they did not take the temperatures of the fruit cups prior to service because they did not have a sheet where they could document foods like desserts. Interview on 09/03/25 at 01:56 PM, the former Dietary Manager revealed the food temperatures were sometimes out of range. She revealed the maintenance director was told about this but could not remember a specific date and could not remember a specific date when the walk-in refrigerator was giving temperatures above 41 degrees Fahrenheit. She revealed she did not put in a maintenance request in for the refrigerator, but the Maintenance Director was aware. She revealed it was important for the walk-in refrigerator to be within an appropriate temperature so there was no spoiled food, rotten food, or cross contamination. She revealed the RD knew about this and could not remember if they said anything about the temperatures of the walk-in refrigerator. She further revealed the walk-in refrigerator was fine as long as it was below 45 degrees Fahrenheit. Interview on 09/03/25 at 03:41 PM, the Maintenance Director revealed he was not told about the temperatures in the walk-in refrigerator fluctuating. He revealed he contacted someone to inspect the walk-in refrigerator yesterday. He revealed it was found that there was a valve that was stuck in the condensing unit outside. He revealed this valve was moved and now there should be colder air blowing in the walk-in refrigerator to make the walk-in refrigerator cooler than what it was at. Interview on 09/09/25 at 1:11pm the RD revealed discard dates did not need to be put on food labels because it was not a part of their policy. She revealed kitchen staff knew to throw food products out after 3 days. She revealed she only knew there were walk-in refrigerator temperatures above 41 degrees Fahrenheit in the month of August. She revealed the corrective action that was taken was the maintenance director fixing this issue. She revealed there were no other corrective action. She revealed having foods at higher than recommended temperatures could cause food borne illnesses and food spoilage. Record review of the FDA Food Code 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 Record review of the facility's policy Food Temperatures, dated 2013, reflected 2. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Record review of the facility's policy General Food Preparation and Handling, dated 2013, reflected 1. The kitchen is kept neat and orderly. a. The kitchen and equipment are clean and sanitized as appropriate. The facility did not have any policy that reflected labeling food products with a discard date, as is reflected in the 2022 FDA Food Code.

Based on interviews, and record reviews the facility failed to implement written policies and procedures that Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, by not screening staff annually for 3 of 7 staff (MA AG, FSM, AD) employed longer than 1 year in that: Medication Aide (MA AG did not have a current EMR/NAR. FSM did not have a current EMR/NAR. AD did not have a current EMR/NAR. The failure could place residents at risk of being abused, neglected, or exploited by unemployable staff. The finding were: Record review of the policy on Abuse/Neglect and Misappropriation, dated 2025 was documented, the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Screening, a. Potential employees will be screened for a history of abuse, neglect, exploitation, o misappropriation of resident property. 1. Background,. Checks shall be conducted on potential employees, contracted temporary staff, student affiliated with academic intuitions, volunteers, and consultants. 3. The facility will maintain documentation of proof that the screening occurred. Record review of personal file for MA AG was documented she was hired on 6/4/2012. Record review of MA AG was documented her last EMR/NAR was dated on 1/16/2024.Record review of personal file for FSM was documented she was hired on 2/18/2022. Record review of FSM was documented her last EMR/NAR was dated on 6/27/2024.Record review of personal file for AD was documented she was hired on 6/24/2019. Record review of AD was documented her last EMR/NAR was dated on 6/26/2024.Interview on 9/5/2025 at 1:20 PM with HR stated she ran the reports for all staff in May 2025, but did not have documented proof that staff MA AG, FSM and AD have a current EMR/NAR on their personnel files. Interview with HR stated she did run the EMR/NAR today and the staff showed no concerns for employment. No other response. Interview on 9/5/2025 at 2:46 PM with ADM states the HR was responsible for ensuring staff EMR/NAR were checked upon hire and annually. The importance of checking the EMR/NAR on staff was to ensure resident safety. No other response.

Based on interview, observation, and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #9) reviewed for care plans. The facility failed to revise Resident #9's comprehensive care plan to reflect the resident's ADL self-care performance for transfers. These deficient practices could place residents at risk of receiving improper care.The findings were: Record review of Resident #9's admission record, dated 09/04/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, acquired absence of left leg above knee (04/01/2023), and acquired absence of right leg below knee (12/31/2018). Record review of Resident #9's quarterly MDS assessment, dated 08/22/2025, reflected resident had a BIMS score of 06 out of 15, indicating severely impaired cognition. It reflected Resident #9 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Chair/bed-to-chair transfer. It revealed Resident #9 had no falls since admission or prior assessment, whichever was more recent. Record review of Resident #9's comprehensive care plan, last review completed on 04/25/25, reflected [Resident #9] has an ADL self-care performance deficit r/t poor cognitive deficit, bil BKA, and decreased function, revised 05/11/2029. Record review of incident and accident report for the past 6 months reflected Resident #9 did not have any falls due to transfers. Observation on 09/02/2025 at 12:13 PM revealed Resident #9 with a sling for a mechanical lift. Attempted to interview Resident #9 but he did not answer any questions. Interview on 09/05/25 at 02:30 PM, RN AE revealed she reviewed care plans for transfers. She revealed things change and that was why care plans were important to get updated for resident care and to keep up with resident changes. She revealed Resident #9 got transferred with a mechanical lift and it should be care planned because it was how they cared for this resident. She revealed he had only one fall within the last year because he was trying to transfer himself from wheelchair to bed without using the call light. She revealed Resident #9 was educated to use the call light and now used the call light for help. Interview on 09/05/25 at 02:49 PM, CNA S revealed he used the Kardex (guidance in the electronic medical record for CNAs) for resident care. He revealed Resident #9 was transferred out of bed via a mechanical lift. Interview on 09/05/25 at 04:37 PM, MDS RN revealed Resident #9 was dependent in transfers per his MDS assessment. She revealed Resident #9 fluctuated from extensive assistance to dependent assistance, but Resident #9 was now dependent for transfers. Interview on 09/05/25 at 5:05 PM, the Interim DON revealed Resident #9's care plan should be updated to reflect he needed to be transferred by a mechanical lift, but sometimes things will change shift to shift with resident care. She revealed it was important for care plans to be updated to reflect the resident's current status. Record review of facility's policy Comprehensive Care Plans, dated 2025, reflected 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on interviews and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision, in that; The facility failed to adequately supervise Resident #1, who had a history of bringing multiple medications including narcotics into the facility without notifying staff, when she consumed a marijuana laced brownie and was found to have both Ambien and trazadone in an unmarked unlabeled container at bedside on 11/19/2024. On 11/19/2024, Resident #1 was found unresponsive and twitching in her room after staff failed to check on her between 11:00 p.m. on 11/18/2024 to 5:00 a.m. on 11/19/2024 despite seeing an unknown visitor in Resident #1's room on the evening of 11/18/2024 . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/22/2024 at 12:50 p.m. The IJ template was provided to the facility on [DATE] at 1:03 p.m. While the IJ was removed on 11/23/24 the facility remained out of compliance at a scope identified as isolated and a severity level of potential for more than minimal harm until interventions were put in place to ensure resident safety because the facility needed to monitor the implementation of the plan of removal. This failure could place residents requiring supervision at risk for consumption of unknown and unregulated medications and illegal substances and place them at risk for an altered mental status, decline in health and/or death. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admitted [DATE] with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy or having medications in her room without staff knowledge. Record review of a provider progress note dated 11/08/2024 by PA J revealed: Patient (Resident #1) went to a pain medication doctor and had morphine prescription received, filled at outside pharmacy which she kept in her room and would self-dose. This was discovered and morphine was taken away from her .Denies alcohol, tobacco, drugs of abuse. Record review of Resident #1's nurse progress notes dated 11/09/2024 at 8:28 a.m., documented by LVN K revealed: Guest approached nurse at nursing station expressing concern. The pharmacy had questioned the medication she was picking (up) for a resident (Resident #1), morphine tablets (narcotic) and melodic (anti-inflammatory). The resident had requested she bring her medication with codeine (hydrocodone/acetaminophen 10/325) (narcotic opioid pain reliever) a week prior from a local pharmacy. The resident (Resident #1) explained that she had received the order from her pain management doctor at a previous appointment as the current pain medication was not effective at managing her pain. The nurse educated the patient (Resident #1) to inform her nurse of any new orders from appointments or her PCP so that her doctor at the facility could adjust her medication and make orders to safely assist her healing and rehab goals. The patient expressed understanding and stated she would not self-administer medication without informing the nurse. Record review of Resident #1's nurse progress notes dated 11/10/2024 at 4:43 p.m. documented by LVN H revealed: a CNA (unknown) notified nurse of suspicious activity. A person entered Resident #1's room with a package and immediately left. The incident was reported to the Administrator. Instruction was given to search room for medication, for patient safety. Patient (Resident #1) on narcotics and has a history of asking friends to bring in narcotic(s) and other pain medication prescribed by other providers into the facility and not adhering to facility policy. Patient education given. Will continue to monitor. Notified MD. Record review of a nurse progress note dated 11/11/2024 documented by LVN K revealed: Nurse notified ADON and MD (circumstances unknown). Received orders for Narcan for the patient (Resident #1 ). Record review of Resident #1's provider notes dated 11/14/2024 documented by PA J revealed: Notation was made that patient's family member was requesting she (Resident #1) not be given any narcotics, but no history of opioid abuse was given and patient was felt to have decision-making capacity, with no POA for involved family .Patient (Resident #1) reports her pain is controlled in her right shoulder and left ankle now that morphine prescribed by pain specialist. She has no acute complaints . 11/12 .pain MD wrote for morphine which she (Resident #1) was taking without notification of nurses, who thereafter noted some sedation and found the bottle . Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended the nurse (LVN A) for further investigation due to a delay in care. EMS arrived and administered Narcan, and the patient (Resident #1) was taken to a local ER and kept overnight for evaluation. The patient (Resident #1) was found to have medication at bedside and hospital records showed marijuana in (her) system). Record review of Resident #1's nurse assessment documented on 11/18/2024 at 5:22 p.m., revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment documented Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room, HOB 35 degrees, right leg hanging off the bed .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall. She reports to me a man went (sic) in her room at 11:00 p.m. and left. I asked if she reported to someone. She said the nurse on the Southside was told. I asked why? I am the nurse here on this side. Holding this 6 am dose (unknown medication). Will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician was notified or that 911 was called or that Resident #1's family had been notified of the sudden change in mental status. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy)when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's. (normal 92-100) and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. He documented LVN A handed him 6 white pills and 3 peach-colored broken pieces and stated the nurse aide obtained the pills from Resident #1's room at 11:00 p.m. last night. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from night shift stated to LVN B that this had been reported to LVN A since 11 p.m. last night (11/18/2024). When LVN B questioned LVN A if patient (Resident #1) was ever able to voice any response, LVN A stated that she (Resident #1) was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub was performed with grunting as the response sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level) and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN and notified the physician and the family of Resident #1. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. One aide (unknown) said there was a man that left the residents room at 11:00 p.m. LVN A wrote she had just left (the area) at 11:08 p.m. and did not see anyone so she asked the aide if she had told someone. LVN A wrote the aide reported she told the nurse for this side (unknown). LVN A wrote all three of the staff went into Resident #1's room and searched drawers, cabinets, and closet. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name) who identified the pills as trazadone (antipsychotic medication) and tramadol (opioid analgesic used for pain). LVN documented a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure) 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room or assist her so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911(unknown time). Record review of a written statement (undated) by NA E read when the (aides) were doing rounds at 10:00 p.m. at the start of their shift, a man walked out of the resident room with a to-go container in a plastic bag. She wrote they did not think anything of it. NA E wrote she told LVN A a weird guy was in the resident's room, but supposedly she did not hear what she said. NA E wrote she also reported it to the nurse on the other side (unknown). NA E wrote the man left at 11 (p.m.). NA E wrote they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night because the resident preferred, they did not wake her up all night with every round unless she called them. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling us (aides) to go try and wake her (Resident #1) up. NA E wrote they (aides) went the resident's room (Resident #1) and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like this at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote they found a little box of pills while searching and LVN A took them. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote she was making rounds with NA E; in another resident's room they noticed a guy walk out of (Resident #1's) room across the hall. NA F documented they saw him re-enter Resident #1's room a few minutes later with what looked like a to-go container. NA F documented she notified LVN A along with NA E that there was a man coming in and out of the resident's room. She wrote she continued making rounds and saw the man leave at approximately 11:00 p.m. NA F documented they did not make rounds on Resident #1 during the night because her chart says not to as she can go to the restroom and move around on her own. NA F documented at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A rushing in saying Resident #1 would not respond to her. She told them to go into the room and try to wake her (Resident #1) up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A to do the rest and continued her rounds. During an interview on 11/19/2024 at 1:39 p.m., the Administrator stated. A nurse (identified as LVN A) found Resident #1 lethargic and not responding like she should have, so EMS was called who administered Narcan twice. She stated Resident #1 also received Narcan via IV at the hospital. The Administrator stated they found a clear container with mixed pills in the resident's room which they had locked up in the DON's office. She said some of the medications were cut in half and unidentifiable and one was trazadone. The Administrator stated a couple of weeks prior they found medications in Resident #1's room, confiscated it and gave the resident education. She stated one of the medications they found was morphine and she could not remember what the other one was. She stated they contacted the resident's physician and gave education. The Administrator stated they also gave education to visitors. She stated the education was documented in PCC under progress notes for Resident #1. She stated a nurse, LVN A was suspended because they thought there was a delay in her response time. During an interview on 11/20/2024 at 10:14 a.m., the Administrator stated they had learned Resident #1 tested positive for both opioids (she had a prescription for opioid medication, so it was an expected outcome) and marijuana. She stated based on this information they conducted another search of Resident #1's room and the strong smell of something odd that was consistent with marijuana was discovered. She stated they identified a brownie on Resident #1's TV stand that had the strong odor. She stated they notified the local police who came and destroyed the brownie. The Administrator stated the original plan was for Resident #1 to discharge tomorrow (11/21/2024) after her doctor appointment and that was still the plan. She stated the facility was accepting Resident #1 back from the hospital today (11/20/2024) because they did not believe in dumping. She stated a discharge notice had never been given to the resident. The Administrator stated she communicated with the staff in person, text and she preferred phone calls. She stated she attended both morning and clinical meetings with staff. She stated during those meetings they did discuss that a CNA found a bottle of prescription medication containing morphine in Resident #1's room. She stated they made the required notifications including to family, physician and they educated the staff and visitors. She stated they do not routinely search residents' rooms or visitors for medications. She stated the resident had both a right to receive visitors and packages. The Administrator stated in lieu of searching Resident #1's room which showed lack of character judgement, LVN A should have provided medical care to Resident #1. The Administrator stated she ensured staff had the knowledge on how to response by in-service training. She stated the facility notified the Medical Director who was also Resident #1's physician of the incident on 11/19/2024. During an interview on 11/20/2024 at 10:45 a.m., Resident #1's family member stated Resident #1 had an accident and broke her foot and prior to that had surgery on her shoulder. The family member stated Resident #1 was currently hospitalized because she was found very lethargic and unresponsive. He stated the doctors at the hospital said she was taking a lot of medications. He stated he was not sure what medications she was taking. He stated Resident #1 was seeing a pain medication doctor, an orthopedic surgeon and had a doctor at the facility but he didn't know who the doctors were and did not know the prescriptions. The family member stated he did not know Resident #1 was getting medications from multiple physicians and multiple pharmacies and did not know why she was now testing positive for marijuana. He stated a few days before she was admitted to the facility, she took a vacation to the Caribbean and spent some time in Chicago and may have had access to marijuana at either of those places. He stated he had no knowledge of any other illegal drug usage. He stated to his knowledge Resident #1 had not had any visitors at the facility. He stated Resident #1 did not have a significant other/boyfriend that he was aware of. He stated there was another family member locally, but that person had no contact with Resident #1. He stated he had minimal contact with Resident #1 and had only visited her twice at the facility. He stated he was unable, unwilling and did not have the capacity to give Resident #1 support. He stated Resident #1 did not leave the facility other than for doctors' appointments, but she did have local grocery and food deliveries at the facility. He stated he did not visit Resident #1 the night of the incident on 11/18/2024-11/19/2024. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bed side but LVN A went to her medication cart. LVN B stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. He stated the physician's response was that a hospital evaluation was appropriate. LVN A stated he had never witnessed any medications in Resident #1's room and had never smelled or identified marijuana in her room. During an interview on 11/20/2024 at 12:25 p.m., NA C stated on 11/19/2024 at 6:06 a.m. she arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with her (LVN A). NA C stated CNA D stated the nurse (LVN A) was not listening to her and there was concern for Resident #1. NA C stated CNA D said a random guy went into Resident #1's room but she did not know what happened. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 laying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1? NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on her (Resident #1) or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into the room and stated, she is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B said to LVN A Why did you wait? NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying? She stated LVN A responded that she had a rough day. NA C stated she had never seen any medications or drugs lying around in any resident room. She stated they were not able to identify the visitor. She stated the front doors are locked at night and require a code to access the facility. NA C stated if she saw medications lying around, she was trained to give them to the nurse. She stated she had training in opioid abuse, administration of Narcan and what to do in case of change of condition. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A came into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids and was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but she was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A stated Resident #1 was a druggy and knew her limits. CNA D stated she thought that comment was inappropriate. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A told 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. CNA D stated the whole situation was a surprise to her. She stated Resident #1 was normally independent, up and about, and alert. She stated she had never seen the resident in any other way. She stated she had never seen any medications or drugs lying around in resident rooms. She stated she was trained to notify the nurse and go up the chain of command if necessary. She stated she had received in-service training on abuse/neglect, medication administration and change of condition following the event. During an interview on 11/20/2024 at 1:06 p.m., NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. she saw a man they did not know come out of Resident #1's room. She stated she also saw Resident #1 who was oriented normally and was up and moving around and asked for ice for her ankle. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told us to try to help wake her (Resident #1) up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A stated, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. NA F stated it was her first overnight shift. She stated she did not know the typical protocol door nighttime, just what LVN A had told her. She stated LVN A told her the aides not to go into Resident #1's room during the night, that it was on her chart not to go in because she was independent, and she could do everything on her own. She stated they might peak into her room from the door but wouldn't enter the room if it looked like the resident was sleeping. NA F stated she didn't have any way to verify what LVN A told her about the chart, they just had to take her word for it. She stated she did not open Resident #1's door between 11 p.m. - 5 am. NA F stated since the incident she had received training on opioid abuse, how to handle an overdose, change of condition and abuse/neglect. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated at the beginning of her shift she saw a gentleman visitor come from outside to Resident #1's room. She stated she did not question the visitor because other staff had said the visitor had been there since 6:00 p.m. NA E stated the outside doors of the facility are locked and require a code to access or Resident #1 may have given the code to the visitor. NA E stated she saw the visitor leave and come back in with a food to go box in a clear plastic bag. She stated she assumed it was food that was delivered to the facility for her. She stated families do it all the time. NA E stated the visitor left at approximately 10:45 p.m. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated this whole time Resident #1 was unconscious and LVN A was not proving care, she did not do vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when they next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for [AGE] years. She stated on the night of 11/18/2024 around approximately 11:08 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg handing off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills a piece of peach-colored pills. She stated she thought the white one [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #1) reviewed for quality of care, in that; The facility failed to immediately assess and intervene when Resident #1 was found unresponsive and twitching on 11/19/2024 at 5:00 a.m. by LVN A until the next shift arrived and LVN B intervened. This change of condition required treatment in a local hospital for altered mental status. The noncompliance was identified as PNC. The IJ began on 11/19/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who experience a change of condition and result in a delay in care, significant injury including permanent disability and death. The findings included: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admitted [DATE] with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. Record review of Resident #1's nurse assessment documented on 11/18/2024 at 5:22 p.m. revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment documented Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall .will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician was notified or that 911 was called or that Resident #1's family had been notified of the sudden change in mental status. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy)when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's. (normal 92-100) and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from night shift stated to LVN B that this had been reported to LVN A since 11 p.m. last night (11/18/2024). When LVN B questioned LVN A if patient (Resident #1) was ever able to voice any response, LVN A stated that she (Resident #1) was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to the room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub was performed with grunting as the response sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level), vital signs were obtained, and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN. LVN B documented he re-assessed Resident #1 prior to EMT (EMS), and no change was noted. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed and the head of the bed elevated 35 degrees. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name). LVN A wrote a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure) 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room to check on the resident or assist her in LVN A in her need to be done so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she continued going in and out of Resident #1's room. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge of the bed, but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she went to get a wheelchair to assist Resident #1 to the nurse's station and told the oncoming nurse (LVN B) that she may be okay because she pulled herself to a sitting position. LVN A wrote LVN B did not want to assist her with an assessment of the situation as to not deal with the situation. LVN A wrote she decided to stay around and she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911 (unknown time) and then went in the room to assist the EMTs in any way she could. Record review of a verbal statement of LVN A given to the Corporate RN which was typed (undated) revealed: at 5:30 a.m. she (LVN A) went to give Resident #1 medications and knew something was not right because the resident was lying with her leg off the bed. LVN A noted that was out of the ordinary for her and the head of the bed was up at 35 degrees. LVN A stated she gave Resident #1 a verbal command and attempted to rouse the resident, she opened her eyes and began speaking in an unclear speech and was lethargic. LVN A stated she took vitals, and they were 101/84 [blood pressure], 96% oxygen saturation 18 respirations and 55 HR (slightly lower than normal of 60-100). LVN A stated she gave Resident #1 a sternal rub and the resident had a facial grimace and then sat up on the side of the bed by herself at 6:00 a.m.LVN A stated she last left the resident around 11 p.m. (11/18/24) and did not check on the resident again until 5:30 a.m. because she was busy doing all her task for the night and the resident did not like to be bothered at night. LVN A stated she searched Resident #1's room and found medications at her bedside. LVN A stated the oncoming nurse came on and she was giving him (LVN B) a report and then he went to look at the resident and they notified 911. Record review of a written statement (undated), NA E wrote they (aides) were doing rounds at 10:00 a.m. they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night because the resident preferred they did not wake her up all night unless she called them, so they did not make rounds on her. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling us (aides) to go try and wake her (Resident #1) up. NA E wrote they (aides) went the resident's room (Resident #1) and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like this at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote they found a little box of pills while searching the room and LVN A took them. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote the aides did not do rounds on Resident #1 during the night because her chart says not to as she could go the restroom and move around on her own. NA F wrote at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A rushed in and said Resident #1 would not respond to her. She told them to go into the room and try to wake her (Resident #1) up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A to do the rest and continued her rounds because she was not qualified to assist with anything else. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside but LVN A went to her medication cart. LVN B stated he asked LVN B if she if she did any interventions for Resident #1 and LVN A replied no. He stated that was why he was alarmed because LVN A did not re-assess or address Resident #1's change of condition and she did not go back into the room between 11-5 am to re-ass the resident. LVN B stated it was important to immediately assess and intervene when a resident had a decrease level of consciousness because it could be an emergency situation. He stated the resident should have an immediate assessment and interventions. LVN B stated failure to respond to a resident in need was neglect and he was trained to address the concerns immediately which he did. He stated he immediately notified the Administrator. During an interview on 11/20/2024 at 12:25 p.m. NA C stated on 11/19/2024 at 6:06 a.m. she was arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with her (LVN A). NA C stated CNA D stated the nurse (LVN A) was not listening to her and there was concern for Resident #1. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 laying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1? NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on her (Resident #1) or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into the room and stated, She is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B said to LVN A Why did you wait? NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying? She stated LVN A responded that she had a rough day. NA C stated she could not do anything else for Resident #1 because she was just a nurse aide in training, but she stayed with the resident and saw when EMS got there. NA C stated Resident #1 was still unresponsive when she left the facility with EMS. NA C stated she was trained to report resident change of condition to the nurse right away. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A came into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids and was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but she was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A stated Resident #1 was a druggy and knew her limits. CNA D stated she thought that comment was inappropriate. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A called 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. CNA D stated she had been trained to notify the nurse right away for a change of condition. During an interview on 11/20/2024 at 1:06 p.m. NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. she saw Resident #1 who was oriented normally and was up and moving around. NA F stated LVN A told the aides not to go into Resident #1's room during night shift. NA F stated the resident did not need help transferring and was able to do everything on her own. She stated she might peak in at the doorway to ensure the resident was not on the floor but she did not enter the room and could not tell anything else from the doorway. NA F stated the aides were reliant on what the nurse told them to do and there was not anyway to look up the information. NA F stated on the night of the incident she did not open Resident #1's door between 11 p.m. - 5 a.m. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told us to try to help wake her (Resident #1) up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A stated, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. She stated she did not go into the resident room between 11 p.m. and 5 a.m. because the resident preferred to not be woken up. She stated they tell her goodnight, and they would see her again in the morning. NA E stated she relied on the nursing staff to tell them what to do for the resident based on the care plan. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do and she was relying on the aides. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated this whole time Resident #1 was unconscious and LVN A was not proving care, she did not do vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when the next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. NA E stated she was trained to notify the nurse of change of condition. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for [AGE] years. She stated on the night of 11/18/2024 around approximately 11:00 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated she did not check on Resident #1 between 11:00 p.m.-5:20 a.m. She stated the facility policy was to check on residents every 2 hours and the aides were making rounds every 2 hours she suspected although she stated she was not certain. She stated she was busy with other duties. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg hanging off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills. LVN A stated at 5:45 a.m. she told another nurse (name unknown) that Resident #1 was unresponsive, but that nurse didn't get off her chair or try to help her. LVN A stated she grew up where nurses help nurses, and they all work together. She stated LVN B was coming in to relieve her from night shift. LVN A stated LVN B did not go into Resident 1's room one time. She stated she was so upset because no one who worked at the facility, no one helped her. LVN A stated she worked her butt off all night long and she was tired. She stated LVN B just came in and where is his heard, he does not have one. LVN A stated she was livid that she had been suspended and LVN A still had a job. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she first obtained vitals at approximately 6:00 a.m. and reported they were normal. She stated she did not know why there was a delay in taking Resident #1's vitals signs from the time she found her with a change of condition until 6:00 a.m. She stated she was just getting information to give to day shift so they could take over. LVN A stated she did not know who to call. She stated the ADON was on vacation and the DON had walked out of the facility. LVN A stated another nurse (name unknown) gave her the phone number for the Administrator, so she called her and told her they needed to discharge Resident #1 from the facility because she was not following the rules. LVN A stated the Administrator did not tell her what to do or give her any idea what to do. LVN A stated she had 35 people to take care of and it was very stressful. LVN A stated after she got off the phone with the Administrator, she called 911 because she thought maybe they could shake her up. LVN A stated she was upset because the Administrator thought she was slow to react, so she found herself suspended. LVN A stated she did not notify Resident #1's physician about her change of condition. She stated she did not notify the physician because she was collecting information, searching her room, and looking up her medication. She stated she also did not call because she thought Resident #1 was going to be okay. She stated she was just gathering information and waiting for the next shift to take over because she herself was tired. LVN A stated was trained to assess, document the assessment, gather information and probably call the doctor for resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. She stated, We are all human, right .I was tired. When asked if she was fit for duty if she was too tired to complete her nursing duties, she stated yes. During an interview on 11/20/2024 at 3:40 p.m., the Corporate RN (VP of Clinical Services) stated the DON left the position approximately 1 month ago and she was monitoring the facility as RN since that time. The Corporate RN stated one of the ADON's was also an RN and was assisting. The Corporate RN stated on 11/19/2024 she was traveling to the facility and was almost there when she received a call at 7:03 a.m. from LVN B. She stated she called the Administrator and EMS was arriving. The Corporate RN stated she interviewed LVN A who told her she had given pills to Resident #1 at 11:00 p.m. (11/18/2024) and then went in at 5:00 a.m. (11/19/2024) and found the resident lethargic, reporting she did not round on the resident during the night because Resident #1 did not like it. The Corporate RN stated LVN A stated she did a sternal rub on Resident #1, who grimaced and then sat up on the side of the bed. LVN A reported that she had NA E and NA F come check on the resident. The Corporate RN stated LVN A said she had not made notifications and that she gave report to oncoming nurse LVN B. The Corporate RN stated she interviewed LVN B who stated he assessed Resident #1 and told LVN A to call 911. The Corporate RN stated she interviewed NA E and NA F who both said they told LVN A around 5:00 a.m. Resident #1 was lethargic and nothing was done. The Corporate RN stated the facility then reported it to HHSC was because there was a delay in care to Resident #1. She stated there was a delay in providing interventions , in alerting EMS and in notifying the physician. The Corporate RN stated after she interviewed the staff, she did not believe LVN A's account of events was accurate. The Corporate RN stated after notifying HHSC of the event she facility began immediately correcting on 11/19/2024 and had completed the correction prior to surveyor arrival. She stated they had: 1. Immediately started staff in-services on abuse/neglect, medication orders, medication administration, opioid overdose management, responding to suspected overdose, how to use Narcan, no medications at bedside, self-administration of medications assessment in which the IDT has to determine if the resident was safe to self-administer, notifications of change of condition, PRN medications. She stated the in-service training for staff in the facility had been completed prior to surveyor arrival on 11/19/2024. 2. The Corporate RN stated a notice had been posted at the time clock and no staff would be allowed to clock in until the in-services had been completed. She stated at the time of this interview all staff had been educated before surveyor arrival on 11/19/2024. 3. The Corporate RN stated the facility completed a 100% assessment audit on residents assuring any change of condition was addressed. She stated this was completed prior to surveyor arrival on 11/19/2024. 4. The Corporate RN stated the facility completed a 100% audit of medical records to ensure any change of condition had notifications of physicians and families documented. She stated no new change of conditions were identified. She stated this was completed prior to surveyor arrival on 11/19/2024. 5. The Corporate RN stated a 100% rounding of medication carts/medication records was completed on 11/19/2024 prior to surveyor arrival and another was completed on 11/20/2024 to ensure there were no medication discrepancies. 6. The Corporate RN stated a text alert was sent to all family members that all medications need to go to the nurses. She stated this was completed prior to the incident on 11/19/2024 in the month on November when Resident #1 had been previously brought in medications from home. 7. The Corporate RN stated QA/PIP tools were put in place to include notification of physician for change of condition with actions to address included. She stated this was completed prior to surveyor arrival on 11/19/2024. 8. The Corporate RN stated the facility notified the Medical Director of the incident and the facility plan to correct. She stated this was completed prior to surveyor arrival on 11/19/2024. 9. The Corporate RN stated LVN A was immediately suspended, and they planned to terminate her employment and refer her nurses license as soon as the investigation was complete. She stated this was completed on 11/19/2024 as soon as LVN A completed her written statement of events and she had been interviewed prior to surveyor arrival. 10. The Corporate RN stated they reviewed facilities policies and ensured they were put out for staff to review. She stated this was completed prior to surveyor arrival on 11/19/2024. During an interview on 11/20/2024 at 4:14 p.m., the Administrator stated on 11/19/2024 she received a call from the Corporate RN about Resident #1, a suspected overdose and that EMS was on their way to the facility to pick up the resident. She stated she told the Corporate RN to interview staff and find out what was going on. The Administrator stated then LVN A called her. She stated LVN A told her it was a suspected overdose, and that EMS were at the facility because she could not get Resident #1 back to baseline. The Administrator stated she arrived at the facility on 11/19/2024 at 8:15 a.m. at which time interviews were completed and staff in-services had already been started. The Administrator stated based on staff interviews they felt there had been a delay in care and that LVN A did not act promptly so they immediately self-reported to HHSC. She stated they worked diligently to correct the error on the morning on 11/19/2024. She stated the Corporate RN had completed the corrections prior to surveyor arrival. The Administrator stated the staff were all pretty upset so she checked on the staff. The Administrator stated she was not a medical person and was not certain what caused Resident #1's change of condition but she did feel LVN A was neglectful of Resident #1. The Administrator stated she had been trying unsuccessfully to reach LVN A so she could terminate her employment and refer her license. The Administrator stated she had reviewed the facility surveillance video and based on that review there were some non-truths to LVN A story. The Administrator stated LVN A had poor judgement of character. The Administrator stated she supervised her staff by ensuring monthly in-service training. She stated in meetings they ta [TRUNCATED]

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in life-threatening conditions for 1 of 5 residents (Resident #1) reviewed for change of condition, in that; The facility failed to notify Resident #1's physician and family on 11/18/2024 when she was found sleepier than usual or notify Resident #1's physician and the resident's family when the resident was found unresponsive and twitching with a significant alteration in mental status at approximately 5:00 a.m. on 11/19/2024 and was treated for altered mental status at the hospital. The noncompliance was identified as PNC. The IJ began on 11/18/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious harm, permanent disability and/or death. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admitted [DATE] with diagnoses which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. Record review of Resident#1's nurse assessment documented by day shift staff on 11/18/2024 at 5:22 p.m. revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment reflected Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. revealed, 0530 (5:30 a.m.) walked into room .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid [sic] on the hall .will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician or family was notified regarding Resident #1's sudden change in mental status from 11/18/2024-11/19/2024. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy) when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's (normal 92-100); and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended LVN A for further investigation due to a delay in care. EMS arrived and administered Narcan, and Resident #1 was taken to a local ER and kept overnight for evaluation. Resident #1 was found to have medication at her bedside and hospital records revealed marijuana in her system. Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from the night shift stated to LVN B that it had been reported to LVN A since 11 p.m. the night before (11/18/2024). When LVN B questioned LVN A if Resident #1 was ever able to voice any response, LVN A stated that Resident #1 was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level) was performed with grunting as the response sternal rub and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN, and also notified the physician and the family of Resident #1. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name). LVN A documented a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure), 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room or assist her, so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge of the bed but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911 (unknown time). Record review of a written statement (undated) by NA E revealed they (aides) were doing rounds at 10:00 a.m. and they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling the aides to go try and wake her (Resident #1) up. NA E wrote they (aides) went to the Resident #1's room and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like that at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A came rushing in saying Resident #1 would not respond to her. She told them to go into the room and try to wake Resident #1 up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A do the rest and continued her rounds. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A said she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A said the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A said she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A said she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides (unknown names) go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside, but LVN A went to her medication cart/ LVN A stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. He stated the physician's response was that a hospital evaluation was appropriate. During an interview on 11/20/2024 at 12:25 p.m. NA C stated on 11/19/2024 at 6:06 a.m. she arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with LVN A. NA C stated CNA D stated the LVN A was not listening to her and there was concern for Resident #1. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 lying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1. NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on Resident #1 or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into Resident #1's room and stated, She is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B asked LVN A Why did you wait?. NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying. She stated LVN A responded that she had a rough day. NA C stated she could not do anything else for Resident #1 because she was just a nurse aide in training, but she stayed with the resident and saw when EMS got there. NA C stated Resident #1 was still unresponsive when she left the facility with EMS. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A went into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids, was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest k rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but LVN A was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A said Resident #1 was a druggy and knew her limits. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A called 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. During an interview on 11/20/2024 at 1:06 p.m. NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. and she saw Resident #1 who was normally oriented was up and moving around. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told them to try to help wake Resident #1 up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A said, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do and she was relying on the aides. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated the whole time Resident #1 was unconscious and LVN A was not providing care, she did not take vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when the next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for [AGE] years. She stated on the night of 11/18/2024 around approximately 11:00 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg hanging off the bed with her head of bed at 45 degrees and her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 opened her eyes a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills. LVN A stated at 5:45 a.m. she told another nurse (name unknown) that Resident #1 was unresponsive, but that nurse didn't get off her chair or try to help her. LVN A stated she grew up where nurses helped nurses, and they all worked together. She stated LVN B was coming in to relieve her from night shift. LVN A stated LVN B did not go into Resident #1's room one time. She stated she was so upset because no one who worked at the facility, no one helped her. LVN A stated she worked her butt off all night long and she was tired. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she did not know who to call. She stated the ADON was on vacation and the DON had walked out of the facility. LVN A stated another nurse (name unknown) gave her the phone number for the Administrator, so she called her and told her they needed to discharge Resident #1 from the facility because she was not following the rules. LVN A stated the Administrator did not tell her what to do or give her any idea what to do. LVN A stated she had 35 people to take care of and it was very stressful. LVN A stated after she got off the phone with the Administrator, she called 911 because she thought maybe they could shake her up. LVN A stated she was upset because the Administrator thought she was slow to react, so she found herself suspended. LVN A stated she did not notify Resident #1's physician about her change of condition. She stated she did not notify the physician because she was collecting information, searching her room, and looking up her medication. She stated she also did not call because she thought Resident #1 was going to be okay. She stated she was just gathering information and waiting for the next shift to take over because she herself was tired. LVN A stated was trained to assess, document the assessment, gather information and probably call the doctor for a resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. She stated, We are all human, right .I was tired. When asked if she was fit for duty if she was too tired to complete her nursing duties, she stated Yes . During an interview on 11/20/2024 at 3:40 p.m., the Corporate RN (VP of Clinical Services) stated the DON left the position approximately 1 month ago and she was monitoring the facility as the RN since that time. The Corporate RN stated one of the ADON's was also an RN and was assisting. The Corporate RN stated on 11/19/2024 she was traveling to the facility and was almost there when she received a call at 7:03 a.m. from LVN B. She stated she called the Administrator and EMS was arriving. The Corporate RN stated she interviewed LVN A who told her she had given pills to Resident #1 at 11:00 p.m. (11/18/2024) and then went in at 5:00 a.m. (11/19/2024) and found the resident lethargic, reporting she did not round on the resident during the night because Resident #1 did not like it. The Corporate RN stated LVN A said she did a sternal rub on Resident #1, who grimaced and then sat up on the side of the bed. LVN A reported that she had NA E and NA F check on the resident. The Corporate RN stated LVN A said she had not made notifications and that she gave report to oncoming nurse LVN B. The Corporate RN stated she interviewed LVN B who stated he assessed Resident #1 and told LVN A to call 911. The Corporate RN stated she interviewed NA E and NA F who both said they told LVN A around 5:00 a.m. Resident #1 was lethargic and nothing was done. The Corporate RN stated the facility then reported it to HHSC because there was a delay in care to Resident #1. She stated there was a delay in providing interventions, in alerting EMS and in notifying the physician . The Corporate RN stated after she interviewed the staff, she did not believe LVN A's account of events was accurate. The Corporate RN stated after notifying HHSC of the event she facility began immediately correcting on 11/19/2024. She stated they had: 1. Immediately started staff in-services on abuse/neglect, medication orders, medication administration, opioid overdose management, responding to suspected overdose, how to use Narcan, no medications at bedside, self-administration of medications assessment in which the IDT had to determine if the resident was safe to self-administer, notifications of change of condition, and PRN medications to all staff that were working and had placed a notice on the time clock preventing any staff from clocking in until they had been in-serviced. She said this was completed immediately on 11/19/2024 and had been top priority 2. The Corporate RN stated a notice had been posted at the time clock and no staff would be allowed to clock in until the in-services had been completed. She stated at the time of this interview all staff had been educated. She stated this was prior to surveyor arrival on 11/19/2024. 3. The Corporate RN stated the facility completed a 100% assessment audit on residents assuring any change of condition was addressed before surveyor arrival on 11/19/2024. 4. The Corporate RN stated the facility completed a 100% audit of medical records to ensure any change of condition had notifications of physicians and families documented. She stated no new change of conditions were identified. She stated this was completed prior to surveyor arrival on 11/19/2024. 5. The Corporate RN stated a 100% rounding of medication carts/medication records was completed on 11/19/2024 before surveyor arrival and another was completed on 11/20/2024 to ensure there were no medication discrepancies. 6. The Corporate RN stated a text alert was sent to all family members that all medications needed to go to the nurses she stated this occurred prior to the 11/19/2024 incident when they first learned Resident #1 was bringing medication by way of visitors into the facility. 7. The Corporate RN stated QA/PIP tools were put in place to include notification of physician for change of condition with actions to address included. She stated this was completed on 11/19/2024 prior to surveyor arrival. 8. The Corporate RN stated the facility notified the Medical Director of the incident and the facility's plan to correct. She stated this occurred on 11/19/2024 before surveyor arrival. 9. The Corporate RN stated LVN A was immediately suspended, and they planned to terminate her employment and refer her nurses license as soon as the investigation was complete. She stated this was completed on 11/19/2024 as soon as LVN A completed her written statement of events and she had been interviewed prior to surveyor arrival. 10. The Corporate RN stated they reviewed facility's policies and ensured they were put out for staff to review. She stated this was completed on 11/19/2024 prior to surveyor arrival. During an interview on 11/20/2024 at 4:14 p.m., the Administrator stated on 11/19/2024 she received a call from the Corporate RN about Resident #1, a suspected overdose and that EMS was on their way to the facility to pick up the resident. She stated she told the Corporate RN to interview staff and find out what was going on. The Administrator stated then LVN A called her. She stated LVN A told her it was a suspected overdose, and that EMS was at the facility because she could not get Resident #1 back to baseline. The Administrator stated she arrived at the facility on 11/19/2024 at 8:15 a.m. at which time interviews were completed and staff in-services had already been started. The Administrator stated based on staff interviews they felt there had been a delay in care and that LVN A did not act promptly so they immediately self-reported to HHSC. The Administrator stated the Corporate RN and herself immediately in-serviced staff in the facility to ensure they were aware and in compliance with facility policy for notification. She stated they worked diligently to correct the error on the morning on 11/19/2024. She stated the Corporate RN had completed the corrections prior to surveyor arrival. The Administrator stated the staff were all pretty upset so she checked on the staff. The Administrator stated she was not a medical person and was not certain what caused Resident #1's change of condition, but she did feel LVN A was neglectful of Resident #1. The Administrator stated she had been trying unsuccessfully to reach LVN A so she could terminate her employment and refer her license. The Administrator stated she had reviewed the facility surveillance video and based on that review there were some non-truths to LVN A's story. The Administrator stated LVN A had poor judgement of character. The Administrator stated she supervised her staff by ensuring monthly in-service training. She stated in meetings they talked a lot of about the facility culture, specifically related to treating people with kindness, acting on kindness and quality of care. She stated the team did a really good job in communicating with the team. She stated she was available 24/7. She stated her number was posted everywhere throughout the facility including by the time clock and on the main bulletin board of the facility and had been posted there prior to this incident. During an interview on 11/20/2024 at 5:34 p.m., Resident #1 stated she could not remember what happened on 11/18/2024-11/19/2024. She stated she normally went to bed around 10:00 p.m. She stated on 11/18/2024 she remembered lying in bed and trying to look at her phone, but her hands were shaking so bad she could not look at it. She stated she did not tell anyone at the facility that was occurring and did not ask for help. She stated she just thought it would diminish on its own and she would check on the shaking in the morning. She stated the next thing she remembered was waking up in the hospital. During an interview on 11/22/2024 at 11:20 a.m., the Corporate RN stated LVN A had completed nurse competencies upon hire in April 2024, although she was not part of the corporation at that time and did not participate in that assessment. She stated the competencies included change of condition and notification of physician for change of condition. The Corporate RN stated as a licensed nurse, LVN A would have to attend a school of nursing where she would be taught those skills. The Corporate RN stated she would have expected LVN A to assess a resident with change of condition and immediately notify EMS, the MD and the RP (family) if a drug overdose was suspected, and to stay with her until she was safely out of the facility. The Corporate RN stated it was important to ensure the patient was provided care and taken care of. The Corporate RN stated she was monitoring staff by looking at PCC (electronic medical record) dashboard, 24-hour reports, reviewing documentation, and frequent rounding. She stated she did not want to speculate on why the situation occurred. During an interview on 11/22/2024 at 12:39 p.m., LVN A stated she had been terminated by the Administrator on 11/22/2024. She stated the Administrator also informed her she was referring her license. During an interview on 11/22/2024 at 3:20 p.m., the MD (Resident #1's physician) stated he had been notified of Resident #1's unresponsiveness and change of condition but he could not remember when that occurred or who notified him. He stated it was just a notification and there was not much of an option at that point. He stated his expectations for the scenario was common sense. He stated unconsciousness was one of the few things they needed to send a resident out for and he would expect that to occur pretty soon. Record review of a facility policy titled Notification of Change of Condition (undated) revealed the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Record review of facility documents post incident for facility correction: Record review of a facility document (undated) titled Action Plan to Ensure Relevant Recommendations are Followed revealed: 1. Notify Medical Record of Incident was documented as completed by the Administrator on 11/19/2024. 2. Complete Disciplinary Actions was documented as employee (LVN A) suspended on 11/19/2024 and was updated on 11/20/2024 as employee terminated. 3. Complete physical assessments on all residents to identify any change of condition was documented as completed on 11/19/2024. < [TRUNCATED]

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Residents #2 and #3) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #2 clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin were secured when they were left in the resident's room. The facility failed to ensure Resident #3's Simbrinza ophthalmic suspension x 2 bottles and 5 medication cups of an unknown ointment were secured when the resident was not in the room. These deficient practices could put residents at risk for inaccurate or inappropriate administration of medications. The findings were: 1. Record review of Resident #2's face sheet dated 11/23/2024 revealed an admitted [DATE] with diagnoses which included: atrial fibrillation (irregular heart rhythm), adult failure to thrive (weight loss and general decline) and muscle weakness. Record review of Resident #2's care plan initiated on 11/10/2024 revealed no relevant care areas. Record review of Resident #2's admission MDS revealed it was still in progress and had not been completed. Record review of Resident #2's physician order summary dated 11/23/2024 revealed he did not have orders for clobetasol shampoo or over-the-counter polysporin. Record review of Resident #2's medical record revealed he had not been assessed for self-administration of medication. During an observation and interview on 11/19/2024 at 1:57 p.m., Resident #2 was observed in bed awake without staff in attendance. A box of clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment (antibiotic ointment) was observed on his dresser. Resident #2 did not answer any questions about the medications and it was unclear if he was cognitively intact. He stated, leave those there please. During an observation and interview on 11/19/2024 at 3:12 p.m., LVN B stated Resident #2 could not keep the clobetasol shampoo in his room or the polysporin. He confirmed the shampoo was a prescription. He stated the staff inspect the rooms and teach the patients, so they know to bring medications to the nurses. He described Resident #2 was cognitively intact. LVN B took the shampoo and polysporin ointment with him while exiting the room and informed Resident #2 he needed to talk to his doctor about the medications. 2. Record review of Resident #3's face sheet dated 11/21/2024 revealed an admitted [DATE] with readmitted [DATE] with diagnoses which included: epilepsy, pain in right knee, right shoulder and dementia. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMs score of 14 which indicated the resident was cognitively intact and without behaviors. Record review of Resident #3's Self-Medication Administration assessment dated [DATE] revealed the resident had been assessed and determined to be able to self-administer medications. Record review of Resident #3's Care Plan initiated on 8/02/2024 revealed the resident could self-administer specific medications with interventions which included: keep medications in a lockbox. Remind as needed to use box only for medication and to lock up in between uses. Record review of Resident #3's physician order summary revealed the following orders: 1. Simbrinza ophthalmic suspension 1-0-2% (brinzolamide-brimonidine tartrate) instill 1 drop in both eyes two times a day for glaucoma. 2. Voltaren arthritis pain external gel 1% (diclofenac sodium) topical ointment: apply to knees, painful sites topically two times a day every Tues, Thurs, Sat for pain as unsupervised self administration whenever patient reports pain, 3. Zoryve External cream 0.3% (roflumilast) topical, apply to right thigh topically every day shift for rash During an observation on 11/19/2024 at 2:33 p.m. two bottles of prescription Simbrinza ophthalmic suspension 1-0-2% and 5 medication cups labeled with different body parts such as groin, knee, leg with a white creamy substance assumed to be a medicated ointment were on the over bed table. Resident #3 was not in the room and no staff were in the room. Multiple gloves were also noted on the table. There was a small clear lockbox on the over bed table that had the key in the lock. The clear lockbox contained individual jelly packets too numerous to count. During an observation and interview on 11/19/2024 at 2:43 p.m. CNA D stated medications were to be administered by the med tech or the nurse. She stated she did not know what the medications were in Resident #3's room. She stated she was not aware of any residents in the facility who were self-administering medication. She stated she was trained to take up the medications and notify the nurse. She stated those medications (referring to the eye drops and multiple medication cups of ointment) need to be picked up. She exited the room leaving the medications in the room unattended. During an observation and interview on 11/19/2024 at 2:51 p.m., LVN P stated Resident #3 self-administered some of his medications. She stated he had been assessed for self-administration. LVN P stated they could leave medications in Resident #3's room but the medications should be in a locked drawer and the resident keeps the key. She stated the nursing staff did not have to observe Resident #3 administering his medication. She stated Resident #3 had pain medication and eye drops that he kept in his room. She stated the rest of his medications were kept in the locked medication cart. She stated unless a resident had been assessed for safe self-administration all medications were to be locked up. Upon observing the eye drops and multiple medication cups with the white gel in them, LVN P stated the white medication was either knee pain gel, a prescription cream for his thighs or moisturizer but she was not certain what was in the medication cups. She stated Resident #3 should be keeping his medications in the locked box and keeping the key with him and not using it to lock up jelly. She stated she was not certain why he had two bottles of the Simbrinza in his room. LVN P stated it was important to keep medications locked up because they have some residents who wander who might be confused and think medications were candy. She stated the eye drops and ointment/pain gel should also be locked up whenever the resident was not in the room. She exited the room and left the medication on the overhead table. During an interview on 11/22/2024 at 8:02 a.m., RN ADON L stated the CNAs should report any medications found in a resident room to the nurse. She stated any medications in a resident room should be removed. Record review of a facility policy titled Medication Administration (undated) revealed the policy did not address storage of medications. Record review of a facility policy titled Resident Self-Administration of Medication (undated) revealed: 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at minimum consider the following: g. The residents ability to ensure that medication is stored safely and securely.

Based on interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 5 residents (Resident #1) reviewed for medical records, in that; The facility failed to ensure staff documented Resident #1's unresponsiveness and SBAR assessment, the pills found in her room on 11/19/2024 or interventions for her change of condition including notification/activation of 911 and transfer to the hospital for treatment. This failure could result in residents not having an accurate overall view of their care and services. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admitted [DATE] with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy or having medications in her room without staff knowledge. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room, HOB 35 degrees, right leg hanging off the bed .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall. She reports to me a man went (sic) in her room at 11:00 p.m. and left. I asked if she reported to someone. She said the nurse on the Southside was told. I asked why? I am the nurse here on this side. Holding this 6 am dose (unknown medication). Will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate any further assessments or that 911 was called or that Resident #1 was transferred to the hospital for a significant change in mental status. Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended the nurse (LVN A) for further investigation due to a delay in care. EMS arrived and administered Narcan, and the patient (Resident #1) was taken to a local ER and kept overnight for evaluation. The patient (Resident #1) was found to have medication at bedside and hospital records showed marijuana in (her) system). During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside but LVN A went to her medication card. LVN A stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated on the night of 11/18/2024 around approximately 11:08 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg handing off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to walk Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills a piece of peach-colored pills. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she called 911 because she thought maybe they could shake her up. LVN A stated was trained to assess, document assessment for resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. During an interview on 11/21/2024 at 9:56 a.m., LVN B stated there was no SBAR or other assessment documented in Resident #1's medical record for her change of condition that occurred on 11/19/2024 or any notifications. He stated he was trained to do an SBAR assessment with change of condition and document it in the medical record. He stated he was also trained to document in the progress notes the assessment and assessed vitals. He stated he did not document his assessment because he gave the information to LVN A. He stated he should have documented when Resident #1 was transferred to the hospital. LVN B stated it was important to document pertinent information in the medical record because it was a confirmation of work done. He stated he had received training by the facility on documentation on an unknown date. During an interview on 11/22/2024 at 11:20 a.m., the Regional RN stated staff were trained to document the SBAR assessment located under documents for resident change of condition. She stated they were trained to document change of condition which included the assessment, vitals, and notifications also in the progress notes. She stated the whole chain of events should be included in the notes including any new orders, transfers, etc. She stated it was important to document so there was continuity of care. Record review of a facility policy, titled Documentation in the Medical Record (undated) revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered i. False information shall not be documented.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that; The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's behaviors of bringing in medications from home, from other providers and from visitors and self-medicating without telling staff. This failure could place residents at risk for not having their needs and preferences met. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admitted [DATE] with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024, revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy, having visitors bring in medications or having medications in her room and self-administering medications without staff knowledge. Record review of a provider progress note dated 11/08/2024 by PA J revealed: Patient (Resident #1) went to a pain medication doctor and had morphine prescription received, filled at outside pharmacy which she kept in her room and would self-dose. This was discovered and morphine was taken away from her .Denies alcohol, tobacco, drugs of abuse. Record review of Resident #1's nurse progress notes dated 11/09/2024 at 8:28 a.m. documented by LVN K revealed: Guest approached nurse at nursing station expressing concern. The pharmacy had questioned the medication she was picking (up) for a resident (Resident #1), morphine tablets (narcotic) and melodic (anti-inflammatory). The resident had requested she bring her medication with codeine (hydrocodone/acetaminophen 10/325) (narcotic opioid pain reliever) a week prior from a local pharmacy. The resident (Resident #1) explained that she had received the order from her pain management doctor at a previous appointment as the current pain medication was not effective at managing her pain. The nurse educated the patient (Resident #1) to inform her nurse of any new orders from appointments or her PCP so that her doctor at the facility could adjust her medication and make orders to safely assist her healing and rehab goals. The patient expressed understanding and stated she would not self-administer medication without informing the nurse. Record review of Resident #1's nurse progress notes dated 11/10/2024 at 4:43 p.m., documented by LVN H revealed: a CNA (unknown) notified nurse of suspicious activity. A person entered Resident #1's room with a package and immediately left. The incident was reported to the Administrator. Instruction was given to search room for medication, for patient safety. Patient (Resident #1) on narcotics and has a history of asking friends to bring in narcotic(s) and other pain medication prescribed by other providers into the facility and not adhering to facility policy. Patient education given. During an interview on 11/21/2024 at 4:46 p.m., RN MDS Coordinator M stated Resident #1's care plan did not address Resident #1's behaviors of bringing in medications from outside the facility and no interventions were put in place. She stated it had never really dawned on her to put it in the care plan. She stated the floor nurses were aware of the behaviors because they were the ones who documented it and she did not believe it happened frequently. RN MDS Coordinator M stated she first learned of the behaviors during morning meeting (unknown date) when she heard the nurses talk about it. She stated in hindsight she should have done it. She stated the purpose of the care plan was to disseminate information to staff such as things the resident was at risk for and their likes/dislikes. She stated it was important because it was a behavior and should have been in the care plan when it occurred so it would have been visible on the Kardex for staff review. During an interview on 11/23/2024 at 2:06 p.m., the Regional RN stated the MDS Coordinator and herself were responsible for care plan updates and completion. She stated during her review of Resident #1's care plan post 11/19/2024 incident and hospitalization was the first time she noted issues with the care plan. She stated Resident #1's behaviors of bringing in medication was something she would have expected to be included in that care plan. She stated it was important, so everyone was aware of the what the plan of care was and how they were to take care of the resident. Record review of a facility policy, titled Comprehensive Care Plans (undated) revealed: The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be address in the plan of care.

Based on interviews and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #1) reviewed for supervision, in that; The facility failed to adequately supervise Resident #1, who had a history of bringing multiple medications including narcotics into the facility without notifying staff, when she consumed a marijuana laced brownie and was found to have both Ambien and trazadone in an unmarked unlabeled container at bedside on 11/19/2024. On 11/19/2024, Resident #1 was found unresponsive and twitching in her room after staff failed to check on her between 11:00 p.m. on 11/18/2024 to 5:00 a.m. on 11/19/2024 despite seeing an unknown visitor in Resident #1's room on the evening of 11/18/2024 . This failure resulted in the identification of an Immediate Jeopardy (IJ) on 11/22/2024 at 12:50 p.m. The IJ template was provided to the facility on [DATE] at 1:03 p.m. While the IJ was removed on 11/23/24 the facility remained out of compliance at a scope identified as isolated and a severity level of potential for more than minimal harm until interventions were put in place to ensure resident safety because the facility needed to monitor the implementation of the plan of removal. This failure could place residents requiring supervision at risk for consumption of unknown and unregulated medications and illegal substances and place them at risk for an altered mental status, decline in health and/or death. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy or having medications in her room without staff knowledge. Record review of a provider progress note dated 11/08/2024 by PA J revealed: Patient (Resident #1) went to a pain medication doctor and had morphine prescription received, filled at outside pharmacy which she kept in her room and would self-dose. This was discovered and morphine was taken away from her .Denies alcohol, tobacco, drugs of abuse. Record review of Resident #1's nurse progress notes dated 11/09/2024 at 8:28 a.m., documented by LVN K revealed: Guest approached nurse at nursing station expressing concern. The pharmacy had questioned the medication she was picking (up) for a resident (Resident #1), morphine tablets (narcotic) and melodic (anti-inflammatory). The resident had requested she bring her medication with codeine (hydrocodone/acetaminophen 10/325) (narcotic opioid pain reliever) a week prior from a local pharmacy. The resident (Resident #1) explained that she had received the order from her pain management doctor at a previous appointment as the current pain medication was not effective at managing her pain. The nurse educated the patient (Resident #1) to inform her nurse of any new orders from appointments or her PCP so that her doctor at the facility could adjust her medication and make orders to safely assist her healing and rehab goals. The patient expressed understanding and stated she would not self-administer medication without informing the nurse. Record review of Resident #1's nurse progress notes dated 11/10/2024 at 4:43 p.m. documented by LVN H revealed: a CNA (unknown) notified nurse of suspicious activity. A person entered Resident #1's room with a package and immediately left. The incident was reported to the Administrator. Instruction was given to search room for medication, for patient safety. Patient (Resident #1) on narcotics and has a history of asking friends to bring in narcotic(s) and other pain medication prescribed by other providers into the facility and not adhering to facility policy. Patient education given. Will continue to monitor. Notified MD. Record review of a nurse progress note dated 11/11/2024 documented by LVN K revealed: Nurse notified ADON and MD (circumstances unknown). Received orders for Narcan for the patient (Resident #1 ). Record review of Resident #1's provider notes dated 11/14/2024 documented by PA J revealed: Notation was made that patient's family member was requesting she (Resident #1) not be given any narcotics, but no history of opioid abuse was given and patient was felt to have decision-making capacity, with no POA for involved family .Patient (Resident #1) reports her pain is controlled in her right shoulder and left ankle now that morphine prescribed by pain specialist. She has no acute complaints . 11/12 .pain MD wrote for morphine which she (Resident #1) was taking without notification of nurses, who thereafter noted some sedation and found the bottle . Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended the nurse (LVN A) for further investigation due to a delay in care. EMS arrived and administered Narcan, and the patient (Resident #1) was taken to a local ER and kept overnight for evaluation. The patient (Resident #1) was found to have medication at bedside and hospital records showed marijuana in (her) system). Record review of Resident #1's nurse assessment documented on 11/18/2024 at 5:22 p.m., revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment documented Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room, HOB 35 degrees, right leg hanging off the bed .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall. She reports to me a man went (sic) in her room at 11:00 p.m. and left. I asked if she reported to someone. She said the nurse on the Southside was told. I asked why? I am the nurse here on this side. Holding this 6 am dose (unknown medication). Will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician was notified or that 911 was called or that Resident #1's family had been notified of the sudden change in mental status. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy)when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's. (normal 92-100) and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. He documented LVN A handed him 6 white pills and 3 peach-colored broken pieces and stated the nurse aide obtained the pills from Resident #1's room at 11:00 p.m. last night. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from night shift stated to LVN B that this had been reported to LVN A since 11 p.m. last night (11/18/2024). When LVN B questioned LVN A if patient (Resident #1) was ever able to voice any response, LVN A stated that she (Resident #1) was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub was performed with grunting as the response sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level) and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN and notified the physician and the family of Resident #1. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. One aide (unknown) said there was a man that left the residents room at 11:00 p.m. LVN A wrote she had just left (the area) at 11:08 p.m. and did not see anyone so she asked the aide if she had told someone. LVN A wrote the aide reported she told the nurse for this side (unknown). LVN A wrote all three of the staff went into Resident #1's room and searched drawers, cabinets, and closet. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name) who identified the pills as trazadone (antipsychotic medication) and tramadol (opioid analgesic used for pain). LVN documented a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure) 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room or assist her so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911(unknown time). Record review of a written statement (undated) by NA E read when the (aides) were doing rounds at 10:00 p.m. at the start of their shift, a man walked out of the resident room with a to-go container in a plastic bag. She wrote they did not think anything of it. NA E wrote she told LVN A a weird guy was in the resident's room, but supposedly she did not hear what she said. NA E wrote she also reported it to the nurse on the other side (unknown). NA E wrote the man left at 11 (p.m.). NA E wrote they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night because the resident preferred, they did not wake her up all night with every round unless she called them. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling us (aides) to go try and wake her (Resident #1) up. NA E wrote they (aides) went the resident's room (Resident #1) and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like this at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote they found a little box of pills while searching and LVN A took them. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote she was making rounds with NA E; in another resident's room they noticed a guy walk out of (Resident #1's) room across the hall. NA F documented they saw him re-enter Resident #1's room a few minutes later with what looked like a to-go container. NA F documented she notified LVN A along with NA E that there was a man coming in and out of the resident's room. She wrote she continued making rounds and saw the man leave at approximately 11:00 p.m. NA F documented they did not make rounds on Resident #1 during the night because her chart says not to as she can go to the restroom and move around on her own. NA F documented at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A rushing in saying Resident #1 would not respond to her. She told them to go into the room and try to wake her (Resident #1) up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A to do the rest and continued her rounds. During an interview on 11/19/2024 at 1:39 p.m., the Administrator stated. A nurse (identified as LVN A) found Resident #1 lethargic and not responding like she should have, so EMS was called who administered Narcan twice. She stated Resident #1 also received Narcan via IV at the hospital. The Administrator stated they found a clear container with mixed pills in the resident's room which they had locked up in the DON's office. She said some of the medications were cut in half and unidentifiable and one was trazadone. The Administrator stated a couple of weeks prior they found medications in Resident #1's room, confiscated it and gave the resident education. She stated one of the medications they found was morphine and she could not remember what the other one was. She stated they contacted the resident's physician and gave education. The Administrator stated they also gave education to visitors. She stated the education was documented in PCC under progress notes for Resident #1. She stated a nurse, LVN A was suspended because they thought there was a delay in her response time. During an interview on 11/20/2024 at 10:14 a.m., the Administrator stated they had learned Resident #1 tested positive for both opioids (she had a prescription for opioid medication, so it was an expected outcome) and marijuana. She stated based on this information they conducted another search of Resident #1's room and the strong smell of something odd that was consistent with marijuana was discovered. She stated they identified a brownie on Resident #1's TV stand that had the strong odor. She stated they notified the local police who came and destroyed the brownie. The Administrator stated the original plan was for Resident #1 to discharge tomorrow (11/21/2024) after her doctor appointment and that was still the plan. She stated the facility was accepting Resident #1 back from the hospital today (11/20/2024) because they did not believe in dumping. She stated a discharge notice had never been given to the resident. The Administrator stated she communicated with the staff in person, text and she preferred phone calls. She stated she attended both morning and clinical meetings with staff. She stated during those meetings they did discuss that a CNA found a bottle of prescription medication containing morphine in Resident #1's room. She stated they made the required notifications including to family, physician and they educated the staff and visitors. She stated they do not routinely search residents' rooms or visitors for medications. She stated the resident had both a right to receive visitors and packages. The Administrator stated in lieu of searching Resident #1's room which showed lack of character judgement, LVN A should have provided medical care to Resident #1. The Administrator stated she ensured staff had the knowledge on how to response by in-service training. She stated the facility notified the Medical Director who was also Resident #1's physician of the incident on 11/19/2024. During an interview on 11/20/2024 at 10:45 a.m., Resident #1's family member stated Resident #1 had an accident and broke her foot and prior to that had surgery on her shoulder. The family member stated Resident #1 was currently hospitalized because she was found very lethargic and unresponsive. He stated the doctors at the hospital said she was taking a lot of medications. He stated he was not sure what medications she was taking. He stated Resident #1 was seeing a pain medication doctor, an orthopedic surgeon and had a doctor at the facility but he didn't know who the doctors were and did not know the prescriptions. The family member stated he did not know Resident #1 was getting medications from multiple physicians and multiple pharmacies and did not know why she was now testing positive for marijuana. He stated a few days before she was admitted to the facility, she took a vacation to the Caribbean and spent some time in Chicago and may have had access to marijuana at either of those places. He stated he had no knowledge of any other illegal drug usage. He stated to his knowledge Resident #1 had not had any visitors at the facility. He stated Resident #1 did not have a significant other/boyfriend that he was aware of. He stated there was another family member locally, but that person had no contact with Resident #1. He stated he had minimal contact with Resident #1 and had only visited her twice at the facility. He stated he was unable, unwilling and did not have the capacity to give Resident #1 support. He stated Resident #1 did not leave the facility other than for doctors' appointments, but she did have local grocery and food deliveries at the facility. He stated he did not visit Resident #1 the night of the incident on 11/18/2024-11/19/2024. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bed side but LVN A went to her medication cart. LVN B stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. He stated the physician's response was that a hospital evaluation was appropriate. LVN A stated he had never witnessed any medications in Resident #1's room and had never smelled or identified marijuana in her room. During an interview on 11/20/2024 at 12:25 p.m., NA C stated on 11/19/2024 at 6:06 a.m. she arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with her (LVN A). NA C stated CNA D stated the nurse (LVN A) was not listening to her and there was concern for Resident #1. NA C stated CNA D said a random guy went into Resident #1's room but she did not know what happened. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 laying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1? NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on her (Resident #1) or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into the room and stated, she is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B said to LVN A Why did you wait? NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying? She stated LVN A responded that she had a rough day. NA C stated she had never seen any medications or drugs lying around in any resident room. She stated they were not able to identify the visitor. She stated the front doors are locked at night and require a code to access the facility. NA C stated if she saw medications lying around, she was trained to give them to the nurse. She stated she had training in opioid abuse, administration of Narcan and what to do in case of change of condition. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A came into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids and was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but she was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A stated Resident #1 was a druggy and knew her limits. CNA D stated she thought that comment was inappropriate. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A told 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. CNA D stated the whole situation was a surprise to her. She stated Resident #1 was normally independent, up and about, and alert. She stated she had never seen the resident in any other way. She stated she had never seen any medications or drugs lying around in resident rooms. She stated she was trained to notify the nurse and go up the chain of command if necessary. She stated she had received in-service training on abuse/neglect, medication administration and change of condition following the event. During an interview on 11/20/2024 at 1:06 p.m., NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. she saw a man they did not know come out of Resident #1's room. She stated she also saw Resident #1 who was oriented normally and was up and moving around and asked for ice for her ankle. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told us to try to help wake her (Resident #1) up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A stated, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. NA F stated it was her first overnight shift. She stated she did not know the typical protocol door nighttime, just what LVN A had told her. She stated LVN A told her the aides not to go into Resident #1's room during the night, that it was on her chart not to go in because she was independent, and she could do everything on her own. She stated they might peak into her room from the door but wouldn't enter the room if it looked like the resident was sleeping. NA F stated she didn't have any way to verify what LVN A told her about the chart, they just had to take her word for it. She stated she did not open Resident #1's door between 11 p.m. - 5 am. NA F stated since the incident she had received training on opioid abuse, how to handle an overdose, change of condition and abuse/neglect. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated at the beginning of her shift she saw a gentleman visitor come from outside to Resident #1's room. She stated she did not question the visitor because other staff had said the visitor had been there since 6:00 p.m. NA E stated the outside doors of the facility are locked and require a code to access or Resident #1 may have given the code to the visitor. NA E stated she saw the visitor leave and come back in with a food to go box in a clear plastic bag. She stated she assumed it was food that was delivered to the facility for her. She stated families do it all the time. NA E stated the visitor left at approximately 10:45 p.m. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated this whole time Resident #1 was unconscious and LVN A was not proving care, she did not do vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when they next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for 33 years. She stated on the night of 11/18/2024 around approximately 11:08 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg handing off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills a piece of peach-colored pills. S[TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #1) reviewed for quality of care, in that; The facility failed to immediately assess and intervene when Resident #1 was found unresponsive and twitching on 11/19/2024 at 5:00 a.m. by LVN A until the next shift arrived and LVN B intervened. This change of condition required treatment in a local hospital for altered mental status. The noncompliance was identified as PNC. The IJ began on 11/19/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who experience a change of condition and result in a delay in care, significant injury including permanent disability and death. The findings included: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. Record review of Resident #1's nurse assessment documented on 11/18/2024 at 5:22 p.m. revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment documented Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall .will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician was notified or that 911 was called or that Resident #1's family had been notified of the sudden change in mental status. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy)when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's. (normal 92-100) and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from night shift stated to LVN B that this had been reported to LVN A since 11 p.m. last night (11/18/2024). When LVN B questioned LVN A if patient (Resident #1) was ever able to voice any response, LVN A stated that she (Resident #1) was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to the room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub was performed with grunting as the response sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level), vital signs were obtained, and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN. LVN B documented he re-assessed Resident #1 prior to EMT (EMS), and no change was noted. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed and the head of the bed elevated 35 degrees. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name). LVN A wrote a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure) 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room to check on the resident or assist her in LVN A in her need to be done so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she continued going in and out of Resident #1's room. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge of the bed, but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she went to get a wheelchair to assist Resident #1 to the nurse's station and told the oncoming nurse (LVN B) that she may be okay because she pulled herself to a sitting position. LVN A wrote LVN B did not want to assist her with an assessment of the situation as to not deal with the situation. LVN A wrote she decided to stay around and she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911 (unknown time) and then went in the room to assist the EMTs in any way she could. Record review of a verbal statement of LVN A given to the Corporate RN which was typed (undated) revealed: at 5:30 a.m. she (LVN A) went to give Resident #1 medications and knew something was not right because the resident was lying with her leg off the bed. LVN A noted that was out of the ordinary for her and the head of the bed was up at 35 degrees. LVN A stated she gave Resident #1 a verbal command and attempted to rouse the resident, she opened her eyes and began speaking in an unclear speech and was lethargic. LVN A stated she took vitals, and they were 101/84 [blood pressure], 96% oxygen saturation 18 respirations and 55 HR (slightly lower than normal of 60-100). LVN A stated she gave Resident #1 a sternal rub and the resident had a facial grimace and then sat up on the side of the bed by herself at 6:00 a.m.LVN A stated she last left the resident around 11 p.m. (11/18/24) and did not check on the resident again until 5:30 a.m. because she was busy doing all her task for the night and the resident did not like to be bothered at night. LVN A stated she searched Resident #1's room and found medications at her bedside. LVN A stated the oncoming nurse came on and she was giving him (LVN B) a report and then he went to look at the resident and they notified 911. Record review of a written statement (undated), NA E wrote they (aides) were doing rounds at 10:00 a.m. they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night because the resident preferred they did not wake her up all night unless she called them, so they did not make rounds on her. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling us (aides) to go try and wake her (Resident #1) up. NA E wrote they (aides) went the resident's room (Resident #1) and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like this at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote they found a little box of pills while searching the room and LVN A took them. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote the aides did not do rounds on Resident #1 during the night because her chart says not to as she could go the restroom and move around on her own. NA F wrote at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A rushed in and said Resident #1 would not respond to her. She told them to go into the room and try to wake her (Resident #1) up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A to do the rest and continued her rounds because she was not qualified to assist with anything else. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside but LVN A went to her medication cart. LVN B stated he asked LVN B if she if she did any interventions for Resident #1 and LVN A replied no. He stated that was why he was alarmed because LVN A did not re-assess or address Resident #1's change of condition and she did not go back into the room between 11-5 am to re-ass the resident. LVN B stated it was important to immediately assess and intervene when a resident had a decrease level of consciousness because it could be an emergency situation. He stated the resident should have an immediate assessment and interventions. LVN B stated failure to respond to a resident in need was neglect and he was trained to address the concerns immediately which he did. He stated he immediately notified the Administrator. During an interview on 11/20/2024 at 12:25 p.m. NA C stated on 11/19/2024 at 6:06 a.m. she was arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with her (LVN A). NA C stated CNA D stated the nurse (LVN A) was not listening to her and there was concern for Resident #1. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 laying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1? NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on her (Resident #1) or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into the room and stated, She is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B said to LVN A Why did you wait? NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying? She stated LVN A responded that she had a rough day. NA C stated she could not do anything else for Resident #1 because she was just a nurse aide in training, but she stayed with the resident and saw when EMS got there. NA C stated Resident #1 was still unresponsive when she left the facility with EMS. NA C stated she was trained to report resident change of condition to the nurse right away. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A came into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids and was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but she was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A stated Resident #1 was a druggy and knew her limits. CNA D stated she thought that comment was inappropriate. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A called 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. CNA D stated she had been trained to notify the nurse right away for a change of condition. During an interview on 11/20/2024 at 1:06 p.m. NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. she saw Resident #1 who was oriented normally and was up and moving around. NA F stated LVN A told the aides not to go into Resident #1's room during night shift. NA F stated the resident did not need help transferring and was able to do everything on her own. She stated she might peak in at the doorway to ensure the resident was not on the floor but she did not enter the room and could not tell anything else from the doorway. NA F stated the aides were reliant on what the nurse told them to do and there was not anyway to look up the information. NA F stated on the night of the incident she did not open Resident #1's door between 11 p.m. - 5 a.m. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told us to try to help wake her (Resident #1) up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A stated, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. She stated she did not go into the resident room between 11 p.m. and 5 a.m. because the resident preferred to not be woken up. She stated they tell her goodnight, and they would see her again in the morning. NA E stated she relied on the nursing staff to tell them what to do for the resident based on the care plan. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do and she was relying on the aides. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated this whole time Resident #1 was unconscious and LVN A was not proving care, she did not do vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when the next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. NA E stated she was trained to notify the nurse of change of condition. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for 33 years. She stated on the night of 11/18/2024 around approximately 11:00 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated she did not check on Resident #1 between 11:00 p.m.-5:20 a.m. She stated the facility policy was to check on residents every 2 hours and the aides were making rounds every 2 hours she suspected although she stated she was not certain. She stated she was busy with other duties. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg hanging off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills. LVN A stated at 5:45 a.m. she told another nurse (name unknown) that Resident #1 was unresponsive, but that nurse didn't get off her chair or try to help her. LVN A stated she grew up where nurses help nurses, and they all work together. She stated LVN B was coming in to relieve her from night shift. LVN A stated LVN B did not go into Resident 1's room one time. She stated she was so upset because no one who worked at the facility, no one helped her. LVN A stated she worked her butt off all night long and she was tired. She stated LVN B just came in and where is his heard, he does not have one. LVN A stated she was livid that she had been suspended and LVN A still had a job. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she first obtained vitals at approximately 6:00 a.m. and reported they were normal. She stated she did not know why there was a delay in taking Resident #1's vitals signs from the time she found her with a change of condition until 6:00 a.m. She stated she was just getting information to give to day shift so they could take over. LVN A stated she did not know who to call. She stated the ADON was on vacation and the DON had walked out of the facility. LVN A stated another nurse (name unknown) gave her the phone number for the Administrator, so she called her and told her they needed to discharge Resident #1 from the facility because she was not following the rules. LVN A stated the Administrator did not tell her what to do or give her any idea what to do. LVN A stated she had 35 people to take care of and it was very stressful. LVN A stated after she got off the phone with the Administrator, she called 911 because she thought maybe they could shake her up. LVN A stated she was upset because the Administrator thought she was slow to react, so she found herself suspended. LVN A stated she did not notify Resident #1's physician about her change of condition. She stated she did not notify the physician because she was collecting information, searching her room, and looking up her medication. She stated she also did not call because she thought Resident #1 was going to be okay. She stated she was just gathering information and waiting for the next shift to take over because she herself was tired. LVN A stated was trained to assess, document the assessment, gather information and probably call the doctor for resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. She stated, We are all human, right .I was tired. When asked if she was fit for duty if she was too tired to complete her nursing duties, she stated yes. During an interview on 11/20/2024 at 3:40 p.m., the Corporate RN (VP of Clinical Services) stated the DON left the position approximately 1 month ago and she was monitoring the facility as RN since that time. The Corporate RN stated one of the ADON's was also an RN and was assisting. The Corporate RN stated on 11/19/2024 she was traveling to the facility and was almost there when she received a call at 7:03 a.m. from LVN B. She stated she called the Administrator and EMS was arriving. The Corporate RN stated she interviewed LVN A who told her she had given pills to Resident #1 at 11:00 p.m. (11/18/2024) and then went in at 5:00 a.m. (11/19/2024) and found the resident lethargic, reporting she did not round on the resident during the night because Resident #1 did not like it. The Corporate RN stated LVN A stated she did a sternal rub on Resident #1, who grimaced and then sat up on the side of the bed. LVN A reported that she had NA E and NA F come check on the resident. The Corporate RN stated LVN A said she had not made notifications and that she gave report to oncoming nurse LVN B. The Corporate RN stated she interviewed LVN B who stated he assessed Resident #1 and told LVN A to call 911. The Corporate RN stated she interviewed NA E and NA F who both said they told LVN A around 5:00 a.m. Resident #1 was lethargic and nothing was done. The Corporate RN stated the facility then reported it to HHSC was because there was a delay in care to Resident #1. She stated there was a delay in providing interventions , in alerting EMS and in notifying the physician. The Corporate RN stated after she interviewed the staff, she did not believe LVN A's account of events was accurate. The Corporate RN stated after notifying HHSC of the event she facility began immediately correcting on 11/19/2024 and had completed the correction prior to surveyor arrival. She stated they had: 1. Immediately started staff in-services on abuse/neglect, medication orders, medication administration, opioid overdose management, responding to suspected overdose, how to use Narcan, no medications at bedside, self-administration of medications assessment in which the IDT has to determine if the resident was safe to self-administer, notifications of change of condition, PRN medications. She stated the in-service training for staff in the facility had been completed prior to surveyor arrival on 11/19/2024. 2. The Corporate RN stated a notice had been posted at the time clock and no staff would be allowed to clock in until the in-services had been completed. She stated at the time of this interview all staff had been educated before surveyor arrival on 11/19/2024. 3. The Corporate RN stated the facility completed a 100% assessment audit on residents assuring any change of condition was addressed. She stated this was completed prior to surveyor arrival on 11/19/2024. 4. The Corporate RN stated the facility completed a 100% audit of medical records to ensure any change of condition had notifications of physicians and families documented. She stated no new change of conditions were identified. She stated this was completed prior to surveyor arrival on 11/19/2024. 5. The Corporate RN stated a 100% rounding of medication carts/medication records was completed on 11/19/2024 prior to surveyor arrival and another was completed on 11/20/2024 to ensure there were no medication discrepancies. 6. The Corporate RN stated a text alert was sent to all family members that all medications need to go to the nurses. She stated this was completed prior to the incident on 11/19/2024 in the month on November when Resident #1 had been previously brought in medications from home. 7. The Corporate RN stated QA/PIP tools were put in place to include notification of physician for change of condition with actions to address included. She stated this was completed prior to surveyor arrival on 11/19/2024. 8. The Corporate RN stated the facility notified the Medical Director of the incident and the facility plan to correct. She stated this was completed prior to surveyor arrival on 11/19/2024. 9. The Corporate RN stated LVN A was immediately suspended, and they planned to terminate her employment and refer her nurses license as soon as the investigation was complete. She stated this was completed on 11/19/2024 as soon as LVN A completed her written statement of events and she had been interviewed prior to surveyor arrival. 10. The Corporate RN stated they reviewed facilities policies and ensured they were put out for staff to review. She stated this was completed prior to surveyor arrival on 11/19/2024. During an interview on 11/20/2024 at 4:14 p.m., the Administrator stated on 11/19/2024 she received a call from the Corporate RN about Resident #1, a suspected overdose and that EMS was on their way to the facility to pick up the resident. She stated she told the Corporate RN to interview staff and find out what was going on. The Administrator stated then LVN A called her. She stated LVN A told her it was a suspected overdose, and that EMS were at the facility because she could not get Resident #1 back to baseline. The Administrator stated she arrived at the facility on 11/19/2024 at 8:15 a.m. at which time interviews were completed and staff in-services had already been started. The Administrator stated based on staff interviews they felt there had been a delay in care and that LVN A did not act promptly so they immediately self-reported to HHSC. She stated they worked diligently to correct the error on the morning on 11/19/2024. She stated the Corporate RN had completed the corrections prior to surveyor arrival. The Administrator stated the staff were all pretty upset so she checked on the staff. The Administrator stated she was not a medical person and was not certain what caused Resident #1's change of condition but she did feel LVN A was neglectful of Resident #1. The Administrator stated she had been trying unsuccessfully to reach LVN A so she could terminate her employment and refer her license. The Administrator stated she had reviewed the facility surveillance video and based on that review there were some non-truths to LVN A story. The Administrator stated LVN A had poor judgement of character. The Administrator stated she supervised her staff by ensuring mo[TRUNCATED]

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in life-threatening conditions for 1 of 5 residents (Resident #1) reviewed for change of condition, in that; The facility failed to notify Resident #1's physician and family on 11/18/2024 when she was found sleepier than usual or notify Resident #1's physician and the resident's family when the resident was found unresponsive and twitching with a significant alteration in mental status at approximately 5:00 a.m. on 11/19/2024 and was treated for altered mental status at the hospital. The noncompliance was identified as PNC. The IJ began on 11/18/2024 and ended on 11/19/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious harm, permanent disability and/or death. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnoses which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. Record review of Resident#1's nurse assessment documented by day shift staff on 11/18/2024 at 5:22 p.m. revealed Resident #1's pain level was assessed at 1 (pain scale of 0-10). The resident was alert and oriented, communicated verbally with clear speech and was neurologically intact. The assessment reflected Resident #1 had no unwanted behaviors witnessed. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. revealed, 0530 (5:30 a.m.) walked into room .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid [sic] on the hall .will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate Resident #1's physician or family was notified regarding Resident #1's sudden change in mental status from 11/18/2024-11/19/2024. Record review of Resident #1's hospital records dated 11/19/2024 revealed the resident presented to the ER with an altered mental status. Per EMS the patient (R1) was somnolent (sleepy) when she arrived with pinpoint pupils, some hypopnea (abnormally slow and shallow breathing which decreases the amount of oxygen in the blood), with oxygen saturation in the high 80's (normal 92-100); and they administered 2 mg Narcan IM and 2 mg Narcan IV (opioid reversal agent-a medication used to treat drug overdose) with some transient (only lasting a short time) improvement in mental status. Resident #1's hospital diagnoses was AMS (altered mental status) and hypoxemia (low blood oxygen). Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended LVN A for further investigation due to a delay in care. EMS arrived and administered Narcan, and Resident #1 was taken to a local ER and kept overnight for evaluation. Resident #1 was found to have medication at her bedside and hospital records revealed marijuana in her system. Record review of a typed statement from LVN B dated 11/19/2024 indicated at 6:25 a.m. as LVN B was coming onto shift, LVN A was sitting down at the nurse's station. LVN B stated LVN A stated Resident #1 was lethargic and non-arousable since 5 am (11/19/2024). A nurse aide (unknown) from the night shift stated to LVN B that it had been reported to LVN A since 11 p.m. the night before (11/18/2024). When LVN B questioned LVN A if Resident #1 was ever able to voice any response, LVN A stated that Resident #1 was non-arousable at 5 a.m. and that she had not assessed the patient from 11 p.m.- 5 a.m. LVN B questioned LVN A if she had notified the MD (physician) about any change in condition or the family since the patient's baseline was alert and oriented x 4 (cognitively intact). LVN B indicated LVN A responded no. LVN B stated he immediately ran to room to assess the patient along with NA C and CNA E while LVN A remained at the nurse's station. LVN B wrote Resident #1 was breathing but was not arousable, a sternal rub (firm rub to a patient's sternum is a painful stimulus to test a patients consciousness level) was performed with grunting as the response sternal rub and he assured 911 was called immediately. LVN B wrote he also immediately notified the Administrator and Regional RN, and also notified the physician and the family of Resident #1. Record review of a written statement dated 11/19/2024 by LVN A indicated at 5:30 a.m. on 11/19/2024 she entered Resident #1's room to see her right leg hanging off the bed. LVN A wrote Resident #1's eyes were closed, and her respirations were even and unlabored. LVN A called the name of Resident #1 (and her response was) squinting her eyes and garbled speech. LVN A wrote the aides were outside her room and she told them about Resident #1's behaviors. LVN A wrote she had the aides search Resident #1's room and they found a small plastic box with 5-6 round pills and 3 pieces of peach-colored pills. LVN A wrote at 5:45 a.m. she told another nurse (unknown name). LVN A documented a midsternal rub with a very strong facial grimace and vital signs of 101/84 (blood pressure), 55 (unclear if it was HR or RR) and 96% on room air (oxygen saturation) (it was unclear who took vitals or when they were taken). LVN A wrote at 6:15 a.m. she gave report to LVN B. LVN A wrote LVN B did not go into Resident #1's room or assist her, so she went back into Resident #1's room to attempt to arouse Resident #1 again. LVN A wrote she told Resident #1 Look! We need to go! Let's go now! She wrote Resident #1 sat on the edge of the bed but LVN A told Resident #1 to wait and put her back to bed. LVN A wrote she called the Administrator and told the Administrator maybe she would just call 911 to have them come shake her up a bit. LVN A wrote she did call 911 (unknown time). Record review of a written statement (undated) by NA E revealed they (aides) were doing rounds at 10:00 a.m. and they went into Resident #1's room and she was alert and awake. She documented she did not round on Resident #1 during the night. NA E wrote she was in a room across the hall changing another resident when LVN A busted in asking questions about Resident #1 telling the aides to go try and wake her (Resident #1) up. NA E wrote they (aides) went to the Resident #1's room and she was not really responding. She twitched a little and moved her lips. She wrote LVN A did not do vitals or anything until the morning nurse came in. NA E wrote LVN A found Resident #1 like that at 5:00 a.m. when LVN A was passing her medicine. NA E wrote Resident #1 never sat up or spoke when she was in the room. NA E wrote LVN A proceeded to do nothing for the resident and tried to blame them (aides). Record review of a written statement (undated) by NA F wrote at 5:00 a.m. (on 11/19/2024) NA E and NA F were changing another resident when LVN A came rushing in saying Resident #1 would not respond to her. She told them to go into the room and try to wake Resident #1 up. NA F wrote Resident #1 was unresponsive, but still breathing and they found a bag of pills on her bedside table which they gave to LVN A. NA F wrote she let LVN A do the rest and continued her rounds. During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A said she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A said the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic but she did not notify anyone and did not notify the doctor. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A said she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A said she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides (unknown names) go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside, but LVN A went to her medication cart/ LVN A stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. He stated the physician's response was that a hospital evaluation was appropriate. During an interview on 11/20/2024 at 12:25 p.m. NA C stated on 11/19/2024 at 6:06 a.m. she arrived at the facility for her morning shift. She stated CNA D had approached her and stated she had it up to here with LVN A. NA C stated CNA D stated the LVN A was not listening to her and there was concern for Resident #1. NA C stated she clocked in and went straight to Resident #1's room to check on her. She stated Resident #1 was not responding to her voice. She stated she saw Resident #1 lying on her back with one arm on her chest. NA C stated Resident #1 was twitching. She stated at first, she saw just her lip twitching and then noted that her fingers and her toes were also twitching, and she would not respond. NA C stated she went to LVN A and asked her what was wrong with Resident #1. NA C stated LVN A responded that she had already checked on Resident #1. NA C stated she told LVN A that Resident #1 was not acting normal to which she did not get a response. NA C stated she (NA C) could at least get Resident #1's vitals since she was not acting right. NA C stated she obtained the vitals and saw LVN A talking to LVN B at the nurse's station. NA C stated LVN A was giving LVN B an update on what was going on. NA C stated LVN B was asking LVN A if she had checked on Resident #1 or if she took vitals. NA C stated she showed LVN B the vitals she just took which included an oxygen saturation of 87% (normal 92-100%). NA C stated LVN B ran into Resident #1's room and stated, She is not okay. NA C stated at approximately. 6:30 a.m., LVN B was telling LVN A she was not normal and to call 911. NA C stated LVN B asked LVN A Why did you wait?. NA C stated LVN A did not seemed concerned at all. NA C stated LVN A lied and said she just came out of the room and Resident #1 was sitting on the edge of the bed. NA C stated she walked into the room to see for herself, and Resident #1 had not moved. She was still not responsive and twitching. NA C stated CNA D was with her and also saw what was occurring. NA C stated she asked LVN A why she was lying. She stated LVN A responded that she had a rough day. NA C stated she could not do anything else for Resident #1 because she was just a nurse aide in training, but she stayed with the resident and saw when EMS got there. NA C stated Resident #1 was still unresponsive when she left the facility with EMS. During an interview on 11/20/2024 at 12:52 p.m., CNA D stated she overheard LVN A talking about how Resident #1 was not doing well. CNA D stated LVN A was telling LVN B that she was having issues with Resident #1, and she was not alert. CNA D stated she went to look at the resident to see if she could help. She stated Resident #1 was in bed and she looked asleep. She stated LVN A went into the room with her and was trying to wake up Resident #1. CNA D stated LVN A was lifting Resident #1's eye lids, was giving her a chest rub and was trying to get vitals. CNA D stated Resident #1 was not responding and did not respond to the chest k rub. CNA D stated she thought the chest rub was very aggressive. CNA D stated she was not sure what the vitals were, but another nurse (unknown name) said the blood pressure was not a normal reading. CNA D stated the next thing she knew LVN A was calling EMS, but LVN A was not happy about it and said the same thing had happened to the resident three times last week. CNA D stated LVN A said Resident #1 was a druggy and knew her limits. She stated she had never seen Resident #1 in any other way. CNA D stated LVN A called 911 on the phone and asked if they would come rough house the resident to wake her up. CNA D stated LVN A was neglectful and was not making Resident #1's needs a priority and making it like it was a bother rather than addressing her change of condition. During an interview on 11/20/2024 at 1:06 p.m. NA F stated she worked the overnight shift on 11/18/2024-11/19/2024. She stated she was doing rounds with NA E at approximately 11:00 p.m. and she saw Resident #1 who was normally oriented was up and moving around. NA F stated at 5:00 a.m. they were across the hall when LVN A asked, What happened to Resident #1? NA F stated they said they did not know but LVN A told them to try to help wake Resident #1 up. NA F stated Resident #1 was breathing but was not responsive. She stated she was saying her name really loud, and they were pushing on her and shaking her, but it was not working. NA F stated they found a bag of pills in the room. NA F stated at approximately 5:30 a.m. she told LVN A she should probably call 911 since Resident #1 was unresponsive. NA F stated LVN A said, Well she is a drug addict, so it doesn't matter. NA F stated LVN A then went back to the nurse's station and did not really acknowledge the situation. NA F stated they (aides) stayed with Resident #1. She stated a while later LVN B came in and assessed Resident #1 and called 911. She stated when she saw LVN B he went right into work mode. He immediately went into Resident #1's room, assessed her and took vital signs. NA F stated Resident #1 was still unresponsive, but LVN B got her help right away. She stated the ambulance came about 5 minutes later but the aides stayed with Resident #1 to make sure she did not stop breathing. NA F described Resident #1 as pale but not blue and looking like she was sleeping but would not wake up. NA F stated LVN A's actions and words were very inappropriate. During an interview on 11/20/2024 at 1:37 p.m., NA E stated she worked 10 p.m.- 6 am shift on 11/18/2024. She stated she last saw Resident #1 well at 11:10 p.m. when she brought her an ice pack for her leg. NA E stated she was acting like her normal self. NA E stated at 5:00 a.m., LVN A said Resident #1 was not waking up and she was trying to give her medications. NA E stated she did not know why LVN A was relying on the aides to do something about it when she was the nurse. NA E stated she went into Resident #1's room and tried to wake her up. She stated she tried calling her name, tapping her shoulder, and giving her a chest rub. NA E stated Resident #1 moved her mouth a little, like a twitch. She stated her legs twitched also and she wouldn't wake up. NA E stated Resident #1 never opened her eyes or responded in any verbal way. NA E stated she then left the room because she had other residents to attend to. NA E stated LVN A was frantic, like she did not know what to do and she was relying on the aides. NA E stated she had them search the room with flashlights and they found a small clear case with multiple pills in it which they gave to LVN A. NA E stated the whole time Resident #1 was unconscious and LVN A was not providing care, she did not take vitals, nothing. NA E stated LVN A then went and sat at the nurse's station. NA E stated the aides were lost and did not know what to do but it seemed like LVN A did not care. NA E stated when the next shift arrived, they took over and asked LVN A if she had called the doctor or called 911 and LVN A said no she did not. NA E stated LVN A admitted she did not notify the doctor or 911. NA E stated the aides were all very stressed out. She stated they were trained to notify the nurse which they did. NA E stated they had thought about calling 911 themselves but did not want to get in trouble. She stated she was trained to tell the Administrator because she was the abuse coordinator, but she couldn't think so she called the on-call person who said she would call the Administrator. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated she had been a nurse for 33 years. She stated on the night of 11/18/2024 around approximately 11:00 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated she couldn't remember a lot of about that night, just that she was in bed, that she did not say a lot, but she was resting quietly. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg hanging off the bed with her head of bed at 45 degrees and her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to wake Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 opened her eyes a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills. LVN A stated at 5:45 a.m. she told another nurse (name unknown) that Resident #1 was unresponsive, but that nurse didn't get off her chair or try to help her. LVN A stated she grew up where nurses helped nurses, and they all worked together. She stated LVN B was coming in to relieve her from night shift. LVN A stated LVN B did not go into Resident #1's room one time. She stated she was so upset because no one who worked at the facility, no one helped her. LVN A stated she worked her butt off all night long and she was tired. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she did not know who to call. She stated the ADON was on vacation and the DON had walked out of the facility. LVN A stated another nurse (name unknown) gave her the phone number for the Administrator, so she called her and told her they needed to discharge Resident #1 from the facility because she was not following the rules. LVN A stated the Administrator did not tell her what to do or give her any idea what to do. LVN A stated she had 35 people to take care of and it was very stressful. LVN A stated after she got off the phone with the Administrator, she called 911 because she thought maybe they could shake her up. LVN A stated she was upset because the Administrator thought she was slow to react, so she found herself suspended. LVN A stated she did not notify Resident #1's physician about her change of condition. She stated she did not notify the physician because she was collecting information, searching her room, and looking up her medication. She stated she also did not call because she thought Resident #1 was going to be okay. She stated she was just gathering information and waiting for the next shift to take over because she herself was tired. LVN A stated was trained to assess, document the assessment, gather information and probably call the doctor for a resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. She stated, We are all human, right .I was tired. When asked if she was fit for duty if she was too tired to complete her nursing duties, she stated Yes . During an interview on 11/20/2024 at 3:40 p.m., the Corporate RN (VP of Clinical Services) stated the DON left the position approximately 1 month ago and she was monitoring the facility as the RN since that time. The Corporate RN stated one of the ADON's was also an RN and was assisting. The Corporate RN stated on 11/19/2024 she was traveling to the facility and was almost there when she received a call at 7:03 a.m. from LVN B. She stated she called the Administrator and EMS was arriving. The Corporate RN stated she interviewed LVN A who told her she had given pills to Resident #1 at 11:00 p.m. (11/18/2024) and then went in at 5:00 a.m. (11/19/2024) and found the resident lethargic, reporting she did not round on the resident during the night because Resident #1 did not like it. The Corporate RN stated LVN A said she did a sternal rub on Resident #1, who grimaced and then sat up on the side of the bed. LVN A reported that she had NA E and NA F check on the resident. The Corporate RN stated LVN A said she had not made notifications and that she gave report to oncoming nurse LVN B. The Corporate RN stated she interviewed LVN B who stated he assessed Resident #1 and told LVN A to call 911. The Corporate RN stated she interviewed NA E and NA F who both said they told LVN A around 5:00 a.m. Resident #1 was lethargic and nothing was done. The Corporate RN stated the facility then reported it to HHSC because there was a delay in care to Resident #1. She stated there was a delay in providing interventions, in alerting EMS and in notifying the physician . The Corporate RN stated after she interviewed the staff, she did not believe LVN A's account of events was accurate. The Corporate RN stated after notifying HHSC of the event she facility began immediately correcting on 11/19/2024. She stated they had: 1. Immediately started staff in-services on abuse/neglect, medication orders, medication administration, opioid overdose management, responding to suspected overdose, how to use Narcan, no medications at bedside, self-administration of medications assessment in which the IDT had to determine if the resident was safe to self-administer, notifications of change of condition, and PRN medications to all staff that were working and had placed a notice on the time clock preventing any staff from clocking in until they had been in-serviced. She said this was completed immediately on 11/19/2024 and had been top priority 2. The Corporate RN stated a notice had been posted at the time clock and no staff would be allowed to clock in until the in-services had been completed. She stated at the time of this interview all staff had been educated. She stated this was prior to surveyor arrival on 11/19/2024. 3. The Corporate RN stated the facility completed a 100% assessment audit on residents assuring any change of condition was addressed before surveyor arrival on 11/19/2024. 4. The Corporate RN stated the facility completed a 100% audit of medical records to ensure any change of condition had notifications of physicians and families documented. She stated no new change of conditions were identified. She stated this was completed prior to surveyor arrival on 11/19/2024. 5. The Corporate RN stated a 100% rounding of medication carts/medication records was completed on 11/19/2024 before surveyor arrival and another was completed on 11/20/2024 to ensure there were no medication discrepancies. 6. The Corporate RN stated a text alert was sent to all family members that all medications needed to go to the nurses she stated this occurred prior to the 11/19/2024 incident when they first learned Resident #1 was bringing medication by way of visitors into the facility. 7. The Corporate RN stated QA/PIP tools were put in place to include notification of physician for change of condition with actions to address included. She stated this was completed on 11/19/2024 prior to surveyor arrival. 8. The Corporate RN stated the facility notified the Medical Director of the incident and the facility's plan to correct. She stated this occurred on 11/19/2024 before surveyor arrival. 9. The Corporate RN stated LVN A was immediately suspended, and they planned to terminate her employment and refer her nurses license as soon as the investigation was complete. She stated this was completed on 11/19/2024 as soon as LVN A completed her written statement of events and she had been interviewed prior to surveyor arrival. 10. The Corporate RN stated they reviewed facility's policies and ensured they were put out for staff to review. She stated this was completed on 11/19/2024 prior to surveyor arrival. During an interview on 11/20/2024 at 4:14 p.m., the Administrator stated on 11/19/2024 she received a call from the Corporate RN about Resident #1, a suspected overdose and that EMS was on their way to the facility to pick up the resident. She stated she told the Corporate RN to interview staff and find out what was going on. The Administrator stated then LVN A called her. She stated LVN A told her it was a suspected overdose, and that EMS was at the facility because she could not get Resident #1 back to baseline. The Administrator stated she arrived at the facility on 11/19/2024 at 8:15 a.m. at which time interviews were completed and staff in-services had already been started. The Administrator stated based on staff interviews they felt there had been a delay in care and that LVN A did not act promptly so they immediately self-reported to HHSC. The Administrator stated the Corporate RN and herself immediately in-serviced staff in the facility to ensure they were aware and in compliance with facility policy for notification. She stated they worked diligently to correct the error on the morning on 11/19/2024. She stated the Corporate RN had completed the corrections prior to surveyor arrival. The Administrator stated the staff were all pretty upset so she checked on the staff. The Administrator stated she was not a medical person and was not certain what caused Resident #1's change of condition, but she did feel LVN A was neglectful of Resident #1. The Administrator stated she had been trying unsuccessfully to reach LVN A so she could terminate her employment and refer her license. The Administrator stated she had reviewed the facility surveillance video and based on that review there were some non-truths to LVN A's story. The Administrator stated LVN A had poor judgement of character. The Administrator stated she supervised her staff by ensuring monthly in-service training. She stated in meetings they talked a lot of about the facility culture, specifically related to treating people with kindness, acting on kindness and quality of care. She stated the team did a really good job in communicating with the team. She stated she was available 24/7. She stated her number was posted everywhere throughout the facility including by the time clock and on the main bulletin board of the facility and had been posted there prior to this incident. During an interview on 11/20/2024 at 5:34 p.m., Resident #1 stated she could not remember what happened on 11/18/2024-11/19/2024. She stated she normally went to bed around 10:00 p.m. She stated on 11/18/2024 she remembered lying in bed and trying to look at her phone, but her hands were shaking so bad she could not look at it. She stated she did not tell anyone at the facility that was occurring and did not ask for help. She stated she just thought it would diminish on its own and she would check on the shaking in the morning. She stated the next thing she remembered was waking up in the hospital. During an interview on 11/22/2024 at 11:20 a.m., the Corporate RN stated LVN A had completed nurse competencies upon hire in April 2024, although she was not part of the corporation at that time and did not participate in that assessment. She stated the competencies included change of condition and notification of physician for change of condition. The Corporate RN stated as a licensed nurse, LVN A would have to attend a school of nursing where she would be taught those skills. The Corporate RN stated she would have expected LVN A to assess a resident with change of condition and immediately notify EMS, the MD and the RP (family) if a drug overdose was suspected, and to stay with her until she was safely out of the facility. The Corporate RN stated it was important to ensure the patient was provided care and taken care of. The Corporate RN stated she was monitoring staff by looking at PCC (electronic medical record) dashboard, 24-hour reports, reviewing documentation, and frequent rounding. She stated she did not want to speculate on why the situation occurred. During an interview on 11/22/2024 at 12:39 p.m., LVN A stated she had been terminated by the Administrator on 11/22/2024. She stated the Administrator also informed her she was referring her license. During an interview on 11/22/2024 at 3:20 p.m., the MD (Resident #1's physician) stated he had been notified of Resident #1's unresponsiveness and change of condition but he could not remember when that occurred or who notified him. He stated it was just a notification and there was not much of an option at that point. He stated his expectations for the scenario was common sense. He stated unconsciousness was one of the few things they needed to send a resident out for and he would expect that to occur pretty soon. Record review of a facility policy titled Notification of Change of Condition (undated) revealed the facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. Record review of facility documents post incident for facility correction: Record review of a facility document (undated) titled Action Plan to Ensure Relevant Recommendations are Followed revealed: 1. Notify Medical Record of Incident was documented as completed by the Administrator on 11/19/2024. 2. Complete Disciplinary Actions was documented as employee (LVN A) suspended on 11/19/2024 and was updated on 11/20/2024 as employee terminated. 3. Complete physical assessments on all residents to identify any change of [TRUNCATED]

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Residents #2 and #3) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #2 clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin were secured when they were left in the resident's room. The facility failed to ensure Resident #3's Simbrinza ophthalmic suspension x 2 bottles and 5 medication cups of an unknown ointment were secured when the resident was not in the room. These deficient practices could put residents at risk for inaccurate or inappropriate administration of medications. The findings were: 1. Record review of Resident #2's face sheet dated 11/23/2024 revealed an admission date of 11/09/2024 with diagnoses which included: atrial fibrillation (irregular heart rhythm), adult failure to thrive (weight loss and general decline) and muscle weakness. Record review of Resident #2's care plan initiated on 11/10/2024 revealed no relevant care areas. Record review of Resident #2's admission MDS revealed it was still in progress and had not been completed. Record review of Resident #2's physician order summary dated 11/23/2024 revealed he did not have orders for clobetasol shampoo or over-the-counter polysporin. Record review of Resident #2's medical record revealed he had not been assessed for self-administration of medication. During an observation and interview on 11/19/2024 at 1:57 p.m., Resident #2 was observed in bed awake without staff in attendance. A box of clobetasol propionate 0.05% prescription shampoo and over-the-counter polysporin ointment (antibiotic ointment) was observed on his dresser. Resident #2 did not answer any questions about the medications and it was unclear if he was cognitively intact. He stated, leave those there please. During an observation and interview on 11/19/2024 at 3:12 p.m., LVN B stated Resident #2 could not keep the clobetasol shampoo in his room or the polysporin. He confirmed the shampoo was a prescription. He stated the staff inspect the rooms and teach the patients, so they know to bring medications to the nurses. He described Resident #2 was cognitively intact. LVN B took the shampoo and polysporin ointment with him while exiting the room and informed Resident #2 he needed to talk to his doctor about the medications. 2. Record review of Resident #3's face sheet dated 11/21/2024 revealed an admission date of 11/16/2020 with readmission date of 5/29/2024 with diagnoses which included: epilepsy, pain in right knee, right shoulder and dementia. Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMs score of 14 which indicated the resident was cognitively intact and without behaviors. Record review of Resident #3's Self-Medication Administration assessment dated [DATE] revealed the resident had been assessed and determined to be able to self-administer medications. Record review of Resident #3's Care Plan initiated on 8/02/2024 revealed the resident could self-administer specific medications with interventions which included: keep medications in a lockbox. Remind as needed to use box only for medication and to lock up in between uses. Record review of Resident #3's physician order summary revealed the following orders: 1. Simbrinza ophthalmic suspension 1-0-2% (brinzolamide-brimonidine tartrate) instill 1 drop in both eyes two times a day for glaucoma. 2. Voltaren arthritis pain external gel 1% (diclofenac sodium) topical ointment: apply to knees, painful sites topically two times a day every Tues, Thurs, Sat for pain as unsupervised self administration whenever patient reports pain, 3. Zoryve External cream 0.3% (roflumilast) topical, apply to right thigh topically every day shift for rash During an observation on 11/19/2024 at 2:33 p.m. two bottles of prescription Simbrinza ophthalmic suspension 1-0-2% and 5 medication cups labeled with different body parts such as groin, knee, leg with a white creamy substance assumed to be a medicated ointment were on the over bed table. Resident #3 was not in the room and no staff were in the room. Multiple gloves were also noted on the table. There was a small clear lockbox on the over bed table that had the key in the lock. The clear lockbox contained individual jelly packets too numerous to count. During an observation and interview on 11/19/2024 at 2:43 p.m. CNA D stated medications were to be administered by the med tech or the nurse. She stated she did not know what the medications were in Resident #3's room. She stated she was not aware of any residents in the facility who were self-administering medication. She stated she was trained to take up the medications and notify the nurse. She stated those medications (referring to the eye drops and multiple medication cups of ointment) need to be picked up. She exited the room leaving the medications in the room unattended. During an observation and interview on 11/19/2024 at 2:51 p.m., LVN P stated Resident #3 self-administered some of his medications. She stated he had been assessed for self-administration. LVN P stated they could leave medications in Resident #3's room but the medications should be in a locked drawer and the resident keeps the key. She stated the nursing staff did not have to observe Resident #3 administering his medication. She stated Resident #3 had pain medication and eye drops that he kept in his room. She stated the rest of his medications were kept in the locked medication cart. She stated unless a resident had been assessed for safe self-administration all medications were to be locked up. Upon observing the eye drops and multiple medication cups with the white gel in them, LVN P stated the white medication was either knee pain gel, a prescription cream for his thighs or moisturizer but she was not certain what was in the medication cups. She stated Resident #3 should be keeping his medications in the locked box and keeping the key with him and not using it to lock up jelly. She stated she was not certain why he had two bottles of the Simbrinza in his room. LVN P stated it was important to keep medications locked up because they have some residents who wander who might be confused and think medications were candy. She stated the eye drops and ointment/pain gel should also be locked up whenever the resident was not in the room. She exited the room and left the medication on the overhead table. During an interview on 11/22/2024 at 8:02 a.m., RN ADON L stated the CNAs should report any medications found in a resident room to the nurse. She stated any medications in a resident room should be removed. Record review of a facility policy titled Medication Administration (undated) revealed the policy did not address storage of medications. Record review of a facility policy titled Resident Self-Administration of Medication (undated) revealed: 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at minimum consider the following: g. The residents ability to ensure that medication is stored safely and securely.

Based on interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 5 residents (Resident #1) reviewed for medical records, in that; The facility failed to ensure staff documented Resident #1's unresponsiveness and SBAR assessment, the pills found in her room on 11/19/2024 or interventions for her change of condition including notification/activation of 911 and transfer to the hospital for treatment. This failure could result in residents not having an accurate overall view of their care and services. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's Care Plan initiated on 10/16/2024 revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy or having medications in her room without staff knowledge. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's nurse progress notes documented by LVN A on 11/19/2024 at 5:55 a.m. read 0530 (5:30 a.m.) walked into room, HOB 35 degrees, right leg hanging off the bed .(Resident #1) lethargic, unable to fully arouse, garbled words incomprehensible. Informed the aid (sic) on the hall. She reports to me a man went (sic) in her room at 11:00 p.m. and left. I asked if she reported to someone. She said the nurse on the Southside was told. I asked why? I am the nurse here on this side. Holding this 6 am dose (unknown medication). Will report to oncoming shift. Record review of Resident #1's medical record revealed there were no further progress notes or assessments to indicate any further assessments or that 911 was called or that Resident #1 was transferred to the hospital for a significant change in mental status. Record review of 3613-A Provider Investigative Report dated 11/19/2024 revealed on 7/19/2024 (incorrect date, actual date 11/19/2024), the facility was notified that a nurse (LVN A) found a patient (Resident #1) unresponsive at 5:30 am and called EMS at 6:30 a.m. The facility suspended the nurse (LVN A) for further investigation due to a delay in care. EMS arrived and administered Narcan, and the patient (Resident #1) was taken to a local ER and kept overnight for evaluation. The patient (Resident #1) was found to have medication at bedside and hospital records showed marijuana in (her) system). During an interview on 11/20/2024 at 12:04 p.m., LVN B stated on 11/19/2024 at 6:25 a.m. he came onto duty. He stated night shift nurse LVN A was seated at the nurse's station trying to give him report when he arrived. LVN B stated LVN A stated she noticed a change of condition for Resident #1 related to level of consciousness. LVN B stated LVN A stated the aides told her about the change of condition at 11:00 p.m. when Resident #1 had visitors and was lethargic. LVN B stated LVN A told him she assessed Resident #1 at 11:00 p.m. (11/18/2024) and found her lethargic. LVN B stated LVN A told him she went into Resident #1's room at 5:00 a.m. to assess the resident and she was not arousable. LVN B stated he questioned LVN A to see if she had notified the physician or transferred the resident to the hospital since Resident #1 was normally A/O x 4 (alert and oriented x 4 which indicated she was cognitively intact). LVN B stated LVN A stated she had not notified anyone. LVN B stated as soon as he heard LVN A say that he ran directly to Resident #1's room. He stated he had not yet clocked into work, but he was concerned since LVN A did not seem to know what was going on. LVN B stated LVN A stated she thought it might be medication related since the night aides found medication in Resident #1's room. LVN B stated he was alarmed. He stated he had two aides go with him. He stated when he saw Resident #1, he knew immediately something was wrong. He stated Resident #1 was very lethargic and was not able to verbalize anything. He stated she was just grunting. He stated she was breathing, and he obtained vital signs which were stable. He stated he made sure someone stayed with Resident #1 because he knew she needed to go to the hospital. LVN B stated he went to find LVN A and told her to call 911, which she did. He stated he went back to Resident #1's bedside but LVN A went to her medication card. LVN A stated he notified Resident #1's physician and her family. LVN A stated he told the physician Resident #1 was minimally responsive and that EMS had been activated. During an interview on 11/20/2024 at 2:56 p.m., LVN A stated on the night of 11/18/2024 around approximately 11:08 p.m. she noted that Resident #1 was drowsier than normal but was otherwise alert and oriented. LVN A stated on 11/19/2024 at 5:30 a.m. she went into Resident #1's room to give scheduled morphine and noted the resident's right leg handing off the bed with her head of bed at 45 degrees with her head to the side. LVN A stated Resident #1 was sleeping. She stated she tried to walk Resident #1 up and noted she was hard to wake up. LVN A stated Resident #1 slit her eyes open a little and was trying to talk but she could not understand her. LVN A stated she thought Oh my gosh. She stated the aides were just outside the room in the hallway. She stated she couldn't remember who the aides were but there were two of them and she wanted them to come inside the room because Resident #1 would not wake up. LVN A stated Resident #1 was drug seeking so she started searching her room and found 5-6 pills a piece of peach-colored pills. LVN A stated Resident #1 was not unresponsive. She stated she opened her eyes and garbled something. LVN A stated she kept going in and out of the room and noted Resident #1 gave a big grimace with a sternal rub. LVN A stated when she saw the big grimace she thought Oh God, she is okay and it was the end of her shift, and she was tired. LVN A stated she called 911 because she thought maybe they could shake her up. LVN A stated was trained to assess, document assessment for resident change of condition. LVN A stated she did not know why she deviated from how she was trained other than she was pretty tired and had worked her butt off. During an interview on 11/21/2024 at 9:56 a.m., LVN B stated there was no SBAR or other assessment documented in Resident #1's medical record for her change of condition that occurred on 11/19/2024 or any notifications. He stated he was trained to do an SBAR assessment with change of condition and document it in the medical record. He stated he was also trained to document in the progress notes the assessment and assessed vitals. He stated he did not document his assessment because he gave the information to LVN A. He stated he should have documented when Resident #1 was transferred to the hospital. LVN B stated it was important to document pertinent information in the medical record because it was a confirmation of work done. He stated he had received training by the facility on documentation on an unknown date. During an interview on 11/22/2024 at 11:20 a.m., the Regional RN stated staff were trained to document the SBAR assessment located under documents for resident change of condition. She stated they were trained to document change of condition which included the assessment, vitals, and notifications also in the progress notes. She stated the whole chain of events should be included in the notes including any new orders, transfers, etc. She stated it was important to document so there was continuity of care. Record review of a facility policy, titled Documentation in the Medical Record (undated) revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered i. False information shall not be documented.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that; The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's behaviors of bringing in medications from home, from other providers and from visitors and self-medicating without telling staff. This failure could place residents at risk for not having their needs and preferences met. The findings were: Record review of Resident #1's face sheet dated 11/20/2024 revealed an admission date of 10/15/2024 with diagnosis which included: displaced bimalleolar fracture of left lower leg (broken bone of the ankle), subsequent encounter for closed fracture with routine healing, complete rotator cuff tear or rupture of right shoulder (muscles and tendons which surround the shoulder joint), not specified as traumatic, depression, anxiety disorder and chronic pain syndrome. Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMs score of 15 which indicated she was cognitively intact and did not have any behaviors. The MDS assessment indicated the resident had a history of frequent pain that occasionally interfered with ADL's. Record review of Resident #1's Care Plan initiated on 10/16/2024, revealed the resident had chronic pain syndrome and was followed by a pain specialist with interventions which included: administer analgesics as per orders. The care plan did not address behaviors of polypharmacy, having visitors bring in medications or having medications in her room and self-administering medications without staff knowledge. Record review of a provider progress note dated 11/08/2024 by PA J revealed: Patient (Resident #1) went to a pain medication doctor and had morphine prescription received, filled at outside pharmacy which she kept in her room and would self-dose. This was discovered and morphine was taken away from her .Denies alcohol, tobacco, drugs of abuse. Record review of Resident #1's nurse progress notes dated 11/09/2024 at 8:28 a.m. documented by LVN K revealed: Guest approached nurse at nursing station expressing concern. The pharmacy had questioned the medication she was picking (up) for a resident (Resident #1), morphine tablets (narcotic) and melodic (anti-inflammatory). The resident had requested she bring her medication with codeine (hydrocodone/acetaminophen 10/325) (narcotic opioid pain reliever) a week prior from a local pharmacy. The resident (Resident #1) explained that she had received the order from her pain management doctor at a previous appointment as the current pain medication was not effective at managing her pain. The nurse educated the patient (Resident #1) to inform her nurse of any new orders from appointments or her PCP so that her doctor at the facility could adjust her medication and make orders to safely assist her healing and rehab goals. The patient expressed understanding and stated she would not self-administer medication without informing the nurse. Record review of Resident #1's nurse progress notes dated 11/10/2024 at 4:43 p.m., documented by LVN H revealed: a CNA (unknown) notified nurse of suspicious activity. A person entered Resident #1's room with a package and immediately left. The incident was reported to the Administrator. Instruction was given to search room for medication, for patient safety. Patient (Resident #1) on narcotics and has a history of asking friends to bring in narcotic(s) and other pain medication prescribed by other providers into the facility and not adhering to facility policy. Patient education given. During an interview on 11/21/2024 at 4:46 p.m., RN MDS Coordinator M stated Resident #1's care plan did not address Resident #1's behaviors of bringing in medications from outside the facility and no interventions were put in place. She stated it had never really dawned on her to put it in the care plan. She stated the floor nurses were aware of the behaviors because they were the ones who documented it and she did not believe it happened frequently. RN MDS Coordinator M stated she first learned of the behaviors during morning meeting (unknown date) when she heard the nurses talk about it. She stated in hindsight she should have done it. She stated the purpose of the care plan was to disseminate information to staff such as things the resident was at risk for and their likes/dislikes. She stated it was important because it was a behavior and should have been in the care plan when it occurred so it would have been visible on the [NAME] for staff review. During an interview on 11/23/2024 at 2:06 p.m., the Regional RN stated the MDS Coordinator and herself were responsible for care plan updates and completion. She stated during her review of Resident #1's care plan post 11/19/2024 incident and hospitalization was the first time she noted issues with the care plan. She stated Resident #1's behaviors of bringing in medication was something she would have expected to be included in that care plan. She stated it was important, so everyone was aware of the what the plan of care was and how they were to take care of the resident. Record review of a facility policy, titled Comprehensive Care Plans (undated) revealed: The comprehensive care plan will be developed within 7 days after completion of the comprehensive MDS assessment. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be address in the plan of care.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: 1. [NAME] I was not wearing a moustache or beard guard while preparing food. 2. The walk-in refrigerator and walk in freezer both contained improperly stored food items. These deficient practices could place residents who consumed meals and/or snacks from the kitchen at risk for food borne illness. The findings were: 1. Observation on 07/30/2024 at 9:36 a.m. revealed [NAME] I was standing at the kitchen range and preparing the lunchtime meal. Further observation revealed three containers of food were on the kitchen range and were uncovered. Additional observation revealed [NAME] I had a moustache and a beard and was not wearing a moustache restraint or a beard restraint. During an interview, at the same time as the observation, [NAME] I stated that he does not wear moustache or beard restraints, had never been directed to do so, and said, I don't know if we have any [restraints]. During an interview with the Dietary Manager on 07/30/2024 at 9:45 a.m., the Dietary Manager stated that it was the policy for kitchen staff to utilize moustache and beard restraint to cover facial hair while inside the kitchen. Record review of the facility policy, Dietary Employee Personal Hygiene, undated, revealed, 4. Hair Restraints a. All dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 3-305.14 Food Preparation, During preparation, unpackaged food shall be protected from environmental sources of contamination. 2. Observation on 08/01/2024 at 3:00 p.m. inside the walk-in refrigerator revealed a cardboard container of lunchmeat on the top shelf. The bottom and part of the lower section on the side of the container were wet and the cardboard was coming apart. Further observation inside the walk-in refrigerator revealed a cardboard container with approximately 10 blocks of butter wrapped in wax paper. The cardboard container did not have a lid and there were multiple loose pieces of butter on the inside of the container and on the wrapped blocks of butter. Observation on 08/01/2024 at 3:05 p.m. inside the walk-in freezer revealed three unsealed cardboard containers: one with tater tots, one with vegetable medley, and the last with cinnamon roll pinwheels. Each food item was inside a plastic bag which was also unsealed, and the food items were exposed to the air. During an interview with the Dietary Manager on 08/01/2024 at 3:15 p.m., the Dietary Manager stated that the above listed food items should have been stored in sealed containers to protect them from freezer burn and contaminates. Record review of the facility policy, Food Safety Requirements, undated, revealed, Food will also be stored, prepared, distributed, and served n accordance with professional standards for food service safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 3 of 8 residents (Residents #19, #21 and #49) who were observed for call light placement. The facility failed to ensure the call light was within reach for Residents #19, #21, and #49. This deficient practice could affect any resident and keep them from calling for help as needed. The findings included: Record review of Resident #19's face sheet, dated 08/01/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety, age-related osteoporosis without current pathological fracture, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting, unspecified side, weakness, and other abnormalities of gait and mobility. Record review of Resident #19's Quarterly MDS assessment, dated 06/24/2024, reflected the resident's BIMS score was 03, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #19 required substantial/maximal assistance (helper does more than half the effort) for mobility roll left and right, sit to lying, sit to stand, chair/bed to chair transfer, lying to sitting on side of bed, dependent (helper does all the effort) for toileting hygiene, shower/bathe self, lower body dressing. Record review of Resident #19's care plan, revision date of 07/31/2024, reflected Focus: [resident name] is High risk for falls history of falls dementia, generalized weakness, left sided weakness . with Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance. Observation on 08/01/24 4:28 p.m. revealed Resident #19 with her call light located on the floor under the side of her bed near the nightstand. During an interview on 08/01/2024 at 4:31 p.m. MA D stated Resident #19 did use her call light sometimes and placed resident's call light back on the bed. MA D further stated whoever assisted residents or laid them down were supposed to make sure residents could reach them. MA D stated residents used call lights if they need anything or had an emergency for their safety. Record review of Resident #21's face sheet, dated 08/01/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, acute kidney failure, unspecified, weakness, and cognitive communication deficit. Record review of Resident #21's Quarterly MDS assessment, dated 07/25/2024, reflected the resident's BIMS score was 02, which indicated severe cognitive impairment. The Quarterly MDS assessment further revealed Resident #21 required substantial/maximal assistance (helper does more than half the effort) for mobility sit to lying, sit to stand, chair/bed to chair transfer, lying to sitting on side of bed, shower/bathe self, lower body dressing and dependent (helper does all the effort) for toileting hygiene. Record review of Resident #21's care plan, revision date of 07/19/2024, reflected Focus: [resident name] is High risk for falls history of falls r/t cognitive impairment, wears glasses, unsteady gait/balance. with Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance. Observation and interview on 07/30/2024 at 11:12 a.m. revealed Resident #21's call light was on the floor next to her bed. CNA C stated she did not believe Resident #21 used her call light, but the call light should have been within reach of Resident #21. CNA C placed call light under Resident #21's hand after picking it up off the floor. Observation on 08/01/2024 at 4:28 p.m. revealed Resident #21 with call light located on the floor near the head of bed. During an interview on 08/01/2024 at 4:31 p.m. MA D stated Resident #21 did use her call light sometimes and placed resident's call light back on the bed. MA D further stated whoever assisted residents or laid them down were supposed to make sure residents could reach them. MA D stated residents used call lights if they need anything or had an emergency for their safety. Record review of Resident #49's face sheet, dated 07/10/2024, reflected she was admitted to the facility on [DATE] with diagnoses which included: metabolic encephalopathy, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unsteadiness on feet, and other abnormalities of gait and mobility. Record review of Resident #49's Admission MDS assessment, dated 06/03/2024, reflected the resident's BIMS score was 03, which indicated severe cognitive impairment. The Admission MDS assessment further revealed Resident #49 required substantial/maximal assistance (helper does more than half the effort) for sit to lying, dependent (helper does all the effort for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, roll left and right, lying to sitting on the side of bed, and chair/bed-to-chair transfer. Record review of Resident #49's care plan, revision date of 07/29/2024, reflected Focus: The resident is at risk for falls r/t advanced dementia with associated risk of decreased safety awareness and impulsivity, Deconditioning, Gait/balance problems, Incontinent episodes (highly prefers having BM in toilet potential risk for self-transfer attempt) . with Interventions: Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Observation and interview on 07/30/2024 at 10:50 a.m. revealed Resident #49 sitting in w/c next to her bed wearing her oxygen with her soft touch call light hanging on the quarter rail of her bed behind Resident #49. Resident #49 stated she did push it sometimes and further stated she could not reach it right then. During an interview on 07/30/2024 at 10:58 a.m. CNA C stated Resident #49 she did not believe used the call light, however, the residents were to always have it with them. CNA C further stated it was important for residents to be able to reach their call lights so the residents could call for help. Observation and interview on 08/01/2024 at 4:37 p.m. revealed Resident #49 lying in bed with the head of her bed elevated and call light on the floor next to the bed. ADON A entered the room, picked up the call light off the floor and placed across resident. ADON A stated Resident #49 would not have been able to reach it, and this was why she picked it up and gave it to Resident #49. During an interview on 08/01/2024 at 5:15 p.m. the DON stated anybody who was in the room should ensure the call lights were in reach when leaving the rooms. The DON further stated call lights are part of their fall prevention measures. The DON stated call lights were used by residents for emergencies, in any situation they needed assistance, and she knew many did not use the call light, but the call light should still be in place. Record review of facility's Call Lights: Accessibility and Timely Response policy, no revised date, read Policy the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistances . Policy Explanation and Compliance Guidelines: 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interview and record review, the facility failed to ensure that a resident CPR/advance directive/physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] RN A performed CPR on Resident #1 who had a DNR order in place. The resident expired in the facility. This failure could affect residents with advance directives and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] to [DATE]. This was determined to be a Past Non-compliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. The findings were: Record review of Resident #1's face sheet, revealed initial admitted [DATE] with a readmission of [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS (Minimum Data Sheet) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 which indicated cognitively intact. Activities of daily living for mobility functionality revealed supervision set up for transfer. Walk in room supervision assist with one person. Toilet use and personal hygiene, supervision with set up help only. Record review of Resident #1's Care plan dated [DATE] revealed Resident as DNR and does not want CPR performed. Fully executed OOH (Out of Hospital) DNR in place. Goal: Resident, family, surrogate will have wishes respected. Interventions: Ensure chart is properly identified. Ensure OOH DNR form is on the resident's chart and corresponds to the EMR(Electronic Medical Record). If resident is without pulse and respirations, do NOT attempt CPR. Record review of Resident #1's clinical record revealed an OOH-DNR Order was signed by the resident on [DATE]. Record review of Resident #1's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During in an interview on [DATE] at 10:07 am COO (Chief Operating Officer) revealed during entrance conference an incident on [DATE] had occurred with a resident receiving CPR when she was a DNR. COO stated on [DATE] around 3:10 p.m. a code blue was called in the 400-hall shower room for Resident #1. CNA D called for help as Resident #1 became unresponsive. RN A responded to CNA D's call for help. Upon entry at 3:11 p.m., RN A found Resident #1 slumped forward in her shower chair. Assessment by RN A determined Resident #1 had no pulse or respirations. CPR was initiated at 3:12 p.m. RN A went to check paper chart after LVN C relieved her, for Resident #1's code status. COO confirmed RN A picked up the wrong chart and proceeded to identify Resident #1 as a Full code. At 3:15 p.m. LVN C determined Resident #1 was a DNR by checking the correct chart. At 3:18 p.m. 911 EMT's (Emergency Medical Technicians) arrived, they were informed Resident #1 was a DNR and CPR was stopped. Resident #1 was pronounced deceased at 3:21 p.m. in facility. COO provided surveyor with Action plan dated [DATE] with signature which included the IDON (interim director of nursing), Medical Director and Administrator. 100% audit of residents EMR (electronic medical record) and paper chart was conducted to include Code status, MD order in EMR, and code status in EMR profile. COO confirmed at time of investigation RN A had looked at the wrong chart, obtained wrong information for Resident #1's code status and performed CPR on Resident #1, who had a fully executed an OOH (Out of Hospital) DNR in place. COO confirmed proper procedure for determining code status of a resident is to look in EMR on the face sheet. During an interview on [DATE] at 10:43 a.m. with LVN ADON stated on [DATE] around 3:00 p.m. she heard a code blue called and went to assist. When entering the shower room, she asked RN A if Resident #1 was a full code or DNR. At that time, she was told by RN A Resident #1 was a full code. LVN stated a few minutes later another nurse came in a told RN A and LVN Resident #1 was a DNR, but since they had initiated CPR they were continuing until EMS got there. She stated once EMS arrived and checked resident she was pronounced at 3:21 p.m. LVN further revealed standard practice at facility is to check the residents EMR for the resident's code status. This is located on the resident's face sheet at the top of the form. She stated there is a paper chart also available with the resident's code status in the front of the chart. She further revealed the CNA's can check in their electronic documentation for a resident's code status. During a phone interview on [DATE] at 11:54 a.m., RN A stated she had received the okay to move Resident #1 back to her room, on 600 Hall as she had completed her quarantine period. CNA D started shouting she needed help. RN A stated she responded and found Resident #1 slumped over in the shower chair. The resident was not breathing, and she was unable to feel a pulse. RN A stated she instructed CNA D to get help. EMT's were called. When CNA D returned, RN A went to find the resident's code status. She stated she thought Resident #1 was a FULL CODE. RN A stated, I picked up the wrong chart I didn't use [EMR name] because it is slow and the paper chart was quicker. With the help of the CNA and another nurse, we placed Resident #1 on the floor and started chest compressions. Another nurse (LVN C) found the correct information and revealed the resident was a DNR. Since we had already started chest compressions, we continued doing them. When EMS arrived, they attached their defibrillator and the resident was asystole (no pulse). CPR was stopped, and RN A was asked to call the time of death of 3:21 p.m. RN A said that it is normal practice is to look in [EMR name] on the face sheet for code status. RN A stated, I chose the paper chart instead because it was faster. I made a mistake and picked up the wrong chart. During an interview on [DATE] at 12:15 p.m. LVN B stated he was in orientation when the housekeeping supervisor came to ask him if he could help with a code blue. LVN B went to the shower room and relieved LVN C, who was performing compressions on Resident #1. LVN B stated when EMS arrived, he left. He did not hear anyone ask about code status. When asked how to determine code status he stated we are to look in [EMR name] and it is at the top of the face sheet. There are paper charts with green for code and red for DNR also, but first choice is [EMR name]. During a phone interview on [DATE] at 2:21 p.m. LVN C stated on the [DATE] around 3:00 p.m. she was called to assist with a code blue in the shower room on 400 hall. LVN C went to assist and ask if Resident #1 was full code. RN A stated, yes. LVN C initiated CPR. LVN B came in and relieved her and she went to check EMR chart to print face sheet and papers for 911. In [EMR name] on the face sheet LVN C saw where Resident #1 was a DNR. LVN C stated she went back and told RN A that Resident #1 was a DNR but because they started CPR, they continued and when EMS came they pronounced the resident. Interview on [DATE] at 3:00 p.m. with IDON (Interim Director of Nursing) revealed she conducted an investigation which revealed RN A performed CPR on Resident #1 who was a DNR; and confirmed CPR should not have been provided to Resident #1 by RN. IDON further confirmed RN A should have checked [EMR] for Resident #1's code status and not the paper chart. Further interview revealed staff are trained when they are hired regarding DNR/advance directives. During the admission process the Social Worker and /or Admission Coordinator provides advance directive information to the resident and/or responsible party to be followed through to the residents medical record. Record review of facility policy titled: Adult Cardiopulmonary Resuscitation with no date revealed; Policy statement: To establish circulation and ventilation on a resident with absence if respirations and pulse. Procedure: 1. First nurse arrives evaluates airway, breathing, level of consciousness and vital signs taken and evaluated and verbalized by nurse in charge. 2. Responder calls for help, stays with resident. 3. A licensed nurse will review OOH-DNR and/or code status in EHR (electronic health record) in order to establish the current code status. On [DATE] at 3:30 p.m. the COO and IDON were notified of a past noncompliance IJ from [DATE] to [DATE]. The facility took the following actions to correct the non compliance on [DATE]. On [DATE] at 10:00 a.m. the COO provided surveyor with document titled , Action Plan: DNR status Plan of Correction with Monitoring, dated [DATE]. Resident Rights specific to Code status: 1. Licensed nurses, CNA's and CMA's were educated regarding Advance Directive, Code Status, and how to update changes in code status. Initiated [DATE] Completed [DATE]. Record review of inservice log Topic: When to initiate CPR, you verify in [EMR name] or POC code status and nurse initiating verifying code status. 2. 100% chart audit was done to ensure resident code status was correct. Orders were reviewed to ensure paper charts match physician order. Initiated [DATE] Completed [DATE]. 3. Licensed nurses, CNA's, and CMA's were educated as to where to locate code status for residents. Initiated [DATE] Completed [DATE]. Record review of inservice log Topic: When to initiate CPR, you verify in [EMR name] or POC code status and nurse initiating verifying code status. 4. Paper charts will be audited weekly to ensure code status is accurate and that red or green sheet matches the order. Initiated [DATE] Completed [DATE]. Continue. 5. Licensed staff will be interviewed weekly to ensure they understand the CPR Policy of the facility and where to locate code status. Initiated [DATE] Completed [DATE]. 6. Facility conducted QAPI meeting on [DATE] to discuss CPR policy and self-report incident in detail. 7. Action plan developed and enacted. Initiated [DATE]. Completed [DATE]. 8. Facility medical director, resident physician and responsible party informed of incident. Initiated [DATE] Completed [DATE]. Verification : Verification of items below were done on [DATE] by surveyor. Document titled , Action Plan: DNR status Plan of Correction with Monitoring, dated [DATE]. 1. Inservice record signed by 11 of 18 LVN/RN's and 25 of 31 staff (CNA's ,CMA's, and ancillary.) COO and IDON stated remaining staff will have inservice before their next working shift. Verification by interviews (14 of 18 staff interviewed) completed on [DATE]. 2. Record review of 94 of 94 residents electronic and paper charts verified completed on [DATE]. 3. Inservice record signed by 11 of 18 LVN/RN's and 25 of 31 staff (CNA's ,CMA's, and ancillary.) COO and IDON stated remaining staff will have inservice before their next working shift. Verification by interviews (14 of 18 staff interviewed) completed on [DATE]. 4. Interview on [DATE] with COO and IDON revealed , IDON/ADON or designee will audit paper charts for accuracy of code status. 5. Interview on [DATE] with COO and IDON revealed , IDON/ADON or designee will interview licensed staff and document on inservice record. Verification by interviews of staff (14 of 18 staff interviewed) completed on [DATE]. 6. Record review verified on [DATE] of QAPI meeting with attendance of COO, IDON, ADON, and Medical Director. 7. Record review was verified on [DATE] by surveyor. 8. Record review was verified on [DATE] by surveyor.

Based on interview and record review, the facility failed to impletment their policies and procedures to prohibit neglect for 1 of 7 residents (Resident #4) reviewed for neglect. The facility failed to administer [MEDICAL CONDITION] medicaitons, Lacosamide 200 mg as ordered by the physician for 9.5 days or 19 doses, and aministered [MEDICATION NAME] 1000 mg daily instead of twice a day as ordered. This resulted in Resident #4 experiencing multiple [MEDICAL CONDITION] and was sent to the hospital where he was discharged home with hospice services. These failures placed Resident #4 in an Immediate Jeopardy (IJ) from 08/09/2016 through 08/22/2016. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice has the potential to negatively affect 6 residents in the building who take [MEDICAL CONDITION] medications by having increased [MEDICAL CONDITION], loss of consciousness and death. Findings include: Record review of Resident #4 reflected a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] reflected Resident #4 having a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognitive deficits. Resident #4 had [MEDICAL CONDITION] that fluctuated and had psychotic behaviors 1-3 days of the 7 day look back period. Resident #4 required extensive assistance of 2 people for bed mobility and 1 person for transfers, ambulation with his wheelchair, hygiene and bathing. Resident #4 required total assistance of 1 person for eating as he has a peg tube. Resident #4 was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #4's Interim Care Plan dated 08/09/2016 reflected the resident was alert and required assistance of 1 person with his ADLs. Record review of the Provider Self Reporting of Incidents - Report Details dated 08/19/2016 was as follows: Resident admitted to facility on 08/08/2016 from hospital. Admission nurse failed to communicate that Lacosamide, [MEDICAL CONDITION] medication, was a controlled medication that needed approval from an agent of the physician. The pharmacy did not follow protocol by requesting agent information or calling the facility regarding the prescription and therefore the medication was not delivered. The nurse on duty on 08/18 called the resident's wife and was inquiring about the medication asking if she could bring it in. It was then found that the order was for BID and that he had missed 19 doses. Approximately less than 1 hour after discovery that the medication was missing, the resident began [MEDICAL CONDITION] activity. The facility immediately contacted the physician and received an order for [REDACTED]. Facility ADON called ER and was told by the nurse that the resident was alert and talking and not had any further [MEDICAL CONDITION] activity. Record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m., reflected no documentation of whether or not the attending physician verified orders to continue the medication Lacosamide. Record review of Resident #4's Progress Note, dated 08/04/2016, from the hospital documenting his current medications and the days they were started was as follows: 06/29/2016 Lacosamide 200 mg PEG BID 08/01/2016 Valporic Acid ([MEDICATION NAME] - brand name [MEDICAL CONDITION] medication) 250 mg PO BID Record review of Resident #4's discharge orders from the hospital dated 08/05/2016 reflected a prescription for: Rx: Lacosamide 200 mg or tablet SIG: 1 tab PEG BID Rx: [MEDICATION NAME] 500 mg oral tablet SIG: 2 tab PEG BID Record review of Resident #4's admission orders [REDACTED] Lacosamide 200 mg per peg tube BID [MEDICATION NAME] 500 mg 2 tabs per peg tube BID Record review of Resident #4's Administration Record for the month of August 2016 reflected Lacosamide 200 mg to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the 19 doses since admission to the nursing facility on 08/08/2016. In an interview with LVN C on 08/29/2016 at 11:56 a.m., he stated if there is an initial that is circled on the MAR indicated [REDACTED]. The row for the 9 a.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN C's initials with them circled 08/10/2016 LVN C's initials with them circled 08/11/2016 LVN C's initials with them circled 08/12/2016 LVN D's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN E's initials with them circled 08/15/2016 LVN C's initials with them circled 08/16/2016 LVN C's initials with them circled 08/17/2016 LVN C's initials with them circled No documentation for the morning dose for 08/18/2016, this was LVN D's shift. The row for the 5 p.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN B's initials with them circled 08/10/2016 LVN D's initials with them circled 08/11/2016 LVN D's initials with them circled 08/12/2016 LVN B's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN B's initials with them circled 08/15/2016 LVN B's initials with them circled 08/16/2016 LVN D's initials with them circled No documentation for the evening dose for the 08/17/2016, this was LVN D's shift. Record review of Resident #4's Administration Record for the month of August reflected [MEDICATION NAME] 500 mg 2 tabs to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses on the 5 p.m. shift since admission. The 9th through the 16th there is only an arrow across the record indicating no medication given on the 5 p.m. shift and no documentation for the 5 p.m. shift on the 17th. Record review of the instruction of the Administration Record was to document on the back of the form the reason for a missed dose; however, there was no documentation. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Nursing Home to Hospital Transfer Form created by LVN D, dated 08/18/2016, reflected Resident #4 having [MEDICAL CONDITION]. Record review of the Nursing Note dated 08/18/2016 timed as 6-2 created by LVN D was as follows: During shift resident started having [MEDICAL CONDITION], this nurse called DR and he put in order for 1 mg [MEDICATION NAME] ([MEDICATION NAME]) PPT, this nurse administered MED, a short time after resident appeared to continue to have smaller [MEDICAL CONDITION], subsequently n.o. (new order) was put in for an additional dose [MEDICATION NAME] ([MEDICATION NAME]) 1mg to give IM, which was administered a short time later during reassessment resident appeared tired but continued to have twitching in both of his hands. Decision made to send resident out to ER to give report & spoke to a female nurse & informed her of situation, informed her about the medications resident was supposed to be taking & how much & when & how many doses he had taken & missed in the last 10 days prior. This nurse also informed her of all the PRN [MEDICATION NAME] that he'd been administered to combat current [MEDICAL CONDITION] activity. After giving her report she tells this nurse that we seem to have done everything we can possibly do for him at this time. This nurse then informs her that his wife was voicing wanting to send him out of the facility for treatment, she voiced understanding. Resident was then sent out to ER for treatment. In an interview with Family #1 on 08/29/2016 at 10:17 a.m., they stated Resident #4 had seized due to not getting his medications and his [MEDICAL CONDITION] lasted about 3 hours before they could get them under control. Family # 1 stated the resident had not had a [MEDICAL CONDITION] in about 2 months prior to this incident. Family #1 said Resident #4 was not returning to the facility; that when he discharged from the hospital and he went back home on hospice services. In an interview on 08/29/2016 at 11:00 a.m. with the DON she said Resident #4 came into the facility with orders for [MEDICATION NAME] and Lacosamide, no one realized the Lacosamide was a controlled substance. DON said when there is a medication that is controlled the pharmacy requires an Agent of Physician approval to get the medication filled; Agent of Physician is a person the physician appoints the authority in the nursing home to give verbal permission to fill a controlled medication. The DON stated the pharmacy did not follow through with the procedure to get the Lacosamide approved. The DON said LVN B made a transcription error for the [MEDICATION NAME] and it was supposed to be given twice a day and was only given once a day. The DON said the Lacosamide was not given at all. The DON stated when the error was noticed by LVN D she called Resident #4's Family #2 and she brought in the medication on 08/18/2016 in the morning before the resident began seizing. The DON said it wasn't an hour after the medication error was acknowledged that Resident #4 began seizing. The DON said there was an order received and 1 mg of [MEDICATION NAME] was given via peg tube immediately. The DON then stated Resident #4 was still seizing about 10 minutes after receiving the first dose of [MEDICATION NAME] and then LVN D got another order for [MEDICATION NAME] 1 mg IM. The DON said at this point Resident #4's Family #2 wanted him sent to the emergency room and she chose to take the resident home on hospice services instead of returning him to the facility. The DON added that the error with the [MEDICATION NAME] and Lacosamide was found on the 18th of August. In an interview on 08/29/2016 at 11:50 a.m. with ADON A she stated the physician was supposed to be contacted upon admission to continue Lacosamide, but was not based off of the record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m. When asked if the orders were verified ADON A stated LVN B did not mark the box on the admission paperwork indicating she verified the orders with the physician. ADON A stated there is usually a copy of the discharge orders from the hospital with all of the medications Resident #4 should be taking with the admission orders [REDACTED]. ADON A said the resident came to the facility via personal vehicle and the wife had a stack of printed off medication orders. ADON A said the wife gave us those prescriptions and this is how we found out later while going through the chart Resident #4 was supposed to be on Lacosamide. ADON A said it is the ADONs responsibility to follow up after an admission comes in to ensure the medication reconciliation is correct. ADON A said she was on vacation when Resident #4 admitted to the facility. In an interview on 08/29/2016 at 1:08 p.m. with the Pharmacy Director, PHARM, he stated the process for filling medications from the nursing home is when a nurse sends in an order for [REDACTED]. PHARM said the pharmacy company never got the order, but no one from the nursing facility followed up. PHARM stated Resident #4 did not get his medications for a 9 day period. In an interview with LVN B on 08/29/2016 at 1:20 p.m. she stated she did Resident #4's admission on the 8th of August shortly before dinner. LVN B said she was not given any notice that the facility was going to get an admission; the family came to LVN B and told her Resident #4 was there to be admitted . LVN B said her main priority was getting the medications approved through the pharmacy so they would be there the next morning. LVN B said Resident #4's wife brought her the discharge packet from the hospital while she was in the middle of med pass. LVN B said she finished her med pass and went over the medications and paperwork for Resident #4. LVN B said she contacted the physician and went through the paperwork with him, while doing this she found prescriptions in the packets and they matched up with the majority of his medications from the hospital so she verified Resident #4's medications. LVN B said she did not notice Resident #4 had not received the [MEDICAL CONDITION] medication in as many days that he did not get it. LVN B stated ADON A typically goes over all medications, but she wasn't here that week. LVN B said on the third day she noticed she did not give the Lacosamide to Resident #4 and she checked the emergency medication kit, but the medication was not in there so she contacted the pharmacy to let them know Resident #4 never received his Lacosamide. LVN B said the Lacosamide was not on the Admission/discharge paperwork from the hospital, but it was on all of the other documentation, LVN B said she did verify. LVN B said Resident #4 did not get the Lacosamide for 9.5 days, 19 doses due to it being prescribed twice a day. LVN B said she did not realize Resident #4 had not had this medication in that many days until she was called in and the DON talked to her about it. LVN B said there is no excuse in a medication being missed that many times. The DON met with LVN B after Resident #4 discharged to the hospital. LVN B said LVN D was working the day Resident #4 discharged to the hospital. LVN B said she just missed the [MEDICATION NAME] dosing when transcribing the medication. LVN B said she made a medication error. In an interview with LVN C on 08/29/2016 at 1:56 p.m. he stated he continued to circle the Lacosamide on the MAR indicated [REDACTED]. LVN C said he thought the next shift would follow up on it, but it never happened. LVN C stated most of the admissions come in on the 2 p.m. - 10 p.m. shift so he generally does not do them as he works the 6 a.m. - 2 p.m. shift. When asked about the [MEDICATION NAME] only being given once a day instead of twice he stated they get their own medications for their shift and don't look any further in the day because it was not his shift. In an interview with the physician, DR, on 08/30/2016 at 9:25 a.m. he stated LVN B verified the medications. DR stated if the Lacosamide had been missed once it would not be a big deal, but the medication being stopped did cause Resident #4's [MEDICAL CONDITION]. In an interview with LVN D on 08/30/2016 at 2:10 p.m. she said Resident #4 did not get his [MEDICAL CONDITION] medication and she was the one who found that it was not being given. LVN D said 3 days prior to Resident #4 seizing she realized the medication was not being provided and she left a note in the 24 hour report book; however, the note is missing. LVN D said she wondered if the medication was being provided by the family. When LVN D was asked about not giving the [MEDICATION NAME] twice a day, she stated the facility paperwork said once a day and she had a difficult time reading the order. LVN D said on 08/18/2016 when she realized the medication wasn't being given, she contacted Family #2 and she brought Resident #4's supply from home and gave Resident #4 a dose. LVN D said about 30 minutes after the medication was given Resident #4 began seizing and it looked like a grand mal [MEDICAL CONDITION]. LVN D said she was unsure how long the [MEDICAL CONDITION] lasted, but there was one big [MEDICAL CONDITION] and then Resident #4's hands began to tremor and continually having [MEDICAL CONDITION]. LVN D stated Resident #4's Family #2 requested he be sent to the ER. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 08/09/2016 through 08/18/2016. The facility took the following actions to correct the non-compliance on 08/22/2016. Record review of in-services the facility implemented were: Admission Audits dated 08/18/2016 for ADON A, ADON F, and MR; All admission/readmissions will be reviewed by ADON's assigned to patients' unit to include required assessments, admission orders [REDACTED]. Medical Records will input all admission/Readmission orders [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medications dated 08/19-22/2016 for all licensed nurses and CMAs; All medications that are not available in cart must be reported to the DON and charge nurse to obtain it ASAP. A circled medication on MAR indicated [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medication Cart Audit dated 08/22/2016 for ADON A and ADON F; Medication cart audits initiated on all carts for both units to verify disposition of all medications as order by physician are present and being administered. This in-service was completed by the DON and signed by all applicable staff members. A New Admission Checklist was created and implemented by the DON. The areas this checklist addressed was hospital discharge orders, admission orders [REDACTED]. In interviews with 7 staff members on 08/30/2016, 7 out of 7 staff were able to identify what to do if a medication is not available in the cart, what a circle initial in the MAR indicated [REDACTED]. Record review of the last day of in-services completed in the facility relating to the Past Noncompliant Immediate Jeopardy was 08/22/2016. Record review of the facility's Abuse Policy and Procedure (No Date) documented: The Administrator has overall responsibility and accountability for implementing the Resident Abuse Prevention Program. Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Purpose: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion, and misappropriation of property for all customers. Record review of the ORDERING AND REORDERING MEDICATIONS policy received 08/29/2016 at 12:30 p.m. by the DON entails the following: POLICY: To ensure that ordered medication is present in the facility and available to be given to each resident according to their physician orders [REDACTED]. To order new medications: [REDACTED] 1. After the physician order [REDACTED]. 3. If the new medication order is a controlled substance, then the physician or nurse practitioner must provide the new prescription to the pharmacy. On 08/30/2016 at 10:40 a.m. the DON was notified that an Immediate Jeopardy situation had been identified that existed from 08/09/2016 through 08/18/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 08/29/2016, 6 residents in the facility take [MEDICAL CONDITION] medications.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohib neglect for 1 of 7 residents (Resident #4) reviewed for significant neglect. The facility failed to administer [MEDICAL CONDITION] medicaitons, Lacosamide 200 mg as ordered by the physician for 9.5 days or 19 doses, and aministered [MEDICATION NAME] 1000 mg daily instead of twice a day as ordered. This resulted in Resident #4 experiencing multiple [MEDICAL CONDITION] and was sent to the hospital where he was discharged home with hospice services. These failures placed Resident #4 in an Immediate Jeopardy (IJ) from 08/09/2016 through 08/22/2016. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice has the potential to negatively affect 6 residents in the building who take [MEDICAL CONDITION] medications by having increased [MEDICAL CONDITION], loss of consciousness and death. Findings include: Record review of the facility's Abuse Policy and Procedure (No Date) documented: The Administrator has overall responsibility and accountability for implementing the Resident Abuse Prevention Program. Neglect is defined as: Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Purpose: To ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, involuntary seclusion, and misappropriation of property for all customers. Record review of Resident #4 reflected a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] reflected Resident #4 having a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognitive deficits. Resident #4 had [MEDICAL CONDITION] that fluctuated and had psychotic behaviors 1-3 days of the 7 day look back period. Resident #4 required extensive assistance of 2 people for bed mobility and 1 person for transfers, ambulation with his wheelchair, hygiene and bathing. Resident #4 required total assistance of 1 person for eating as he has a peg tube. Resident #4 was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #4's Interim Care Plan dated 08/09/2016 reflected the resident was alert and required assistance of 1 person with his ADLs. Record review of the Provider Self Reporting of Incidents - Report Details dated 08/19/2016 was as follows: Resident admitted to facility on 08/08/2016 from hospital. Admission nurse failed to communicate that Lacosamide, [MEDICAL CONDITION] medication, was a controlled medication that needed approval from an agent of the physician. The pharmacy did not follow protocol by requesting agent information or calling the facility regarding the prescription and therefore the medication was not delivered. The nurse on duty on 08/18 called the resident's wife and was inquiring about the medication asking if she could bring it in. It was then found that the order was for BID and that he had missed 19 doses. Approximately less than 1 hour after discovery that the medication was missing, the resident began [MEDICAL CONDITION] activity. The facility immediately contacted the physician and received an order for [REDACTED]. Facility ADON called ER and was told by the nurse that the resident was alert and talking and not had any further [MEDICAL CONDITION] activity. Record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m., reflected no documentation of whether or not the attending physician verified orders for the Lacosamide to be continued. Record review of Resident #4's Progress Note, dated 08/04/2016, from the hospital documenting his current medications and the days they were started was as follows: 06/29/2016 Lacosamide 200 mg PEG BID 08/01/2016 Valporic Acid ([MEDICATION NAME] - brand name [MEDICAL CONDITION] medication) 250 mg PO BID Record review of Resident #4's discharge orders from the hospital dated 08/05/2016 reflected a prescription for: Rx: Lacosamide 200 mg or tablet SIG: 1 tab PEG BID Rx: [MEDICATION NAME] 500 mg oral tablet SIG: 2 tab PEG BID Record review of Resident #4's admission orders [REDACTED] Lacosamide 200 mg per peg tube BID [MEDICATION NAME] 500 mg 2 tabs per peg tube BID Record review of Resident #4's Administration Record for the month of August 2016 reflected Lacosamide 200 mg to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses since admission to the nursing facility on 08/08/2016. In an interview with LVN C on 08/29/2016 at 11:56 a.m., he stated if there is an initial that is circled on the MAR indicated [REDACTED]. The row for the 9 a.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN C's initials with them circled 08/10/2016 LVN C's initials with them circled 08/11/2016 LVN C's initials with them circled 08/12/2016 LVN D's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN E's initials with them circled 08/15/2016 LVN C's initials with them circled 08/16/2016 LVN C's initials with them circled 08/17/2016 LVN C's initials with them circled No documentation for the morning dose for 08/18/2016, this was LVN D's shift. The row for the 5 p.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN B's initials with them circled 08/10/2016 LVN D's initials with them circled 08/11/2016 LVN D's initials with them circled 08/12/2016 LVN B's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN B's initials with them circled 08/15/2016 LVN B's initials with them circled 08/16/2016 LVN D's initials with them circled No documentation for the evening dose for the 08/17/2016, this was LVN D's shift. Record review of Resident #4's Administration Record for the month of August reflected [MEDICATION NAME] 500 mg 2 tabs to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses on the 5 p.m. shift since admission. The 9th through the 16th there is only an arrow across the record indicating no medication given on the 5 p.m. shift and no documentation for the 5 p.m. shift on the 17th. Record review of the instruction of the Administration Record was to document on the back of the form the reason for a missed dose; however, there was no documentation. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Nursing Home to Hospital Transfer Form created by LVN D, dated 08/18/2016, reflected Resident #4 having [MEDICAL CONDITION]. Record review of the Nursing Note dated 08/18/2016 timed as 6-2 created by LVN D was as follows: During shift resident started having [MEDICAL CONDITION], this nurse called DR and he put in order for 1 mg [MEDICATION NAME] ([MEDICATION NAME]) PPT, this nurse administered MED, a short time after resident appeared to continue to have smaller [MEDICAL CONDITION], subsequently n.o. (new order) was put in for an additional dose [MEDICATION NAME] ([MEDICATION NAME]) 1mg to give IM, which was administered a short time later during reassessment resident appeared tired but continued to have twitching in both of his hands. Decision made to send resident out to ER to give report & spoke to a female nurse & informed her of situation, informed her about the medications resident was supposed to be taking & how much & when & how many doses he had taken & missed in the last 10 days prior. This nurse also informed her of all the PRN [MEDICATION NAME] that he'd been administered to combat current [MEDICAL CONDITION] activity. After giving her report she tells this nurse that we seem to have done everything we can possibly do for him at this time. This nurse then informs her that his wife was voicing wanting to send him out of the facility for treatment, she voiced understanding. Resident was then sent out to ER for treatment. In an interview with Family #1 on 08/29/2016 at 10:17 a.m., they stated Resident #4 had seized due to not getting his medications and his [MEDICAL CONDITION] lasted about 3 hours before they could get them under control. Family # 1 stated the resident had not had a [MEDICAL CONDITION] in about 2 months prior to this incident. Family #1 said Resident #4 was not returning to the facility; that when he discharged from the hospital and he went back home on hospice services. In an interview on 08/29/2016 at 11:00 a.m. with the DON she said Resident #4 came into the facility with orders for [MEDICATION NAME] and Lacosamide, no one realized the Lacosamide was a controlled substance. DON said when there is a medication that is controlled the pharmacy requires an Agent of Physician approval to get the medication filled; Agent of Physician is a person the physician appoints the authority in the nursing home to give verbal permission to fill a controlled medication. The DON stated the pharmacy did not follow through with the procedure to get the Lacosamide approved. The DON said LVN B made a transcription error for the [MEDICATION NAME] and it was supposed to be given twice a day and was only given once a day. The DON said the Lacosamide was not given at all. The DON stated when the error was noticed by LVN D she called Resident #4's Family #2 and she brought in the medication on 08/18/2016 in the morning before the resident began seizing. The DON said it wasn't an hour after the medication error was acknowledged that Resident #4 began seizing. The DON said there was an order received and 1 mg of [MEDICATION NAME] was given via peg tube immediately. The DON then stated Resident #4 was still seizing about 10 minutes after receiving the first dose of [MEDICATION NAME] and then LVN D got another order for [MEDICATION NAME] 1 mg IM. The DON said at this point Resident #4's Family #2 wanted him sent to the emergency room and she chose to take the resident home on hospice services instead of returning him to the facility. The DON added that the error with the [MEDICATION NAME] and Lacosamide was found on the 18th of August. In an interview on 08/29/2016 at 11:50 a.m. with ADON A she stated the physician was supposed to be contacted upon admission to continue Lacosamide, but was not based off of the record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m. When asked if the orders were verified ADON A stated LVN B did not mark the box on the admission paperwork indicating she verified the orders with the physician. ADON A stated there is usually a copy of the discharge orders from the hospital with all of the medications Resident #4 should be taking with the admission orders [REDACTED]. ADON A said the resident came to the facility via personal vehicle and the wife had a stack of printed off medication orders. ADON A said the wife gave us those prescriptions and this is how we found out later while going through the chart Resident #4 was supposed to be on Lacosamide. ADON A said it is the ADONs responsibility to follow up after an admission comes in to ensure the medication reconciliation is correct. ADON A said she was on vacation when Resident #4 admitted to the facility. In an interview on 08/29/2016 at 1:08 p.m. with the Pharmacy Director, PHARM, he stated the process for filling medications from the nursing home is when a nurse sends in an order for [REDACTED]. PHARM said the pharmacy company never got the order, but no one from the nursing facility followed up. PHARM stated Resident #4 did not get his medications for a 9 day period. In an interview with LVN B on 08/29/2016 at 1:20 p.m. she stated she did Resident #4's admission on the 8th of August shortly before dinner. LVN B said she was not given any notice that the facility was going to get an admission; the family came to LVN B and told her Resident #4 was there to be admitted . LVN B said her main priority was getting the medications approved through the pharmacy so they would be there the next morning. LVN B said Resident #4's wife brought her the discharge packet from the hospital while she was in the middle of med pass. LVN B said she finished her med pass and went over the medications and paperwork for Resident #4. LVN B said she contacted the physician and went through the paperwork with him, while doing this she found prescriptions in the packets and they matched up with the majority of his medications from the hospital so she verified Resident #4's medications. LVN B said she did not notice Resident #4 had not received the [MEDICAL CONDITION] medication in as many days that he did not get it. LVN B stated ADON A typically goes over all medications, but she wasn't here that week. LVN B said on the third day she noticed she did not give the Lacosamide to Resident #4 and she checked the emergency medication kit, but the medication was not in there so she contacted the pharmacy to let them know Resident #4 never received his Lacosamide. LVN B said the Lacosamide was not on the Admission/discharge paperwork from the hospital, but it was on all of the other documentation, LVN B said she did verify. LVN B said Resident #4 did not get the Lacosamide for 9.5 days, 19 doses due to it being prescribed twice a day. LVN B said she did not realize Resident #4 had not had this medication in that many days until she was called in and the DON talked to her about it. LVN B said there is no excuse in a medication being missed that many times. The DON met with LVN B after Resident #4 discharged to the hospital. LVN B said LVN D was working the day Resident #4 discharged to the hospital. LVN B said she just missed the [MEDICATION NAME] dosing when transcribing the medication. LVN B said she made a medication error. In an interview with LVN C on 08/29/2016 at 1:56 p.m. he stated he continued to circle the Lacosamide on the MAR indicated [REDACTED]. LVN C said he thought the next shift would follow up on it, but it never happened. LVN C stated most of the admissions come in on the 2 p.m. - 10 p.m. shift so he generally does not do them as he works the 6 a.m. - 2 p.m. shift. When asked about the [MEDICATION NAME] only being given once a day instead of twice he stated they get their own medications for their shift and don't look any further in the day because it was not his shift. In an interview with the physician, DR, on 08/30/2016 at 9:25 a.m. he stated LVN B verified the medications. DR stated if the Lacosamide had been missed once it would not be a big deal, but the medication being stopped did cause Resident #4's [MEDICAL CONDITION]. In an interview with LVN D on 08/30/2016 at 2:10 p.m. she said Resident #4 did not get his [MEDICAL CONDITION] medication and she was the one who found that it was not being given. LVN D said 3 days prior to Resident #4 seizing she realized the medication was not being provided and she left a note in the 24 hour report book; however, the note is missing. LVN D said she wondered if the medication was being provided by the family. When LVN D was asked about not giving the [MEDICATION NAME] twice a day, she stated the facility paperwork said once a day and she had a difficult time reading the order. LVN D said on 08/18/2016 when she realized the medication wasn't being given, she contacted Family #2 and she brought Resident #4's supply from home and gave Resident #4 a dose. LVN D said about 30 minutes after the medication was given Resident #4 began seizing and it looked like a grand mal [MEDICAL CONDITION]. LVN D said she was unsure how long the [MEDICAL CONDITION] lasted, but there was one big [MEDICAL CONDITION] and then Resident #4's hands began to tremor and continually having [MEDICAL CONDITION]. LVN D stated Resident #4's Family #2 requested he be sent to the ER. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 08/09/2016 through 08/18/2016. The facility took the following actions to correct the non-compliance on 08/22/2016. Record review of in-services the facility implemented were: Admission Audits dated 08/18/2016 for ADON A, ADON F, and MR; All admission/readmissions will be reviewed by ADON's assigned to patients' unit to include required assessments, admission orders [REDACTED]. Medical Records will input all admission/Readmission orders [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medications dated 08/19-22/2016 for all licensed nurses and CMAs; All medications that are not available in cart must be reported to the DON and charge nurse to obtain it ASAP. A circled medication on MAR indicated [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medication Cart Audit dated 08/22/2016 for ADON A and ADON F; Medication cart audits initiated on all carts for both units to verify disposition of all medications as order by physician are present and being administered. This in-service was completed by the DON and signed by all applicable staff members. A New Admission Checklist was created and implemented by the DON. The areas this checklist addressed was hospital discharge orders, admission orders [REDACTED]. In interviews with 7 staff members on 08/30/2016, 7 out of 7 staff were able to identify what to do if a medication is not available in the cart, what a circle initial in the MAR indicated [REDACTED]. Record review of the last day of in-services completed in the facility relating to the Past Noncompliant Immediate Jeopardy was 08/22/2016. Record review of the ORDERING AND REORDERING MEDICATIONS policy received 08/29/2016 at 12:30 p.m. by the DON entails the following: POLICY: To ensure that ordered medication is present in the facility and available to be given to each resident according to their physician orders [REDACTED]. To order new medications: [REDACTED] 1. After the physician order [REDACTED]. 3. If the new medication order is a controlled substance, then the physician or nurse practitioner must provide the new prescription to the pharmacy. On 08/30/2016 at 10:40 a.m. the DON was notified that an Immediate Jeopardy situation had been identified that existed from 08/09/2016 through 08/18/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 08/29/2016, 6 residents in the facility take [MEDICAL CONDITION] medications.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #4) reviewed for significant medication errors. The facility failed to administer [MEDICAL CONDITION] medications, Lacosamide 200 mg as ordered by the physician for 9.5 days or 19 doses, and administered [MEDICATION NAME] 1000 mg daily instead of twice a day as ordered. This resulted in Resident #4 experiencing multiple [MEDICAL CONDITION] and was sent to the hospital where he was discharged home with hospice services. These failures placed Resident #4 in an Immediate Jeopardy (IJ) from 08/09/2016 through 08/22/2016. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice has the potential to negatively affect 6 residents in the building who take [MEDICAL CONDITION] medications by having increased [MEDICAL CONDITION], loss of consciousness and death. Findings include: Record review of Resident #4 reflected a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] reflected Resident #4 having a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognitive deficits. Resident #4 had [MEDICAL CONDITION] that fluctuated and had psychotic behaviors 1-3 days of the 7 day look back period. Resident #4 required extensive assistance of 2 people for bed mobility and 1 person for transfers, ambulation with his wheelchair, hygiene and bathing. Resident #4 required total assistance of 1 person for eating as he has a peg tube. Resident #4 was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #4's Interim Care Plan dated 08/09/2016 reflected the resident was alert and required assistance of 1 person with his ADLs. Record review of the Provider Self Reporting of Incidents - Report Details dated 08/19/2016 was as follows: Resident admitted to facility on 08/08/2016 from hospital. Admission nurse failed to communicate that Lacosamide, [MEDICAL CONDITION] medication, was a controlled medication that needed approval from an agent of the physician. The pharmacy did not follow protocol by requesting agent information or calling the facility regarding the prescription and therefore the medication was not delivered. The nurse on duty on 08/18 called the resident's wife and was inquiring about the medication asking if she could bring it in. It was then found that the order was for BID and that he had missed 19 doses. Approximately less than 1 hour after discovery that the medication was missing, the resident began [MEDICAL CONDITION] activity. The facility immediately contacted the physician and received an order for [REDACTED]. Facility ADON called ER and was told by the nurse that the resident was alert and talking and not had any further [MEDICAL CONDITION] activity. Record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m., reflected no documentation of whether or not the attending physician verified orders to continue Lacosamide. Record review of Resident #4's Progress Note, dated 08/04/2016, from the hospital documenting his current medications and the days they were started was as follows: 06/29/2016 Lacosamide 200 mg PEG BID 08/01/2016 Valporic Acid ([MEDICATION NAME] - brand name [MEDICAL CONDITION] medication) 250 mg PO BID Record review of Resident #4's discharge orders from the hospital dated 08/05/2016 reflected a prescription for: Rx: Lacosamide 200 mg or tablet SIG: 1 tab PEG BID Rx: [MEDICATION NAME] 500 mg oral tablet SIG: 2 tab PEG BID Record review of Resident #4's admission orders [REDACTED] Lacosamide 200 mg per peg tube BID [MEDICATION NAME] 500 mg 2 tabs per peg tube BID Record review of Resident #4's Administration Record for the month of August 2016 reflected Lacosamide 200 mg to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the 19 doses since admission to the nursing facility on 08/08/2016. In an interview with LVN C on 08/29/2016 at 11:56 a.m., he stated if there is an initial that is circled on the MAR indicated [REDACTED]. The row for the 9 a.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN C's initials with them circled 08/10/2016 LVN C's initials with them circled 08/11/2016 LVN C's initials with them circled 08/12/2016 LVN D's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN E's initials with them circled 08/15/2016 LVN C's initials with them circled 08/16/2016 LVN C's initials with them circled 08/17/2016 LVN C's initials with them circled No documentation for the morning dose for 08/18/2016, this was LVN D's shift. The row for the 5 p.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN B's initials with them circled 08/10/2016 LVN D's initials with them circled 08/11/2016 LVN D's initials with them circled 08/12/2016 LVN B's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN B's initials with them circled 08/15/2016 LVN B's initials with them circled 08/16/2016 LVN D's initials with them circled No documentation for the evening dose for the 08/17/2016, this was LVN D's shift. Record review of Resident #4's Administration Record for the month of August reflected [MEDICATION NAME] 500 mg 2 tabs to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses on the 5 p.m. shift since admission. The 9th through the 16th there is only an arrow across the record indicating no medication given on the 5 p.m. shift and no documentation for the 5 p.m. shift on the 17th. Record review of the instruction of the Administration Record was to document on the back of the form the reason for a missed dose; however, there was no documentation. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Nursing Home to Hospital Transfer Form created by LVN D, dated 08/18/2016, reflected Resident #4 having [MEDICAL CONDITION]. Record review of the Nursing Note dated 08/18/2016 timed as 6-2 created by LVN D was as follows: During shift resident started having [MEDICAL CONDITION], this nurse called DR and he put in order for 1 mg [MEDICATION NAME] ([MEDICATION NAME]) PPT, this nurse administered MED, a short time after resident appeared to continue to have smaller [MEDICAL CONDITION], subsequently n.o. (new order) was put in for an additional dose [MEDICATION NAME] ([MEDICATION NAME]) 1mg to give IM, which was administered a short time later during reassessment resident appeared tired but continued to have twitching in both of his hands. Decision made to send resident out to ER to give report & spoke to a female nurse & informed her of situation, informed her about the medications resident was supposed to be taking & how much & when & how many doses he had taken & missed in the last 10 days prior. This nurse also informed her of all the PRN [MEDICATION NAME] that he'd been administered to combat current [MEDICAL CONDITION] activity. After giving her report she tells this nurse that we seem to have done everything we can possibly do for him at this time. This nurse then informs her that his wife was voicing wanting to send him out of the facility for treatment, she voiced understanding. Resident was then sent out to ER for treatment. In an interview with Family #1 on 08/29/2016 at 10:17 a.m., they stated Resident #4 had seized due to not getting his medications and his [MEDICAL CONDITION] lasted about 3 hours before they could get them under control. Family # 1 stated the resident had not had a [MEDICAL CONDITION] in about 2 months prior to this incident. Family #1 said Resident #4 was not returning to the facility; that when he discharged from the hospital and he went back home on hospice services. In an interview on 08/29/2016 at 11:00 a.m. with the DON she said Resident #4 came into the facility with orders for [MEDICATION NAME] and Lacosamide, no one realized the Lacosamide was a controlled substance. DON said when there is a medication that is controlled the pharmacy requires an Agent of Physician approval to get the medication filled; Agent of Physician is a person the physician appoints the authority in the nursing home to give verbal permission to fill a controlled medication. The DON stated the pharmacy did not follow through with the procedure to get the Lacosamide approved. The DON said LVN B made a transcription error for the [MEDICATION NAME] and it was supposed to be given twice a day and was only given once a day. The DON said the Lacosamide was not given at all. The DON stated when the error was noticed by LVN D she called Resident #4's Family #2 and she brought in the medication on 08/18/2016 in the morning before the resident began seizing. The DON said it wasn't an hour after the medication error was acknowledged that Resident #4 began seizing. The DON said there was an order received and 1 mg of [MEDICATION NAME] was given via peg tube immediately. The DON then stated Resident #4 was still seizing about 10 minutes after receiving the first dose of [MEDICATION NAME] and then LVN D got another order for [MEDICATION NAME] 1 mg IM. The DON said at this point Resident #4's Family #2 wanted him sent to the emergency room and she chose to take the resident home on hospice services instead of returning him to the facility. The DON added that the error with the [MEDICATION NAME] and Lacosamide was found on the 18th of August. In an interview on 08/29/2016 at 11:50 a.m. with ADON A she stated the physician was supposed to be contacted upon admission to continue Lacosamide, but was not based off of the record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m. When asked if the orders were verified ADON A stated LVN B did not mark the box on the admission paperwork indicating she verified the orders with the physician. ADON A stated there is usually a copy of the discharge orders from the hospital with all of the medications Resident #4 should be taking with the admission orders [REDACTED]. ADON A said the resident came to the facility via personal vehicle and the wife had a stack of printed off medication orders. ADON A said the wife gave us those prescriptions and this is how we found out later while going through the chart Resident #4 was supposed to be on Lacosamide. ADON A said it is the ADONs responsibility to follow up after an admission comes in to ensure the medication reconciliation is correct. ADON A said she was on vacation when Resident #4 admitted to the facility. In an interview on 08/29/2016 at 1:08 p.m. with the Pharmacy Director, PHARM, he stated the process for filling medications from the nursing home is when a nurse sends in an order for [REDACTED]. PHARM said the pharmacy company never got the order, but no one from the nursing facility followed up. PHARM stated Resident #4 did not get his medications for a 9 day period. In an interview with LVN B on 08/29/2016 at 1:20 p.m. she stated she did Resident #4's admission on the 8th of August shortly before dinner. LVN B said she was not given any notice that the facility was going to get an admission; the family came to LVN B and told her Resident #4 was there to be admitted . LVN B said her main priority was getting the medications approved through the pharmacy so they would be there the next morning. LVN B said Resident #4's wife brought her the discharge packet from the hospital while she was in the middle of med pass. LVN B said she finished her med pass and went over the medications and paperwork for Resident #4. LVN B said she contacted the physician and went through the paperwork with him, while doing this she found prescriptions in the packets and they matched up with the majority of his medications from the hospital so she verified Resident #4's medications. LVN B said she did not notice Resident #4 had not received the [MEDICAL CONDITION] medication in as many days that he did not get it. LVN B stated ADON A typically goes over all medications, but she wasn't here that week. LVN B said on the third day she noticed she did not give the Lacosamide to Resident #4 and she checked the emergency medication kit, but the medication was not in there so she contacted the pharmacy to let them know Resident #4 never received his Lacosamide. LVN B said the Lacosamide was not on the Admission/discharge paperwork from the hospital, but it was on all of the other documentation, LVN B said she did verify. LVN B said Resident #4 did not get the Lacosamide for 9.5 days, 19 doses due to it being prescribed twice a day. LVN B said she did not realize Resident #4 had not had this medication in that many days until she was called in and the DON talked to her about it. LVN B said there is no excuse in a medication being missed that many times. The DON met with LVN B after Resident #4 discharged to the hospital. LVN B said LVN D was working the day Resident #4 discharged to the hospital. LVN B said she just missed the [MEDICATION NAME] dosing when transcribing the medication. LVN B said she made a medication error. In an interview with LVN C on 08/29/2016 at 1:56 p.m. he stated he continued to circle the Lacosamide on the MAR indicated [REDACTED]. LVN C said he thought the next shift would follow up on it, but it never happened. LVN C stated most of the admissions come in on the 2 p.m. - 10 p.m. shift so he generally does not do them as he works the 6 a.m. - 2 p.m. shift. When asked about the [MEDICATION NAME] only being given once a day instead of twice he stated they get their own medications for their shift and don't look any further in the day because it was not his shift. In an interview with the physician, DR, on 08/30/2016 at 9:25 a.m. he stated LVN B verified the medications. DR stated if the Lacosamide had been missed once it would not be a big deal, but the medication being stopped did cause Resident #4's [MEDICAL CONDITION]. In an interview with LVN D on 08/30/2016 at 2:10 p.m. she said Resident #4 did not get his [MEDICAL CONDITION] medication and she was the one who found that it was not being given. LVN D said 3 days prior to Resident #4 seizing she realized the medication was not being provided and she left a note in the 24 hour report book; however, the note is missing. LVN D said she wondered if the medication was being provided by the family. When LVN D was asked about not giving the [MEDICATION NAME] twice a day, she stated the facility paperwork said once a day and she had a difficult time reading the order. LVN D said on 08/18/2016 when she realized the medication wasn't being given, she contacted Family #2 and she brought Resident #4's supply from home and gave Resident #4 a dose. LVN D said about 30 minutes after the medication was given Resident #4 began seizing and it looked like a grand mal [MEDICAL CONDITION]. LVN D said she was unsure how long the [MEDICAL CONDITION] lasted, but there was one big [MEDICAL CONDITION] and then Resident #4's hands began to tremor and continually having [MEDICAL CONDITION]. LVN D stated Resident #4's Family #2 requested he be sent to the ER. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 08/09/2016 through 08/18/2016. The facility took the following actions to correct the non-compliance on 08/22/2016. Record review of in-services the facility implemented were: Admission Audits dated 08/18/2016 for ADON A, ADON F, and MR; All admission/readmissions will be reviewed by ADON's assigned to patients' unit to include required assessments, admission orders [REDACTED]. Medical Records will input all admission/Readmission orders [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medications dated 08/19-22/2016 for all licensed nurses and CMAs; All medications that are not available in cart must be reported to the DON and charge nurse to obtain it ASAP. A circled medication on MAR indicated [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medication Cart Audit dated 08/22/2016 for ADON A and ADON F; Medication cart audits initiated on all carts for both units to verify disposition of all medications as order by physician are present and being administered. This in-service was completed by the DON and signed by all applicable staff members. A New Admission Checklist was created and implemented by the DON. The areas this checklist addressed was hospital discharge orders, admission orders [REDACTED]. In interviews with 7 staff members on 08/30/2016, 7 out of 7 staff were able to identify what to do if a medication is not available in the cart, what a circle initial in the MAR indicated [REDACTED]. Record review of the last day of in-services completed in the facility relating to the Past Noncompliant Immediate Jeopardy was 08/22/2016. Record review of the ORDERING AND REORDERING MEDICATIONS policy received 08/29/2016 at 12:30 p.m. by the DON entails the following: POLICY: To ensure that ordered medication is present in the facility and available to be given to each resident according to their physician orders [REDACTED]. To order new medications: [REDACTED] 1. After the physician order [REDACTED]. 3. If the new medication order is a controlled substance, then the physician or nurse practitioner must provide the new prescription to the pharmacy. On 08/30/2016 at 10:40 a.m. the DON was notified that an Immediate Jeopardy situation had been identified that existed from 08/09/2016 through 08/18/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 08/29/2016, 6 residents in the facility take [MEDICAL CONDITION] medications.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 7 residents (Resident #4) reviewed for pharmacy services. The facility failed to administer seizure medicaitons, Lacosamide 200 mg as ordered by the physician for 9.5 days or 19 doses, and aministered Keppra 1000 mg daily instead of twice a day as ordered. This resulted in Resident #4 experiencing multiple seizures and was sent to the hospital where he was discharged home with hospice services. These failures placed Resident #4 in an Immediate Jeopardy (IJ) from 08/09/2016 through 08/22/2016. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice has the potential to negatively affect 6 residents in the building who take seizure medications by having increased seizures, loss of consciousness and death. Findings include: Record review of Resident #4 reflected a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] reflected Resident #4 having a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognitive deficits. Resident #4 had delirium that fluctuated and had psychotic behaviors 1-3 days of the 7 day look back period. Resident #4 required extensive assistance of 2 people for bed mobility and 1 person for transfers, ambulation with his wheelchair, hygiene and bathing. Resident #4 required total assistance of 1 person for eating as he has a peg tube. Resident #4 was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #4's Interim Care Plan dated 08/09/2016 reflected the resident was alert and required assistance of 1 person with his ADLs. Record review of the Provider Self Reporting of Incidents - Report Details dated 08/19/2016 was as follows: Resident admitted to facility on 08/08/2016 from hospital. Admission nurse failed to communicate that Lacosamide, seizure medication, was a controlled medication that needed approval from an agent of the physician. The pharmacy did not follow protocol by requesting agent information or calling the facility regarding the prescription and therefore the medication was not delivered. The nurse on duty on 08/18 called the resident's wife and was inquiring about the medication asking if she could bring it in. It was then found that the order was for BID and that he had missed 19 doses. Approximately less than 1 hour after discovery that the medication was missing, the resident began seizure activity. The facility immediately contacted the physician and received an order for [REDACTED]. Facility ADON called ER and was told by the nurse that the resident was alert and talking and not had any further seizure activity. Record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m., reflected no documentation of whether or not the attending physician verified orders to continue Lacosamide. Record review of Resident #4's Progress Note, dated 08/04/2016, from the hospital documenting his current medications and the days they were started was as follows: 06/29/2016 Lacosamide 200 mg PEG BID 08/01/2016 Valporic Acid (Depakote - brand name seizure medication) 250 mg PO BID Record review of Resident #4's discharge orders from the hospital dated 08/05/2016 reflected a prescription for: Rx: Lacosamide 200 mg or tablet SIG: 1 tab PEG BID Rx: Keppra 500 mg oral tablet SIG: 2 tab PEG BID Record review of Resident #4's admission orders [REDACTED] Lacosamide 200 mg per peg tube BID Keppra 500 mg 2 tabs per peg tube BID Record review of Resident #4's Administration Record for the month of August 2016 reflected Lacosamide 200 mg to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the 19 doses since admission to the nursing facility on 08/08/2016. In an interview with LVN C on 08/29/2016 at 11:56 a.m., he stated if there is an initial that is circled on the MAR indicated [REDACTED]. The row for the 9 a.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN C's initials with them circled 08/10/2016 LVN C's initials with them circled 08/11/2016 LVN C's initials with them circled 08/12/2016 LVN D's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN E's initials with them circled 08/15/2016 LVN C's initials with them circled 08/16/2016 LVN C's initials with them circled 08/17/2016 LVN C's initials with them circled No documentation for the morning dose for 08/18/2016, this was LVN D's shift. The row for the 5 p.m. dose of Lacosamide is listed as follows: 08/09/2016 LVN B's initials with them circled 08/10/2016 LVN D's initials with them circled 08/11/2016 LVN D's initials with them circled 08/12/2016 LVN B's initials with them circled 08/13/2016 LVN E's initials with them circled 08/14/2016 LVN B's initials with them circled 08/15/2016 LVN B's initials with them circled 08/16/2016 LVN D's initials with them circled No documentation for the evening dose for the 08/17/2016, this was LVN D's shift. Record review of Resident #4's Administration Record for the month of August reflected Keppra 500 mg 2 tabs to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses on the 5 p.m. shift since admission. The 9th through the 16th there is only an arrow across the record indicating no medication given on the 5 p.m. shift and no documentation for the 5 p.m. shift on the 17th. Record review of the instruction of the Administration Record was to document on the back of the form the reason for a missed dose; however, there was no documentation. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Nursing Home to Hospital Transfer Form created by LVN D, dated 08/18/2016, reflected Resident #4 having seizures. Record review of the Nursing Note dated 08/18/2016 timed as 6-2 created by LVN D was as follows: During shift resident started having seizures, this nurse called DR and he put in order for 1 mg Lorazepam (Ativan) PPT, this nurse administered MED, a short time after resident appeared to continue to have smaller seizures, subsequently n.o. (new order) was put in for an additional dose Lorazepam (Ativan) 1mg to give IM, which was administered a short time later during reassessment resident appeared tired but continued to have twitching in both of his hands. Decision made to send resident out to ER to give report & spoke to a female nurse & informed her of situation, informed her about the medications resident was supposed to be taking & how much & when & how many doses he had taken & missed in the last 10 days prior. This nurse also informed her of all the PRN Lorazepam that he'd been administered to combat current seizure activity. After giving her report she tells this nurse that we seem to have done everything we can possibly do for him at this time. This nurse then informs her that his wife was voicing wanting to send him out of the facility for treatment, she voiced understanding. Resident was then sent out to ER for treatment. In an interview with Family #1 on 08/29/2016 at 10:17 a.m., they stated Resident #4 had seized due to not getting his medications and his seizure lasted about 3 hours before they could get them under control. Family # 1 stated the resident had not had a seizure in about 2 months prior to this incident. Family #1 said Resident #4 was not returning to the facility; that when he discharged from the hospital and he went back home on hospice services. In an interview on 08/29/2016 at 11:00 a.m. with the DON she said Resident #4 came into the facility with orders for Keppra and Lacosamide, no one realized the Lacosamide was a controlled substance. DON said when there is a medication that is controlled the pharmacy requires an Agent of Physician approval to get the medication filled; Agent of Physician is a person the physician appoints the authority in the nursing home to give verbal permission to fill a controlled medication. The DON stated the pharmacy did not follow through with the procedure to get the Lacosamide approved. The DON said LVN B made a transcription error for the Keppra and it was supposed to be given twice a day and was only given once a day. The DON said the Lacosamide was not given at all. The DON stated when the error was noticed by LVN D she called Resident #4's Family #2 and she brought in the medication on 08/18/2016 in the morning before the resident began seizing. The DON said it wasn't an hour after the medication error was acknowledged that Resident #4 began seizing. The DON said there was an order received and 1 mg of Ativan was given via peg tube immediately. The DON then stated Resident #4 was still seizing about 10 minutes after receiving the first dose of Ativan and then LVN D got another order for Ativan 1 mg IM. The DON said at this point Resident #4's Family #2 wanted him sent to the emergency room and she chose to take the resident home on hospice services instead of returning him to the facility. The DON added that the error with the Keppra and Lacosamide was found on the 18th of August. In an interview on 08/29/2016 at 11:50 a.m. with ADON A she stated the physician was supposed to be contacted upon admission to continue Lacosamide, but was not based off of the record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m. When asked if the orders were verified ADON A stated LVN B did not mark the box on the admission paperwork indicating she verified the orders with the physician. ADON A stated there is usually a copy of the discharge orders from the hospital with all of the medications Resident #4 should be taking with the admission orders [REDACTED]. ADON A said the resident came to the facility via personal vehicle and the wife had a stack of printed off medication orders. ADON A said the wife gave us those prescriptions and this is how we found out later while going through the chart Resident #4 was supposed to be on Lacosamide. ADON A said it is the ADONs responsibility to follow up after an admission comes in to ensure the medication reconciliation is correct. ADON A said she was on vacation when Resident #4 admitted to the facility. In an interview on 08/29/2016 at 1:08 p.m. with the Pharmacy Director, PHARM, he stated the process for filling medications from the nursing home is when a nurse sends in an order for [REDACTED]. PHARM said the pharmacy company never got the order, but no one from the nursing facility followed up. PHARM stated Resident #4 did not get his medications for a 9 day period. In an interview with LVN B on 08/29/2016 at 1:20 p.m. she stated she did Resident #4's admission on the 8th of August shortly before dinner. LVN B said she was not given any notice that the facility was going to get an admission; the family came to LVN B and told her Resident #4 was there to be admitted . LVN B said her main priority was getting the medications approved through the pharmacy so they would be there the next morning. LVN B said Resident #4's wife brought her the discharge packet from the hospital while she was in the middle of med pass. LVN B said she finished her med pass and went over the medications and paperwork for Resident #4. LVN B said she contacted the physician and went through the paperwork with him, while doing this she found prescriptions in the packets and they matched up with the majority of his medications from the hospital so she verified Resident #4's medications. LVN B said she did not notice Resident #4 had not received the seizure medication in as many days that he did not get it. LVN B stated ADON A typically goes over all medications, but she wasn't here that week. LVN B said on the third day she noticed she did not give the Lacosamide to Resident #4 and she checked the emergency medication kit, but the medication was not in there so she contacted the pharmacy to let them know Resident #4 never received his Lacosamide. LVN B said the Lacosamide was not on the Admission/discharge paperwork from the hospital, but it was on all of the other documentation, LVN B said she did verify. LVN B said Resident #4 did not get the Lacosamide for 9.5 days, 19 doses due to it being prescribed twice a day. LVN B said she did not realize Resident #4 had not had this medication in that many days until she was called in and the DON talked to her about it. LVN B said there is no excuse in a medication being missed that many times. The DON met with LVN B after Resident #4 discharged to the hospital. LVN B said LVN D was working the day Resident #4 discharged to the hospital. LVN B said she just missed the Keppra dosing when transcribing the medication. LVN B said she made a medication error. In an interview with LVN C on 08/29/2016 at 1:56 p.m. he stated he continued to circle the Lacosamide on the MAR indicated [REDACTED]. LVN C said he thought the next shift would follow up on it, but it never happened. LVN C stated most of the admissions come in on the 2 p.m. - 10 p.m. shift so he generally does not do them as he works the 6 a.m. - 2 p.m. shift. When asked about the Keppra only being given once a day instead of twice he stated they get their own medications for their shift and don't look any further in the day because it was not his shift. In an interview with the physician, DR, on 08/30/2016 at 9:25 a.m. he stated LVN B verified the medications. DR stated if the Lacosamide had been missed once it would not be a big deal, but the medication being stopped did cause Resident #4's seizures. In an interview with LVN D on 08/30/2016 at 2:10 p.m. she said Resident #4 did not get his seizure medication and she was the one who found that it was not being given. LVN D said 3 days prior to Resident #4 seizing she realized the medication was not being provided and she left a note in the 24 hour report book; however, the note is missing. LVN D said she wondered if the medication was being provided by the family. When LVN D was asked about not giving the Keppra twice a day, she stated the facility paperwork said once a day and she had a difficult time reading the order. LVN D said on 08/18/2016 when she realized the medication wasn't being given, she contacted Family #2 and she brought Resident #4's supply from home and gave Resident #4 a dose. LVN D said about 30 minutes after the medication was given Resident #4 began seizing and it looked like a grand mal seizure. LVN D said she was unsure how long the seizure lasted, but there was one big seizure and then Resident #4's hands began to tremor and continually having seizures. LVN D stated Resident #4's Family #2 requested he be sent to the ER. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 08/09/2016 through 08/18/2016. The facility took the following actions to correct the non-compliance on 08/22/2016. Record review of in-services the facility implemented were: Admission Audits dated 08/18/2016 for ADON A, ADON F, and MR; All admission/readmissions will be reviewed by ADON's assigned to patients' unit to include required assessments, admission orders [REDACTED]. Medical Records will input all admission/Readmission orders [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medications dated 08/19-22/2016 for all licensed nurses and CMAs; All medications that are not available in cart must be reported to the DON and charge nurse to obtain it ASAP. A circled medication on MAR indicated [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medication Cart Audit dated 08/22/2016 for ADON A and ADON F; Medication cart audits initiated on all carts for both units to verify disposition of all medications as order by physician are present and being administered. This in-service was completed by the DON and signed by all applicable staff members. A New Admission Checklist was created and implemented by the DON. The areas this checklist addressed was hospital discharge orders, admission orders [REDACTED]. In interviews with 7 staff members on 08/30/2016, 7 out of 7 staff were able to identify what to do if a medication is not available in the cart, what a circle initial in the MAR indicated [REDACTED]. Record review of the last day of in-services completed in the facility relating to the Past Noncompliant Immediate Jeopardy was 08/22/2016. Record review of the ORDERING AND REORDERING MEDICATIONS policy received 08/29/2016 at 12:30 p.m. by the DON entails the following: POLICY: To ensure that ordered medication is present in the facility and available to be given to each resident according to their physician orders [REDACTED]. To order new medications: [REDACTED] 1. After the physician order [REDACTED]. 3. If the new medication order is a controlled substance, then the physician or nurse practitioner must provide the new prescription to the pharmacy. On 08/30/2016 at 10:40 a.m. the DON was notified that an Immediate Jeopardy situation had been identified that existed from 08/09/2016 through 08/18/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 08/29/2016, 6 residents in the facility take seizure medications.

Based on interview and record review, the administrator and DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively specifically in the area of pharmacy services reviewed for administrative services. 1. The administrator failed to supervise the DON to ensure she was training the staff on the facility's policies that specified the procedures for ordering controlled medications and ensuring all of the medications were administered accurately to the residents, failed to ensure the policies and procedures to ensure controlled medications were ordered and received in an efficient and timely manner and ensure all of the medications were administered accurately to the residents were implemented, failed to supervise the staff when ordering controlled medications and ensuring the medications were delivered by the pharmacy, and failed to identify the medication errors for Resident #4. 2. The DON failed to ensure she was training the staff on the facility's policies that specified the procedures for ordering controlled medications and ensuring all of the medications were administered accurately to the residents, failed to ensure the policies and procedures to ensure controlled medications were ordered and received in an efficient and timely manner and ensure all of the medications were administered accurately to the residents were implemented, failed to supervise the staff when ordering controlled medications and ensuring the medications were delivered by the pharmacy, and failed to identify the medication errors for Resident #4. Findings include: Record review of Resident #4 reflected a [AGE] year old male who admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #4's admission MDS assessment dated [DATE] reflected Resident #4 having a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognitive deficits. Resident #4 had [MEDICAL CONDITION] that fluctuated and had psychotic behaviors 1-3 days of the 7 day look back period. Resident #4 required extensive assistance of 2 people for bed mobility and 1 person for transfers, ambulation with his wheelchair, hygiene and bathing. Resident #4 required total assistance of 1 person for eating as he has a peg tube. Resident #4 was frequently incontinent of bowel and always incontinent of bladder. Record review of Resident #4's Interim Care Plan dated 08/09/2016 reflected the resident was alert and required assistance of 1 person with his ADLs. Record review of the Provider Self Reporting of Incidents - Report Details dated 08/19/2016 was as follows: Resident admitted to facility on 08/08/2016 from hospital. Admission nurse failed to communicate that Lacosamide, [MEDICAL CONDITION] medication, was a controlled medication that needed approval from an agent of the physician. The pharmacy did not follow protocol by requesting agent information or calling the facility regarding the prescription and therefore the medication was not delivered. The nurse on duty on 08/18 called the resident's wife and was inquiring about the medication asking if she could bring it in. It was then found that the order was for BID and that he had missed 19 doses. Approximately less than 1 hour after discovery that the medication was missing, the resident began [MEDICAL CONDITION] activity. The facility immediately contacted the physician and received an order for [REDACTED]. Facility ADON called ER and was told by the nurse that the resident was alert and talking and not had any further [MEDICAL CONDITION] activity. Record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m., reflected no documentation of whether or not the attending physician verified orders to continue Lacosamide. Record review of Resident #4's Progress Note, dated 08/04/2016, from the hospital documenting his current medications and the days they were started was as follows: 06/29/2016 Lacosamide 200 mg PEG BID 08/01/2016 Valporic Acid ([MEDICATION NAME] - brand name [MEDICAL CONDITION] medication) 250 mg PO BID Record review of Resident #4's discharge orders from the hospital dated 08/05/2016 reflected a prescription for: Rx: Lacosamide 200 mg or tablet SIG: 1 tab PEG BID Rx: [MEDICATION NAME] 500 mg oral tablet SIG: 2 tab PEG BID Record review of Resident #4's admission orders [REDACTED] Lacosamide 200 mg per peg tube BID [MEDICATION NAME] 500 mg 2 tabs per peg tube BID Record review of Resident #4's Administration Record for the month of August 2016 reflected Lacosamide 200 mg to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the 19 doses since admission to the nursing facility on 08/08/2016. In an interview with LVN C on 08/29/2016 at 11:56 a.m., he stated if there is an initial that is circled on the MAR indicated [REDACTED]. The row for the 9 a.m. dose of Lacosamide was missed 10 times. The row for the 5 p.m. dose of Lacosamide was missed 9 times. Record review of Resident #4's Administration Record for the month of August reflected [MEDICATION NAME] 500 mg 2 tabs to be given twice a day per peg tube; a dose at 9 a.m. and a 5 p.m. dose. Documentation of the Administration Record reflected Resident #4 never received any of the doses on the 5 p.m. shift since admission. The 9th through the 16th there is only an arrow across the record indicating no medication given on the 5 p.m. shift and no documentation for the 5 p.m. shift on the 17th. Record review of the instruction of the Administration Record was to document on the back of the form the reason for a missed dose; however, there was no documentation. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Nursing Home to Hospital Transfer Form created by LVN D, dated 08/18/2016, reflected Resident #4 having [MEDICAL CONDITION]. Record review of the Nursing Note dated 08/18/2016 timed as 6-2 created by LVN D was as follows: During shift resident started having [MEDICAL CONDITION], this nurse called DR and he put in order for 1 mg [MEDICATION NAME] ([MEDICATION NAME]) PPT, this nurse administered MED, a short time after resident appeared to continue to have smaller [MEDICAL CONDITION], subsequently n.o. (new order) was put in for an additional dose [MEDICATION NAME] ([MEDICATION NAME]) 1mg to give IM, which was administered a short time later during reassessment resident appeared tired but continued to have twitching in both of his hands. Decision made to send resident out to ER to give report & spoke to a female nurse & informed her of situation, informed her about the medications resident was supposed to be taking & how much & when & how many doses he had taken & missed in the last 10 days prior. This nurse also informed her of all the PRN [MEDICATION NAME] that he'd been administered to combat current [MEDICAL CONDITION] activity. After giving her report she tells this nurse that we seem to have done everything we can possibly do for him at this time. This nurse then informs her that his wife was voicing wanting to send him out of the facility for treatment, she voiced understanding. Resident was then sent out to ER for treatment. In an interview with Family #1 on 08/29/2016 at 10:17 a.m., they stated Resident #4 had seized due to not getting his medications and his [MEDICAL CONDITION] lasted about 3 hours before they could get them under control. Family # 1 stated the resident had not had a [MEDICAL CONDITION] in about 2 months prior to this incident. Family #1 said Resident #4 was not returning to the facility; that when he discharged from the hospital and he went back home on hospice services. In an interview on 08/29/2016 at 11:00 a.m. with the DON she said Resident #4 came into the facility with orders for [MEDICATION NAME] and Lacosamide, no one realized the Lacosamide was a controlled substance. DON said when there is a medication that is controlled the pharmacy requires an Agent of Physician approval to get the medication filled; Agent of Physician is a person the physician appoints the authority in the nursing home to give verbal permission to fill a controlled medication. The DON stated the pharmacy did not follow through with the procedure to get the Lacosamide approved. The DON said LVN B made a transcription error for the [MEDICATION NAME] and it was supposed to be given twice a day and was only given once a day. The DON said the Lacosamide was not given at all. The DON stated when the error was noticed by LVN D she called Resident #4's Family #2 and she brought in the medication on 08/18/2016 in the morning before the resident began seizing. The DON said it wasn't an hour after the medication error was acknowledged that Resident #4 began seizing. The DON said there was an order received and 1 mg of [MEDICATION NAME] was given via peg tube immediately. The DON then stated Resident #4 was still seizing about 10 minutes after receiving the first dose of [MEDICATION NAME] and then LVN D got another order for [MEDICATION NAME] 1 mg IM. The DON said at this point Resident #4's Family #2 wanted him sent to the emergency room and she chose to take the resident home on hospice services instead of returning him to the facility. The DON added that the error with the [MEDICATION NAME] and Lacosamide was found on the 18th of August. In an interview on 08/29/2016 at 11:50 a.m. with ADON A she stated the physician was supposed to be contacted upon admission to continue Lacosamide, but was not based off of the record review of the Admission/Readmission Data Collection summary, dated 08/08/2016 at 4:30 p.m. When asked if the orders were verified ADON A stated LVN B did not mark the box on the admission paperwork indicating she verified the orders with the physician. ADON A stated there is usually a copy of the discharge orders from the hospital with all of the medications Resident #4 should be taking with the admission orders [REDACTED]. ADON A said the resident came to the facility via personal vehicle and the wife had a stack of printed off medication orders. ADON A said the wife gave us those prescriptions and this is how we found out later while going through the chart Resident #4 was supposed to be on Lacosamide. ADON A said it is the ADONs responsibility to follow up after an admission comes in to ensure the medication reconciliation is correct. ADON A said she was on vacation when Resident #4 admitted to the facility. In an interview on 08/29/2016 at 1:08 p.m. with the Pharmacy Director, PHARM, he stated the process for filling medications from the nursing home is when a nurse sends in an order for [REDACTED]. PHARM said the pharmacy company never got the order, but no one from the nursing facility followed up. PHARM stated Resident #4 did not get his medications for a 9 day period. In an interview with LVN B on 08/29/2016 at 1:20 p.m. she stated she did Resident #4's admission on the 8th of August shortly before dinner. LVN B said she was not given any notice that the facility was going to get an admission; the family came to LVN B and told her Resident #4 was there to be admitted . LVN B said her main priority was getting the medications approved through the pharmacy so they would be there the next morning. LVN B said Resident #4's wife brought her the discharge packet from the hospital while she was in the middle of med pass. LVN B said she finished her med pass and went over the medications and paperwork for Resident #4. LVN B said she contacted the physician and went through the paperwork with him, while doing this she found prescriptions in the packets and they matched up with the majority of his medications from the hospital so she verified Resident #4's medications. LVN B said she did not notice Resident #4 had not received the [MEDICAL CONDITION] medication in as many days that he did not get it. LVN B stated ADON A typically goes over all medications, but she wasn't here that week. LVN B said on the third day she noticed she did not give the Lacosamide to Resident #4 and she checked the emergency medication kit, but the medication was not in there so she contacted the pharmacy to let them know Resident #4 never received his Lacosamide. LVN B said the Lacosamide was not on the Admission/discharge paperwork from the hospital, but it was on all of the other documentation, LVN B said she did verify. LVN B said Resident #4 did not get the Lacosamide for 9.5 days, 19 doses due to it being prescribed twice a day. LVN B said she did not realize Resident #4 had not had this medication in that many days until she was called in and the DON talked to her about it. LVN B said there is no excuse in a medication being missed that many times. The DON met with LVN B after Resident #4 discharged to the hospital. LVN B said LVN D was working the day Resident #4 discharged to the hospital. LVN B said she just missed the [MEDICATION NAME] dosing when transcribing the medication. LVN B said she made a medication error. In an interview with LVN C on 08/29/2016 at 1:56 p.m. he stated he continued to circle the Lacosamide on the MAR indicated [REDACTED]. LVN C said he thought the next shift would follow up on it, but it never happened. LVN C stated most of the admissions come in on the 2 p.m. - 10 p.m. shift so he generally does not do them as he works the 6 a.m. - 2 p.m. shift. When asked about the [MEDICATION NAME] only being given once a day instead of twice he stated they get their own medications for their shift and don't look any further in the day because it was not his shift. In an interview with the physician, DR, on 08/30/2016 at 9:25 a.m. he stated LVN B verified the medications. DR stated if the Lacosamide had been missed once it would not be a big deal, but the medication being stopped did cause Resident #4's [MEDICAL CONDITION]. In an interview with LVN D on 08/30/2016 at 2:10 p.m. she said Resident #4 did not get his [MEDICAL CONDITION] medication and she was the one who found that it was not being given. LVN D said 3 days prior to Resident #4 seizing she realized the medication was not being provided and she left a note in the 24 hour report book; however, the note is missing. LVN D said she wondered if the medication was being provided by the family. When LVN D was asked about not giving the [MEDICATION NAME] twice a day, she stated the facility paperwork said once a day and she had a difficult time reading the order. LVN D said on 08/18/2016 when she realized the medication wasn't being given, she contacted Family #2 and she brought Resident #4's supply from home and gave Resident #4 a dose. LVN D said about 30 minutes after the medication was given Resident #4 began seizing and it looked like a grand mal [MEDICAL CONDITION]. LVN D said she was unsure how long the [MEDICAL CONDITION] lasted, but there was one big [MEDICAL CONDITION] and then Resident #4's hands began to tremor and continually having [MEDICAL CONDITION]. LVN D stated Resident #4's Family #2 requested he be sent to the ER. It was determined these failures placed Resident #4 in an Immediate Jeopardy (IJ) situation from 08/09/2016 through 08/18/2016. The facility took the following actions to correct the non-compliance on 08/22/2016. Record review of in-services the facility implemented were: Admission Audits dated 08/18/2016 for ADON A, ADON F, and MR; All admission/readmissions will be reviewed by ADON's assigned to patients' unit to include required assessments, admission orders [REDACTED]. Medical Records will input all admission/Readmission orders [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medications dated 08/19-22/2016 for all licensed nurses and CMAs; All medications that are not available in cart must be reported to the DON and charge nurse to obtain it ASAP. A circled medication on MAR indicated [REDACTED]. This in-service was completed by the DON and signed by all applicable staff members. Medication Cart Audit dated 08/22/2016 for ADON A and ADON F; Medication cart audits initiated on all carts for both units to verify disposition of all medications as order by physician are present and being administered. This in-service was completed by the DON and signed by all applicable staff members. A New Admission Checklist was created and implemented by the DON. The areas this checklist addressed was hospital discharge orders, admission orders [REDACTED]. In interviews with 7 staff members on 08/30/2016, 7 out of 7 staff were able to identify what to do if a medication is not available in the cart, what a circle initial in the MAR indicated [REDACTED]. Record review of the last day of in-services completed in the facility relating to the Past Noncompliant Immediate Jeopardy was 08/22/2016. Record review of the ORDERING AND REORDERING MEDICATIONS policy received 08/29/2016 at 12:30 p.m. by the DON entails the following: POLICY: To ensure that ordered medication is present in the facility and available to be given to each resident according to their physician orders [REDACTED]. To order new medications: [REDACTED] 1. After the physician order [REDACTED]. 3. If the new medication order is a controlled substance, then the physician or nurse practitioner must provide the new prescription to the pharmacy. On 08/30/2016 at 10:40 a.m. the DON was notified that an Immediate Jeopardy situation had been identified that existed from 08/09/2016 through 08/18/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 08/29/2016, 6 residents in the facility take [MEDICAL CONDITION] medications.