Every finding on record at Premier Living and Rehab Center

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to failure to submit data for the quarter, which resulted in an indication of excessively low weekend staffing, no Registered Nurse (RN) hours, and failed to have licensed coverage 24 hours/day for Federal Fiscal Year (FY) 2025 Quarter 4 (July 1, 2025, through September 30, 2025)and Federal Fiscal Year 2026 Quarter 1 (October 1, 2025, through December 31, 2025). This was for 2 of 3 quarters reviewed for sufficient staffing.The findings included:The PBJ report for FY 2025 revealed for Quarter 4 (July 1, 2025, through September 30, 2025) there was no data submitted for the Quarter. The failure to submit data triggered the facility for one star staffing rating; excessively low weekend staffing; no RN hours; and failed to have licensed nursing coverage 24/hours a day.The PBJ report for FY 2026 revealed for Quarter 1 (October 1, 2026, through December 31, 2026) there was no data submitted for the Quarter. The failure to submit data triggered the facility for one star staffing rating; excessively low weekend staffing; no RN hours; and failed to have licensed nursing coverage 24/hours a day.An interview was conducted with the Unit Manager/Scheduler on 8/26/26 1:20 PM in the presence of the Administrator and the Chief Operating Officer (CEO). The Unit Manager stated she had a notebook that the previous administration had left her that contained information regarding the data submitted to Centers for Medicare and Medicaid Services (CMS). The documents from CMS, dated 10/28/25, 11/3/25, and 12/9/25, revealed a file was received from the facility. There was no confirmation from CMS the data was accurate or able to be opened by CMS. An interview was conducted with the Administrator in the presence of the Chief Operating Officer (CEO) on 8/26/26 at 1:25 PM. The Administrator stated that she had started working at the facility in June 2026. She stated she could not say why the staffing data for Quarter 1 and Quarter 4 were not submitted prior to her working there. The Administrator indicated that the payroll data had been submitted on time since she became the administrator and the facility had not been triggered for Quarter 2 of 2026 in areas for staffing concerns.An interview was completed with Chief Operating Officer (CEO) on 8/26/26 at 1:30 PM. The CEO stated his company had started managing the facility in January 2026. He stated he could not say why the staffing data for Quarter 4 2025 and Quarter 1 2026 were not submitted. The CEO indicated that the staffing data had been submitted on time since they took over, and they had not triggered any areas for concern regarding staffing in Quarter 2 on the PBJ for 2026.

Based on record review and staff interviews, the facility failed to 1) implement an effective water management program to minimize the risk of Legionella, a bacterium that grows in warm water (77-113 F) and can multiply in building water systems. The facility failed to conduct a documented risk assessment and did not maintain a flow diagram of the facility's water systems to identify and evaluate areas at risk of Legionella growth. The facility established hot water control limits between 100-115 F, a range that supports Legionella growth, but failed to document corrective actions when hot water temperatures measured within this range. The facility also failed to monitor or document cold water temperatures and to establish a cold water control limit with corrective actions for water temperatures greater than 68 F. Although a written water management plan was provided, the facility did not demonstrate implementation of required monitoring or corrective actions. This failure had the potential to effect 76 of 76 residents, placing residents, staff, and visitors at risk for exposure to Legionella and other waterborne pathogens. 2) implement their infection control policy and procedures for Contact Precautions by not wearing required personal protective equipment (PPE) while entering and cleaning the room of a resident on Contact Precautions (Resident #65). Housekeeping Aide #1 was observed cleaning Resident #65's room without gloves or a gown, and 3) implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when a nurse aide (NA #6) was observed providing high contact resident care activities for Resident #7 who had a stage IV non pressure chronic left buttock wound. This deficient practice occurred for 3 of 7 staff members observed for infection control practices (Maintenance Director, Housekeeping Aide #1, Nurse Aide #6). Findings included: 1. The facility's Legionella Water Management and Surveillance Policy (revised 01/26/26) stated in part; Legionella could cause Legionnaires' disease, a type of pneumonia that can be fatal in susceptible individuals. Legionella grows best in water temperatures of 77–108 degrees F particularly in water that was not moving or that does not have enough disinfectant to kill germs. The purpose of the water management program was to monitor, control, and disinfect the facility's water to reduce the risk of Legionella and other pathogens. The policy required a risk assessment to be conducted by the water management team annually to identify where Legionella and other waterborne pathogens could grow and spread in the facility's water systems. The Water Management Policy identified temperature management and a water system description (flow diagram) as control measures and control measures should be applied to address potential hazards. A variety of control measures that may be used to reduce the risk for Legionella growth and spread included physical controls, temperature management, disinfectant level control, visual inspections or environmental testing for pathogens. The measures should be specified in the water management program action plan. Individuals responsible for testing or visual inspection will document findings and when control limits are not maintained, corrective actions will be taken and documented accordingly. Review of the information provided by the Maintenance Director revealed no evidence of a completed risk assessment or a flow diagram of the facility's water systems. Further review showed that hot water temperatures recorded by the Maintenance Director from 05/01/26 through 08/21/26 were documented weekly and ranged from 100–115 degrees F. There was no evidence that cold water temperatures were monitored or recorded. There was no documentation of corrective action taken to reduce the risk of Legionella growth. An interview was conducted with the Infection Preventionist Nurse on 08/27/26 at 11:00 AM. The Infection Preventionist Nurse stated that the Maintenance Director was fully in charge of the Legionella program. She stated she was responsible for infection surveillance and there had been no Legionella outbreaks in the facility. An interview was conducted with the Maintenance Director on 08/27/26 at 3:00 PM. The Maintenance Director stated that he checked the hot water temperatures in the facility weekly. He stated he selected 3 rooms per hall and conducted water testing and recorded the temperatures on a paper notepad. He reported that he did not check pH and chlorine levels (pH and chlorine levels show whether disinfectant levels were adequate to help control bacterial growth). He stated the hot water temperatures in the facility ranged around 110 degrees F. The Maintenance Director stated the hot water temperatures had to be less than 116 degrees F and indicated he was not clear on the water temperature range that increased the risk of Legionella growth. He stated he was unable to provide documentation of any corrective actions taken or any documentation of cold-water temperature checks. The Maintenance Director stated in July of 2025 he utilized a test kit that he purchased to rule out Legionella. He stated he ran warm water in the facility kitchen when he performed this test and it was negative for Legionella. The Maintenance Director stated he was not aware that he needed to have correction measures in place to test the water when the temperature range was between 100–115 degrees F or when cold temperatures were above 68 degrees F. He added that he never monitored cold temperatures and he was unable to provide a diagram of the facility's water system to identify where Legionella may have the potential to grow. An interview was conducted with the Administrator on 08/27/26 at 3:14 PM. The Administrator stated the facility had a water management program that was updated annually, but she was not aware that the Maintenance Department was not implementing the water management policy. She reported she did not know they lacked a flow diagram of the buildings water systems, or had not conducted a risk assessment, and was not implementing or documenting corrective actions in response to hot or cold water temperature readings. She stated corrective measures were important to keep the facility and residents safe from a potential Legionella outbreak. 2. The Infection Control Policy dated 1/26/26 revealed Contact Precautions were measures implemented to prevent transmission of infectious agents that were spread by direct or indirect contact with the resident or the resident's environment. Staff were to wear gown and gloves for all interactions involving contact with the resident or the resident's environment. Staff were to don PPE upon entering the room and discard it before exiting the room. During an observation on 8/24/26 at 9:15 AM, Housekeeping Aide #1 was observed in Resident #65's room cleaning the room without gloves or a gown. A sign was observed on the door of Resident #65's room instructing staff to don gloves and a gown prior to entering due to the resident being on Contact Precautions. An adequate supply of gloves and gowns were hanging on the room door. During an interview on 8/24/26 at 9:15 AM, Housekeeping Aide #1 stated he was not clear on what Contact Precautions meant or what PPE was required before entering the room. Housekeeping Aide #1 exited the room, walked to the housekeeping supply cart in the hallway outside of Resident #65's room, and then re entered Resident #65's room without donning gloves or a gown. An observation and interview were conducted on 8/24/26 at 9:20 AM with the Director of Nursing (DON). The DON was asked to observe Housekeeping Aide #1 in Resident #65's room. The DON observed Housekeeping Aide #1 cleaning without wearing PPE. She instructed him to wash his hands, exit the room, and don the required PPE. The DON stated she was also serving as the Infection Control Nurse, and that staff were required to follow Contact Precaution signage and don the appropriate PPE before entering a resident's room on Contact Precautions. The DON stated Resident #65 was not in the room at the time of the observation because Resident #65 had been transferred overnight to the hospital for evaluation but remained on Contact Precautions for ESBL (Extended Spectrum Beta Lactamase, a type of bacteria that is resistant to many commonly used antibiotics). The DON indicated that although Resident #65 was not in the room, the room and its environment were potentially contaminated, and staff were required to don PPE when cleaning or coming into contact with the resident's environment, even when the resident was not present. During an interview with the Housekeeping Director on 8/24/26 at 9:30 AM, she stated housekeeping staff had received infection control training on Transmission Based Precautions including Contact Precautions and PPE use. 3. The Infection Control Policy dated 1/26/26 revealed, Enhanced barrier precautions (EBP) referred to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Nurse Aide (NA) #6 was observed on 8/26/26 at 10: 30 AM changing the linens on Resident #7's empty bed wearing gloves and no gown. There was an Enhanced Barrier Precaution sign on the door of Resident #7's room and there was Personal Protective Equipment (PPE) hanging on the front of the door to the room. An interview with NA #6 was conducted on 8/26/26 at 10:32 AM. NA #6 first stated she thought it was the other resident in the room that was on EBP. She then stated that Resident #7 had a wound, but she thought she only had to wear a gown when touching or providing direct care to the resident. She acknowledged the EBP sign listed changing linens as a high contact activity. NA #6 indicated EBP education was provided by the facility. An interview with the Director of Nursing (DON) was conducted on 8/27/26 at 2:45 PM. The DON confirmed she was also the Infection Preventionist until the new Staff Development Coordinator (SDC) Nurse started work next week. She stated that she had conducted several Enhanced Barrier Precautions (EBP) staff in-services. The DON indicated she expected all the nursing staff to follow the EBP and to apply a gown and gloves when providing high contact activities. An interview with the Administrator was completed on 8/27/26 at 3:35 PM. The Administrator stated that she expected all staff to follow EBP when providing high contact activities for residents, including changing linens.

Based on record review and interviews with residents, staff, the Psychiatrist, and the Medical Director, the facility failed to ensure residents were free from exploitation. Nurse Aide #1 accepted $2,000 from Resident #8 and $100 from Resident #80 during her period of employment. Although both residents were assessed as cognitively intact, Nurse Aide #1 repeatedly shared personal hardship stories, including claims of homelessness and financial difficulties, which influenced the residents to provide her with money. This deficient practice resulted in the exploitation of 2 of 2 residents reviewed for abuse (Residents #8 and #80). Findings included: The facility policy titled Abuse, Neglect, and Exploitation revised 2/1/26 read in part; it is the policy of the 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. Exploitation is defined as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. Resident #8 was admitted to the facility on [DATE]. Resident #80 was admitted to the facility on [DATE]. A summary of the facility's investigation dated 10/17/25 conducted by the previous Social Worker (#2) revealed that Resident #8 reported being in a six month relationship with Nurse Aide #1 and stated she had given Nurse Aide #1 approximately $2,000 (through an online money exchange platform) during that period. The Social Worker and Unit Manager interviewed Resident #8 on 10/17/25. Resident #8 initially denied the relationship but later stated she wanted to provide the truth. Resident #8 reported she had not been forced to give money. The Social Worker explained the facility's role in ensuring resident safety and encouraged the resident to report any concerns. Nurse Aide #1 resigned just prior to the facility becoming aware of the situation. During the facility's investigation alert and oriented residents were interviewed and a second resident (Resident #80) stated she had also given Nurse Aide #1 money but stated to staff that it was her money to do with as she pleased. The State Agencies and the police were notified. The 24 hour and 5 day reports were submitted. The 5 day report verified that the allegation was substantiated by the facility, and mental anguish occurred lasting greater than 5 days, reporting Resident #8 was crying and felt very hurt, used, and depressed over the situation. Attempts were made to contact Social Worker #2 who conducted the facility's investigation. There was no response and the Administrator stated Social Worker #2 was no longer employed with the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact.An interview was conducted on 8/25/26 at 9:00 AM with Resident #8. She stated she gave money to Nurse Aide #1 because Nurse Aide #1 frequently shared poor pitiful me stories, including saying that she was homeless. Resident #8 reported she believed Nurse Aide #1 was her friend and stated she had developed feelings for her during their relationship, which made her feel obligated to help because she thought Nurse Aide #1 needed the money. Resident #8 further stated that after speaking with the police and realizing she had been taken advantage of, she felt upset, angry, and embarrassed, and experienced increased depression. She stated that over time she began to feel better and got happy again. Resident #8 also reported that although Nurse Aide #1 no longer worked in the facility, she continued to receive text messages from her asking for money. Resident #8 provided receipts from the online platform used to send money to Nurse Aide #1. The receipts included Nurse Aide #1's name and the dollar amounts transferred, verifying that money had been given to her.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact.During an interview on 8/25/26 at 3:00 PM Resident #80 stated that she had given Nurse Aide #1 approximately $100 during Nurse Aide #1's employment at the facility. Resident #80 reported that she believed Nurse Aide #1 was a good caregiver and wanted to give her money because Nurse Aide #1 had shared stories of having financial problems. Resident #80 stated she thought she was helping Nurse Aide #1 and did not realize at the time that giving money to staff was not appropriate or allowed. Resident #80 indicated she was not affected by the situation. During a phone interview on 8/27/26 at 2:45 PM, Nurse Aide #1 initially denied taking any money from Resident #8 or Resident #80. When informed that receipts verified she had received money from Resident #8, she admitted accepting the money and stated she used it to buy items for the residents such as food and clothes. Nurse Aide #1 stated she didn't know she couldn't take money from residents and she was not currently working as a nurse aide. Nurse Aide #1 had nothing further to say. During an interview on 8/26/26 at 3:00 PM Nurse Aide #4 stated she recalled the incident involving Resident #8 and Nurse Aide #1. She recalled Resident #8 would not get out of bed as much afterwards. Resident #8 told her she felt depressed and seemed lost. Nurse Aide #4 stated during that time staff had to continue to encourage Resident #8 to get out of bed and participate in her usual activities and after some time passed Resident #8 started feeling better. Nurse Aide #4 was not aware Resident #80 was involved in the situation but indicated she did not recall Resident #80 saying anything about it or expressing any concerns. During an interview on 8/26/26 at 11:45 AM, the Unit Manager stated the previous Social Worker conducted the facility's investigation in October 2025 after a staff member notified the facility that Nurse Aide #1 was receiving money and involved in a relationship with Resident #8. The Unit Manager reported that the Administrator and Director of Nursing who were here during the investigation no longer worked in the facility. She stated Nurse Aide #1 resigned around the time the facility became aware of the situation. The Unit Manager stated Resident #8 was very upset after the information came to light and spent most of her time in her room. She reported that after a period of time, Resident #8 gradually started socializing and began coming out of her room again. The Unit Manager stated the previous Social Worker interviewed Resident #80 about giving Nurse Aide #1 money but Resident #80 didn't seem to be affected by it stating she could give her money to whoever she wanted.During an interview on 8/26/26 at 3:30 PM, the Director of Nursing (DON) stated that she was not employed at the facility during the time the incident occurred and had only been informed of the situation earlier in the day. The DON stated that the situation involving Nurse Aide #1 and Resident #8 was inappropriate and should never have taken place. She reported that the facility policy prohibited staff from accepting money from residents and indicated that Resident #8 and Resident #80 had been taken advantage of by Nurse Aide #1. During a phone interview on 8/26/26 at 4:20 PM, the Psychiatrist stated that Resident #8 was evaluated by her about two weeks after the facility was made aware. The Psychiatrist stated Resident #8 demonstrated changes in mood, and overall engagement after learning she had been exploited, however no medication changes were made on that visit because medications were increased during her last visit with Resident #8 in June 2025. The Psychiatrist reported Resident #8 was upset about the situation and had worsening depression, consistent with psychosocial harm related to the event, but then overtime rebounded and started getting out of bed more often and participating in activities. The Psychiatrist was not aware of another resident (Resident #80) being affected by the situation and indicated Resident #80 was not followed by Psychiatry. During an interview on 8/27/26 at 1:00 PM, the Medical Director stated the behavior described by Nurse Aide #1 was a violation of facility policy and professional standards. The Medical Director stated she was not aware of the amount of money Nurse Aide #1 received from Resident #8 or Resident #80. She indicated that residents must be protected from exploitation and that staff were prohibited from receiving money from residents. During an interview with the Administrator on 8/26/26 at 4:00 PM, she stated she was not employed at the facility during the time the incident occurred and only became aware of the matter earlier today when the Director of Nursing informed her. The Administrator stated the facility's policy prohibited staff from accepting money from residents under any circumstances. She further stated that, based on the information provided, Nurse Aide #1 took advantage of a vulnerable resident by asking for and accepting money, which she indicated was a violation of professional and ethical standards. The facility provided its investigation, which included staff witness statements, interviews with alert and oriented residents, documented abuse education for staff, and four weeks of audits. However, the information submitted was insufficient to meet past noncompliance guidelines, therefore it was not accepted. This was discussed with the Administrator and she expressed understanding.

Based on record review, observation, and staff interviews, the facility failed to revise resident care plans in the areas of indwelling urinary catheter (Resident #3), and a scabies infestation (a contagious skin infestation caused by mites), (Resident #74) for 2 of 29 residents reviewed for care plans.Findings included:1. Resident #3 was admitted to the facility on [DATE] with diagnosis that included a Stage 4 (full thickness wound) sacral pressure ulcer.Review of a physician order dated 05/18/26 for Resident #3 revealed the following order: Indwelling urinary catheter for wound. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #3 had an indwelling urinary catheter.On 8/24/26 at 2:50 PM Resident #3 was observed with an indwelling urinary catheter in place.A review of Resident #3's care plan on 08/27/26 revealed that an indwelling urinary catheter care plan was not included.In an interview with the Director of Nursing (DON) on 08/27/26 at 8:30 AM she stated she expected a resident with an indwelling urinary catheter to have a care plan for an indwelling urinary catheter initiated at the time the catheter order was initiated. The DON noted that the remote MDS Nurse initiated and developed the facility care plans. She was not aware that a care plan for Resident #3's indwelling urinary catheter had not been developed. The DON explained that only the remote MDS Nurse was contracted to write care plans and that no staff at the facility initiated resident care plans.In an interview with the remote MDS Nurse on 08/27/26 at 10:30 AM she stated that she was not aware that a care plan for Resident #3's indwelling urinary catheter had not been initiated. She noted that a quarterly MDS assessment for the resident completed on 07/01/26 had correctly coded that the resident had an indwelling urinary catheter, but no care plan had been initiated. She stated whenever she completed any type of MDS assessment she usually checked to make sure all associated care plans were completed but this one got missed.In an interview with the Administrator on 08/27/26 at 12:20 PM she stated whenever a resident had an indwelling urinary catheter she expected a care plan for the catheter to be in the medical record.2. Resident #74 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (stroke).Review of a quarterly MDS assessment dated [DATE] revealed Resident #74 had severely impaired cognition.Review of a dermatology consult dated 08/10/26 revealed a shave biopsy of Resident #74's right palm revealed a scabies infestation.Review of Resident #74's care plan on 08/26/26 revealed that a care plan for a scabies infestation was not included.Review of the physician's orders for Resident #74 revealed the following treatments for scabies:1. Permethrin Topical Cream 5% Apply to neck down to feet topically one time only for scabies for 1 Day APPLY AT BEDTIME; WASH OFF IN AM -Start Date 08/13/26 at8:00 PM.2. Permethrin Topical Cream 5 % Apply to neck down to feet topically one time only for scabies for 1 Day APPLY AT BEDTIME; WASH OFF IN AM -Start Date 08/20/26 at 8:00 PM.3. Permethrin Topical Cream 5 % Apply to neck down to feet topically one time only for scabies for 1 Day APPLY AT BEDTIME; WASH OFF IN AM -Start Date 08/27/26 at 8:00 PM.In an interview with the DON on 08/26/26 at 12:15 PM she stated that a care plan for the scabies infestation should have been initiated on 08/12/26 when the facility was made aware of the dermatology test result and the contact precautions were initiated. She stated that she had contacted the remote MDS Nurse and made her aware of the scabies infestation on 08/12/26 and instructed the remote MDS to initiate a care plan. The DON stated she was not aware that the care plan had not been developed. The DON explained that only the remote MDS Nurse was contracted to write care plans and that no staff at the facility initiated resident care plans.In an interview with the remote MDS Nurse on 08/26/26 at 2:02 PM she stated that normally she would initiate and develop a care plan for scabies as soon as she was notified of the infestation. She noted after reviewing her records that this care plan just got missed.In an interview with the Administrator on 08/27/26 at 12:30 PM she stated that she expected a care plan to be in place as soon as the staff became aware of the infestation.

Based on observations, record review, and resident and staff interviews, the facility failed to implement interventions to prevent accidents after a resident's (Resident #43) wheelchair wheel rolled off the edge of the concrete slab in the smoking area on 7/13/26, resulting in skin tears to both arms. The concrete slab in the smoking area was even with the ground on the side closest to the facility but had a 6-inch drop on the other side. The Resident Council submitted a Resident Concern/Suggestion for the facility to secure a guard rail along the slab's edge to prevent wheelchairs from slipping off the edge of the concrete on 7/31/26. The Maintenance Director did not secure a guardrail until after the surveyor intervened on 8/25/26. This deficient practice occurred for 1 of 6 residents reviewed for accidents.The findings included:Resident #43 was admitted to the facility on [DATE]. Her diagnoses included dementia with unspecified severity and acquired absence of right leg below the knee. The Care Plan for Resident #43 dated 12/17/24 and revised on 4/1/26 revealed a plan of care for at risk for falls related to sit to stand safety issues, balance, medication use and history of falls and recent right below the knee amputation (BKA) and chronic pain and needs staff assistance with transfers at this time. She fell 3/24/26 when trying to transfer in the bathroom (was independent in toileting prior to surgery). She was non-compliant with safety measures. Interventions included to transfer with assist of 1 staff (right BKA), encourage to use call bell to call for assist, keep walkways free from clutter or other obstructions, and maintain a safe environment. There was a plan of care for Resident #43 being a safe and independent smoker. Interventions included to monitor for any signs of unsafe smoking and for the Social Worker to complete the Smoking Assessment to determine continued safety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was moderately cognitively impaired and was independent with activities of daily living (ADL). The assessment was coded yes for using a wheelchair and a walker for ambulation and no for any falls since last review or admission. A Witnessed Fall Report completed by Nurse #2 dated 7/13/26 at 6:05 PM revealed the location of the fall was the smoking patio. Resident #43's description of the incident was that she was trying to feed the cat and her wheelchair wheel slid off the edge of the concrete and fell on her bottom from the wheelchair to the concrete. She denied bumping her head and indicated her pain level was a 5 from the skin tears. The report listed her mobility was by wheelchair and she was oriented to person, situation, place, and time. There were no predisposing environmental factors checked except wheelchair/recliner. The predisposing physiological factors were listed as decreased safety awareness, impulsiveness, and gait imbalanceA nursing progress note written by Nurse #2 on 7/13/26 at 9:43 PM revealed that the fall occurred at approximately 5:46 PM. The note read in part, Writer was called to smoke patio by staff nurse and resident was noted to be sitting on the concrete at the edge of the patio with her wheelchair behind her; resident had on sandal; skin tears noted; underside of left forearm measuring 8 centimeter (cm) by 1 cm and c-shaped; right outer lower forearm measuring 2cm by 0.25 cm and right elbow measuring 0.5 cm by 0.5 cm in size; fresh blood at site. Several residents were on the patio with resident and witnessed the fall and they stated she did not bump her head on anything. Resident stated she was trying to feed the cat and her wheelchair slid off the edge of the concrete and fell on her bottom from the wheelchair to the concrete. She denied bumping her head on anything and she denied pain except to the skin tears.An interview was conducted with Nurse #2 on 8/25/26 at 11:12 AM. Nurse #2 stated she remembered Resident #43's accident occurred around the end of her shift at 7:00 PM. She confirmed Resident #43 was in her wheelchair in the smoking area and apparently, she had leaned over to pet the cat and her wheelchair wheel slipped off the edge of the concrete slab and she fell out of her chair and landed on her buttocks. Nurse #2 indicated that she had assessed Resident #43 and took her vital signs and she was assisted back in her wheelchair by 3 staff members. She stated Resident #43 had 3 skin tears on arms and that she had applied dressings to them. Nurse #2 indicated she had notified the Responsible Party (RP) and the physician on call.An interview was conducted with Resident #43 in the smoking area on 8/25/26 at 10:47 AM. Resident #43 stated that her wheelchair wheel rolled off the edge of the concrete slab when she was reaching down to pet the cat. She indicated she fell on her bottom, and she had skin tears on both her arms from the fall. Resident #43 stated she did not have to go to the hospital and didn't have any other injuries. She stated she didn't think it was safe to not have anything around the concrete slab to prevent the wheelchair wheels from slipping off the edge. A Resident Council Response Form dated 7/31/26 for the Maintenance Department listed a Resident Concern/Suggestion: Residents stated that smoking patio needs a guard placed around the edge to prevent wheelchairs from rolling off the concrete slab. The Facility Response/Action Plan: Maintenance was addressing the smoke area railing. The Form was signed by the Maintenance Director as completed on 8/17/26.A meeting with the Resident Council President (Resident #8) and 5 other alert and oriented residents was conducted on 8/24/26 at 3:23 PM. Resident #8 stated that the Resident Council had asked for a safety railing to be put up around the concrete slab in the smoking area, and it was not done yet. An interview with the Maintenance Director and an observation of the smoking patio was conducted on 8/25/26 at 10:37 AM. The Maintenance Director stated that he was aware that the Resident Council had requested a guard rail around the concrete slab that the smokers used. He confirmed that he had already measured the area and had the boards and was going to get started on the project today. He indicated he was aware that a resident had fallen in the smoking area because the wheelchair wheel had slipped off the concrete slab and she had sustained skin tears to her arm. The Maintenance Director stated he was given the Resident Council Response Form after the Resident Council meeting on 7/31/26. He measured the distance between the concrete slab and the ground where Resident #43 fell was 6 inches.A follow-up interview was completed with the Maintenance Director on 8/26/26 at 1:12 PM. The Maintenance Director stated that the rail around the edge of the concrete slab was completed on 8/25/26. He stated he had just not gotten around to completing the project before yesterday. The Maintenance Director stated he had a lot of things to do, and he didn't have an assistant to help him complete the tasks. He stated he was given the Resident Council Response Form on 7/31/26 and he returned it to the Administrator on 8/17/26. The form was signed by the Maintenance Director, and it was completed on 8/17/26. An interview with the Director of Nursing (DON) was completed on 8/25/26 at 3:50 PM. The DON stated the IDT determined the cause of Resident #43's accident was the gap between the concrete and the ground on the edge of the concrete in the smoking area. She indicated the IDT meeting was on 7/14/26 with Maintenance Director present, and they had determined the cause, and the intervention was to have boards secured in place around the edge of the concrete to prevent wheelchairs from sliding off the edge. The DON stated that approximately 90% of the smokers in the smoking area were in wheelchairs and the boards would help prevent another accident from occurring. She indicated the Maintenance Director should have fixed it right after the cause and the intervention was determined. An interview with the Administrator was conducted on 8/26/26 at 1:20 PM. The Administrator stated she was aware that Resident #43 had a fall in the smoking area. She indicated that they had an IDT meeting on 7/14/26 with the Maintenance Director present, and it was determined that the cause of the fall was the concrete slab was not even with the ground and that it needed it guardrail around the edge to prevent resident's wheelchairs from slipping off the edge. The Administrator stated that she expected Resident Council grievances or concerns regarding safety to be implemented within 72 hours. She indicated she didn't know why it took so long for the Maintenance Director to install the boards for the guard rail.

Based on observations, record review and staff, Registered Dietitian, and Physician interviews, the facility failed to follow a Registered Dietitian's recommendation to discontinue supplemental shakes due to a dialysis resident (Resident #54) who had a significant weight gain and a diagnosis of congestive heart failure for 1 of 1 resident reviewed for nutrition services. Findings included: Resident #54 was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease (CKD) with end stage renal disease (ESRD) dependent on dialysis, gout (a type of arthritis), and congestive heart failure (CHF). The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #54 was cognitively intact and was coded as receiving dialysis services. Review of the Physician orders written on 04/16/26 for Nepro shakes (a high protein/high calorie nutritional supplement for residents on dialysis) with meals, and an order to obtain weight on admission weekly times 4 weeks then monthly. On 04/21/26 a physician order was written for Furosemide (a diuretic medication that removes fluid from the body) and on 06/04/26 a physician order was written for Prednisone (steroid medication to decrease inflammation) 10 milligrams (mg) give 1.5 tablet in the morning for gout arthritis. Review of Resident #54's weights were recorded as follows: 04/16/26 127.0 lbs.04/23/26 133.4 lbs.05/01/26 134.2 lbs.06/03/26 145.2 lbs.07/09/26 148.0 lbs.08/11/26 161.0 lbs.08/19/26 156.0 lbs. A nutrition note written by the Registered Dietitian (RD) on 07/28/26 revealed a nutritional assessment was completed for Resident #54. His current weight was 148.0 lbs. on 07/09/26. Resident's body mass index (a tool used to estimate body fat using resident's weight and height) was within normal range for age. Resident has had a significant weight gain over the last 90 days of 14.6 lbs. or 10.9% significant weight gain. Some degree of weight fluctuation was expected with fluid shifts related to chronic kidney disease and dialysis and diuretic and steroid medication. Resident's current diet order was therapeutically regular. Resident's meal intakes were good, averaging 76-100%, and he currently received supplements - Nepro shake three times daily with meals. Recommend discontinuing Nepro shakes due to adequate oral intake and significant weight gain. Review of the Medication Administration Record for 7/28/26 through 8/26/26 revealed Resident #54 was receiving the Nepro supplement 3 times daily as ordered. A phone interview was conducted with the Registered Dietitian on 08/27/26 at 3:13 PM. The RD confirmed she was not able to sign the nutritional assessment that she completed for Resident #54 on 07/28/26 but she did email the recommendation to the Unit Manager, Director of Nursing, Dietary Manager, and the Administrator on 07/28/26 at 5:12 PM. The RD stated she would have expected the recommendation to have been reviewed and considered due to the resident's significant weight gain. An interview was conducted in conjunction with an observation of Resident #54 on 08/23/26 at 12:30 PM revealed an alert and oriented resident. He was sitting upright eating his lunch and had a Nepro shake on his lunch tray. Resident #54 did not present with any noticeable shortness of breath or visible swelling. During the interview Resident #54 revealed he was getting dialysis 3 times per week. Resident #54 stated he was compliant with his diet and his treatments, and he had no shortness of breath. An interview was conducted with Nurse #4 on 08/26/26 at 1:10 PM. Nurse #4 stated that Resident #54 was eating very well 76 - 100% of his meals. She stated Resident #54 had an order for Nepro nutritional shakes three times daily and he consumed 100% of the shakes whenever she gave it to him. Nurse #4 stated he was weighed monthly at the facility and each time he went to dialysis. Nurse #4 stated she was aware of Resident #54's weight gain, but she was not aware of a Registered Dietitian's recommendation to discontinue Resident #54's shakes. Nurse #4 stated Resident #54 was consistently missing at least one dialysis appointment weekly but has not had any shortness of breath or notable swelling. Nurse #4 stated the Physician was aware of Resident #54 missing treatments and education was provided to the Resident regarding the importance of going to all of his dialysis treatments. An interview was conducted with the Unit Manager on 08/26/26 at 4:00 PM. The Unit Manager stated that when the Registered Dietitian did the nutritional assessment for Resident #54 on 07/28/26, she left the assessment open and did not sign it. The Unit Manager stated she signed off on the assessment as complete. She explained that if a nutritional assessment was not signed, it remained open in the electronic record and appeared to still be in progress. The Unit Manager stated that she did not read the nutritional assessment before signing it and therefore did not see the recommendation to discontinue the Nepro shakes. She acknowledged that she should have reviewed the assessment prior to signing it, which would have allowed her to see the recommendation. The Unit Manager further explained the process for receiving recommendations from the registered dietitians involved the RD emailing recommendations to the Unit Manager; however, she reported that she never received any emails from the RD regarding Resident #54. The Unit Manager added that once she received a recommendation, she would forward it to the Nurse Practitioner or Physician to obtain an order. The Unit Manager stated that the RD worked remotely, and when she asked the RD why the assessment was not completed, the RD reported that the electronic record system would not allow her to complete the assessment. A follow up interview was conducted with the Unit Manager on 08/27/26 at 3:33 PM. The Unit Manager confirmed she had received the email from the RD with the recommendation for Resident #54 on 07/28/26, but she must have overlooked it. An interview was conducted with the Physician on 08/27/26 at 11:17 AM. The Physician reported she was aware of the Resident #54's weight gain and missing dialysis treatments. She stated she had assessed Resident #54 and he had no complaints of shortness of breath or any swelling. The Physician agreed that had she received the recommendation to discontinue Resident #54's Nepro shakes, she would have put an order in to do so due to sufficient oral intake and his weight gain. The Physician stated she would discontinue the Nepro shakes today since Resident #54 was eating well. An interview was conducted with the Director of Nursing (DON) on 08/27/26 at 3:33 PM. The DON checked her emails on 08/27/26 and confirmed that she did receive the email from the RD on 07/28/26 with the recommendation for Resident #54 but she missed it due to a setting in her email messages and as a result she did not follow up on the recommendation. The DON stated the email was sent to the Unit Manager, and the Dietary Manager and out of the three of us, one of us should have followed up on this recommendation.

Based on record review and interviews with the resident and staff, the facility failed to ensure ordered pain medication was administered when requested for a resident (Resident #86) who was admitted on [DATE] with an order for as needed narcotic pain medication. The narcotic pain medication was not available for administration until 8/23/26 requiring an additional order for as needed acetaminophen to be obtained and administered to control the resident's pain. This deficient practice occurred for 1 of 2 residents reviewed for pain management. The Findings included; Resident #86 was admitted to the facility on [DATE] at 2:54 PM. Diagnoses included right hip fracture with open reduction internal fixation (surgical repair involving the use of metal hardware) on 8/18/26.A nursing progress note written by Nurse #3 on Friday, 8/21/26 at 3:24 PM revealed Resident #86 was admitted to the facility via transport stretcher from the hospital. He was alert and oriented times 4 (person, place, time, and situation) and able to make his needs known. He was admitted to the facility with surgical repair of right hip fracture. He was weight bearing as tolerated, continent of bowel and bladder, and he was currently lying in bed at this time with no complaints noted. A Care Plan for Resident #86 dated 8/21/26 listed a plan of care for pain management: potential for pain related to right hip fracture with surgical repair on 8/18/26. Interventions included assessing pain, location, type, frequency and severity using (0-10 pain scale with 0 indicating no pain and 10 being the worst pain ever); administering pain medications as ordered; offering pain medications before pain became severe; and to attempt alternative methods of pain reduction such as: positioning, diversions, and asking the resident what helps easing their pain.A physician's order for Resident #86 dated 8/21/26 indicated revealed an order oxycodone hydrochloride (narcotic pain medication) 5 milligram (mg) tablet give 1 tablet by mouth every 4 hours as needed (PRN) for pain.An interview with Nurse #3 was conducted on 8/24/26 at 8:00 AM. Nurse #3 stated she was the nurse that admitted Resident #86 on Friday 8/21/26. She indicated she had confirmed Resident #86's medications were faxed to the pharmacy by the Admissions Coordinator. Nurse #3 stated she didn't know why the resident's PRN oxycodone was not delivered by the pharmacy on Friday night (8/21/26). An interview was completed with the Director of Nursing (DON) on 8/24/26 at 8:05 AM. The DON confirmed that Resident #86's medications were faxed to the pharmacy on Friday (8/21/26) afternoon when he was admitted . She stated she came in on Saturday morning (8/22/26) and found out that the pain medication was not delivered. She indicated she obtained an order for acetaminophen 500 mg for Resident #86 until the oxycodone arrived from the pharmacy. A physician's order for Resident #86 dated 8/22/26 indicated acetaminophen extra strength oral tablet 500 mg give 1 tablet by mouth every 6 hours PRN for pain.An eCare Triage Note (an electronic clinical documentation tool used to record a resident's reported symptom, concern, or change in condition and the clinical provider's response) written by the DON to the Nurse Practitioner (NP) on 8/22/26 at 8:54 AM indicated that Resident #86 was admitted to the facility yesterday (8/21/26) with a diagnosis of right hip fracture with surgical repair on 8/18/26. His PRN oxycodone was not delivered by the pharmacy last night (8/21/26), the DON was in the process of trying to find out if they could deliver it that night (8/22/26), but until then he needed something for pain. Acetaminophen 500 mg every 6 hours was initiated, but it was not working. The NP responded back on 8/22/26 at 8:59 AM that she would send a prescription for a 3-day supply of oxycodone to the backup pharmacy for Resident #86. During an interview with the DON on 8/24/26 at 8:05 AM she stated the backup pharmacy could not fill the narcotic prescription for oxycodone because it was already in the process of being filled by the facility's pharmacy, and it was too soon to refill. The DON stated that she had not notified the NP that the narcotic medication could not be filled and she had not requested a different narcotic prescription for Resident #86. She stated she should have called the NP back and requested a different narcotic pain medication for Resident #86. The August 2026 Medication Administration Record (MAR) for Resident #86 revealed he was administered PRN acetaminophen extra strength 500 mg on 8/22/26 at 9:30 AM for a pain level of 5 by Nurse #1. She documented that it was effective. A Medication Administration Note documented by Nurse #1 on 8/22/26 at 9:34 AM revealed the acetaminophen extra strength 500 mg was effective and the follow-up pain scale was a 0.A nursing progress note documented by Nurse #1 on 8/22/26 at 2:17 PM indicated that Resident #86's family was present at bedside. The family reported that Resident #86 was used to sleeping during the daytime and awake at night. He was currently resting in bed with no complaints or signs of acute distress noted. She wrote that she was going to continue to monitor resident's condition and provide care as indicated.An interview was conducted with Nurse #1 on 8/25/26 at 2:42 PM. Nurse #1 confirmed she was Resident #86's nurse on the 7:00 AM to 7:00 PM shift on Saturday 8/22/26. She stated that she told the DON on Saturday morning that Resident #86's narcotic pain medication had not arrived on Friday night or Saturday morning. Nurse #1 indicated that the DON communicated with the NP and had her send another prescription to the backup pharmacy and obtained an order for acetaminophen to be given until the narcotic medication arrived from the pharmacy. She stated that the backup pharmacy was unable to fill the prescription because it was too soon. Nurse #1 stated that Resident #86 had complained of pain of 5 on the 0-10 pain scale and she had administered acetaminophen at 9:30 AM, and he had slept most of the day until his family arrived. She stated that she called the pharmacy on Saturday (8/22/26), and they stated the medication would be delivered that night. Nurse #1 stated the pharmacy delivery was at 6:55 PM and the oxycodone was not delivered. She indicated that Resident #86 slept the majority of the day and he hadn't appeared to be in acute pain or distress.During an interview with the DON on 8/24/26 at 8:05 AM she reported the pharmacy delivered Resident #86's oxycodone at 4:04 AM on 8/23/26. The DON stated that she expected residents' pain to be addressed and medications administered at the time they complained of pain. The August 2026 MAR for Resident #86 revealed he was administered oxycodone HCL 5 mg for a pain level of 9 on 8/23/26 at 9:50 AM. An interview was conducted with Nurse #2 on 8/23/26 at 2:40 PM. Nurse #2 stated that she administered Resident #86 oxycodone 5 mg at 9:50 AM that morning and that he had stated his pain level was a 9 on the 0-10 pain scale. She indicated that when she followed up with him regarding the effectiveness of the pain medication, he stated that it was effective. Nurse #2 stated that he had asked for pain medication when she went into give his morning daily medication. An interview with Resident #86 was conducted on 8/23/26 at 2:26 PM. Resident #86 stated that he had been in the facility since Friday 8/21/26 in the afternoon and had just gotten his first dose of pain medicine today (Sunday) around 10:00 AM and he was finally getting some pain relief. He indicated that his pain level had been as high as a 10 on the 0-10 pain scale, and all the facility was giving him was acetaminophen. He stated he had been in the worst pain of his life. Resident #86 stated that the acetaminophen was not as effective as the oxycodone. He indicated his pain level was at a 9 on the 0-10 pain scale when the nurse asked him what his pain level was this morning. Resident #86 stated that whenever he had asked the nursing staff for pain medication, they just kept saying the pharmacy hadn't delivered it yet. He indicated that he just stopped asking them, because they kept saying the same thing.An interview was completed with the Administrator on 8/27/26 at 3:35 PM. The Administrator stated she expected the residents' pain medications to be delivered sooner than 2 days and that pain medication should be administered when it was requested.

Based on record review and interviews with the resident, staff, and Psychiatrist, the facility failed to implement trauma informed care approaches (an approach to delivering care that involves understanding, recognizing and responding to the effects of trauma) for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), a mental health condition that can occur after exposure to traumatic events and may involve distressing memories, heightened anxiety, or strong reactions to triggers. Trauma informed care requires the facility to ensure staff understand a resident's trauma history, identify trauma triggers, and incorporate this information into individualized care planning to avoid re traumatization. The facility failed to conduct a comprehensive trauma assessment, identify the resident's trauma triggers, provide individualized trauma informed interventions, or ensure staff were informed of the resident's trauma history and how to respond appropriately. This deficient practice affected 1 of 1 resident reviewed for trauma informed care (Resident #8). Findings included:Resident #8 was admitted on [DATE], with a diagnosis of PTSD added with an onset date of 12/6/24. Record review from 12/6/24 through 8/27/26 revealed Resident #8 had a significant history of traumatic events, nightmares, depression, and anxiety. Further review of Resident #8's electronic medical record revealed no comprehensive trauma assessment was completed to identify Resident #8's trauma history, triggers, or trauma informed needs. Review of the comprehensive care plan last revised 7/20/26 revealed Resident #8 was care planned for psychotropic medication use related to PTSD with nightmares. However, no care plan was initiated that addressed PTSD using trauma informed approaches including individualized interventions, identification of potential triggers, and no guidance for staff on how to respond to the resident's trauma symptoms.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact, with no behaviors or rejection of care. She received psychotropic medications and required staff assistance with activities of daily living (ADLs).During an interview on 8/26/26 at 9:00 AM, Resident #8 stated she had experienced numerous traumatic events in her lifetime. She stated she frequently became anxious but felt safe in the facility. Resident #8 reported she saw a Psychiatrist every few months, but she indicated that she did not recall discussions with facility staff regarding her trauma history or potential triggers that increased her anxiety or nightmares.During an interview on 8/26/26 at 3:00 PM Nurse Aide #4 stated she routinely provided care to Resident #8. She indicated she was not aware of Resident #8's diagnoses or any interventions in place to guide her care. During an interview on 8/26/26 at 11:45 AM, the Unit Manager stated she was aware Resident #8 had PTSD but indicated she was not aware of what was in the care plan or any potential triggers. During an interview on 8/26/26 at 12:15 PM, the Social Worker stated she began working at the facility in June 2026 and was instructed to complete trauma informed care assessments during admissions. She stated she had not reviewed records of residents admitted prior to her start date to ensure trauma assessments were completed. She acknowledged Resident #8's medical record contained no evidence of a trauma informed care assessment.Attempts were made to contact the previous Social Worker (#2). There was no response and the Administrator stated Social Worker #2 was no longer employed with the facility. During a phone interview on 8/26/26 at 1:00 PM, the MDS nurse reported she worked remotely to complete care plans and had not spoken with Resident #8. She stated she was not aware that residents with PTSD required a trauma specific care plan that included potential triggers and individualized trauma informed interventions.During a phone interview on 8/26/26 at 4:20 PM, the Psychiatrist stated she evaluated Resident #8 routinely and was aware of the resident's PTSD diagnosis. She stated she did not recall specific trauma triggers. The Psychiatrist indicated identifying trauma triggers was important for PTSD management, and she planned to evaluate Resident #8 soon and discuss these concerns.During an interview on 8/26/26 at 3:30 PM, the Director of Nursing (DON) stated she became DON in April 2026. She stated she was not aware Resident #8 had a PTSD diagnosis and agreed Resident #8 should have had a trauma informed assessment completed and a care plan identifying triggers and trauma focused interventions, so that the staff would have better guidance when providing her care.

Based on record review and interviews with staff and the Pharmacist, the facility failed to have an effective system in place to ensure as needed narcotic pain medication was acquired and available for administration when requested for 1 of 6 residents reviewed for pharmacy services. Resident #86 was admitted on [DATE], his narcotic pain medication was not received from the pharmacy until [DATE], and the facility's automated medication dispensing machine did not contain narcotic medications for emergency use. The findings included:Resident #86 was admitted to the facility on [DATE] at 2:54 PM with diagnoses to include right hip fracture with open reduction internal fixation (surgical repair of the fracture using metal hardware).A physician's order for Resident #86 dated [DATE] indicated revealed the following orders oxycodone hydrochloride (HCl) 5 milligram (mg) tablet give 1 tablet by mouth every 4 hours as needed (PRN) for pain was ordered by the physician on [DATE].An interview with Nurse #3 was conducted on [DATE] at 8:00 AM. Nurse #3 stated she was the nurse that admitted Resident #86 on Friday [DATE]. She indicated she had confirmed Resident #86's medications were faxed to the pharmacy by the Admissions Coordinator. Nurse #3 she didn't know why the resident's PRN oxycodone was not delivered by the pharmacy on Friday night. She indicated that the facility did not have narcotics in its automated medication dispensing machine. She believed this was because she didn't think they had a license. Nurse #3 stated the Director of Nursing (DON) would be able to provide more information. During an interview with the DON on [DATE] at 8:05 AM she confirmed the facility could not keep narcotics for backup use in the facility's automated medication dispensing machine. She indicated the facility's Drug Enforcement Administration (DEA) license number had expired when the facility changed pharmacies on [DATE]. The DON reported that Resident #86's medications were faxed to the pharmacy on Friday afternoon when he was admitted . She stated she came in on Saturday morning ([DATE]) and found out that the pain medication was not delivered. The DON stated she had contacted the provider and requested a prescription be sent to the backup pharmacy in town so the medication could be obtained sooner. She indicated she obtained an order for acetaminophen 500 mg for Resident #86 until the oxycodone arrived from the pharmacy. A physician's order for Resident #86 dated [DATE] indicated acetaminophen extra strength oral tablet 500 mg give 1 tablet by mouth every 6 hours PRN for pain.An eCare Triage Note (an electronic clinical documentation tool used to record a resident's reported symptom, concern, or change in condition and the clinical provider's response) written by the DON to the Nurse Practitioner (NP) on [DATE] at 8:54 AM indicated that Resident #86 was admitted to the facility yesterday ([DATE]) with a diagnosis of right hip fracture with surgical repair on [DATE]. His PRN oxycodone was not delivered by the pharmacy last night ([DATE]) and the DON was in the process of trying to find out if they could deliver it that night ([DATE]), but until then he needed something for pain. Acetaminophen 500 mg every 6 hours was initiated, but it was not working. The NP responded back on [DATE] at 8:59 AM that she would send a prescription for a 3-day supply of oxycodone to the backup pharmacy for Resident #86. During an interview with the DON on [DATE] at 8:05 AM she stated the backup pharmacy could not fill the narcotic prescription for oxycodone because it was in the process of being filled by the facility's pharmacy, and they said it was too soon to refill. The DON stated that she had not notified the NP that the narcotic medication could not be filled and she had not requested a different narcotic prescription for Resident #86. She stated she should have called the NP back and requested a different narcotic pain medication for Resident #86. The [DATE] Medication Administration Record (MAR) for Resident #86 revealed he was administered PRN acetaminophen extra strength 500 mg on [DATE] at 9:30 AM for a pain level of 5 by Nurse #1. She documented that it was effective. An interview was conducted with Nurse #1 on [DATE] at 2:42 PM. Nurse #1 confirmed she was Resident #86's nurse on the 7:00 AM to 7:00 PM shift on Saturday [DATE]. She stated that she told the DON on Saturday morning that Resident #86's narcotic pain medication had not arrived on Friday night or Saturday morning. Nurse #1 indicated that the DON communicated with the NP and had her send another prescription to the backup pharmacy and obtained an order for acetaminophen to be given until the narcotic medication arrived from the pharmacy. She stated that the backup pharmacy was unable to fill the prescription because it was too soon. Nurse #1 stated that Resident #86 had complained of pain of 5 on the 0-10 pain scale and she had administered acetaminophen at 9:30 AM, and he had slept most of the day until his family arrived. She stated that she called the pharmacy on Saturday ([DATE]), and they stated the medication would be delivered that night. Nurse #1 stated the pharmacy delivery was at 6:55 PM and the oxycodone was not delivered. She indicated that Resident #86 slept the majority of the day and he hadn't appeared to be in acute pain or distress.The [DATE] MAR for Resident #86 revealed he was administered oxycodone HCL 5 mg for a pain level of 9 on the (0-10) pain scale on [DATE] at 9:50 AM. An interview with the DON on [DATE] at 8:05 AM revealed the pharmacy delivered Resident #86's oxycodone at 4:04 AM on [DATE]. The DON stated she should have done more to obtain narcotic pain medication for Resident #86 by calling the NP back and requesting a different narcotic pain medication for Resident #86. She indicated that it had never taken the pharmacy 2 days to fill pain medications before this incident.A telephone interview was completed with the Pharmacist at the facility pharmacy on [DATE] at 2:19 PM. The Pharmacist stated that the pharmacy was located in [NAME], and they usually made two deliveries a day to the facility, one in the early morning and one in the evening. He confirmed that it usually didn't take 2 days to process a prescription, but the overnight Pharmacist had called off on Friday night [DATE], and there was no one to take his place. The Pharmacist stated that on Saturday the pharmacy staff was so far behind that the prescription was not processed before the nightly run. He stated that it was delivered to the facility on the second run at 4:04 AM on [DATE]. He confirmed that the facility was unable to store narcotics in its automated medication dispensing machine because the facility did not currently have a DEA license number. The Pharmacist stated the facility could have the residents' narcotics on the medication carts because they had a name and a prescription linked to them. An interview was conducted with the Administrator on [DATE] at 1:30 PM. The Administrator stated that the facility had not been able to store narcotics in its automated medication dispensing machine since [DATE], when the facility changed pharmacies. She stated that the automated medication dispensing machine was covered under the former pharmacy's DEA license number and they withdrew it when they stopped providing pharmacy services to the facility. The Administrator indicated the new pharmacy had applied for a new license, but it was not approved yet. A follow-up interview was completed with the Administrator on [DATE] at 3:35 PM. The Administrator stated she expected the residents' pain medications to be delivered sooner than 2 days and that pain medication should be available for administration when it was requested.

Based on observations, record review, and staff interviews, the facility failed to record the opened date on two insulin pens and failed to discard an expired bottle of an ophthalmic solution (eye drops), according to the manufacturer's guidelines. This was observed on 2 of 3 medication carts (100/200 hall medication cart and 300 hall medication cart) reviewed for medication storage. Findings included: Review of the manufacturer's guidelines for Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. Review of the manufacturer's guidelines for Latanoprost ophthalmic solution instructed to discard 6 weeks after opening. a. An observation of the 100/200 hall medication cart on 8/23/26 at 10:45 AM along with Nurse #4 revealed:- One Insulin Glargine (Lantus) pen with no opened date and the insulin pen had been used, - One bottle of Latanoprost ophthalmic solution with an open date of 7/7/26. During an interview on 8/23/26 at 10:50 AM, Nurse #4 stated night shift staff were responsible for checking medication carts weekly for expired medications, but nurses were required to check expiration dates prior to administration and record the date insulin pens were opened. She indicated she had not administered Lantus, or the eye drops, that morning and therefore had not noticed the expiration date or that the insulin pen did not have an opened date recorded. b. An observation of the 300 hall medication cart on 8/23/26 at 11:50 AM along with Nurse #6 revealed: - One Insulin Glargine (Lantus) pen with no opened date and the insulin pen had been used. During an interview on 8/23/26 at 11:50 AM Nurse #6 stated the nurses were required to check medication carts for expired medications and to record the date insulin pens were opened. She stated she had not administered Lantus that morning and therefore had not noticed that the insulin pen did not have an opened date recorded. During an interview on 8/26/26 at 4:00 PM the Director of Nursing (DON) indicated all nurses were responsible for checking medication carts for expired medications and insulin pens should be checked daily and opened dates recorded. She stated the expired eye drops on the medication cart should have been discarded and an open date labeled on the insulin pens.

Based on observations, record review, and staff interviews, the facility failed to post accurate daily staffing information in an area of the facility visible to residents and visitors on 1 of 5 days of the survey (8/23/26). The findings included:On 8/23/26 (Sunday) at 10:09 AM an initial tour was conducted in the facility. The posted daily staffing information sheet was observed on the counter at the reception desk in the lobby and was dated 8/23/26 and the census was listed as 78.An interview with the Director of Nursing (DON) was conducted on 8/23/26 at 10:42 AM. The DON stated that the posted staffing information was incorrect. She confirmed the resident census was 76 with 2 residents out on therapeutic leave, so there were 74 residents in the building. The DON indicated the daily nursing staff posting information should be accurate and up to date.On 8/27/26 at 10:57 AM an interview with the Unit Manager/Scheduler revealed she was responsible for posting daily staffing information sheets. She reported she filled out the staffing information sheets on Friday 8/21/26 for 8/22/26 and 8/23/26, and she didn't work weekends. The Unit Manager/Scheduler stated the night shift nurse was responsible for placing the staffing information sheet at the receptionist desk in the front lobby. She indicated that the night shift nurse didn't know to update the staffing information sheets before posting them. The Unit Manager/Scheduler stated she would usually update the staffing information with the correct information on Monday when she returned to work. The Unit Manager/Scheduler stated she had not had a conversation with the Administrator regarding the implementation of a process to ensure weekend staffing information sheets were accurate. On 3/27/26 at 2:45 PM an interview with the Administrator revealed the Unit Manager/Scheduler was responsible for posting the daily staffing information sheets. She stated she expected the nursing staffing sheets to be accurate and up to date. She confirmed that there should be a process for the nursing staffing sheets to be updated when the Unit Manager/Scheduler was not in the building.

Based on observations, record review and staff and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from neglect when the Nurse Practitioner failed to provide a pain management treatment for a resident (Resident #62) who was reporting pain and demonstrating signs and symptoms of pain after he was assessed for pain on 03/17/25 and 06/16/25. This failure occurred for 1 of 1 resident reviewed for neglect. Findings included: This tag is cross referenced to: F697: Based on observations, record review, staff, and Nurse Practitioner and Physician interviews the facility failed to provide pain management to include medications or non-pharmacological interventions for a resident who was observed by the Nurse Practitioner, the Nursing Aides and Occupational Therapist Assistant to have signs and symptoms of pain. This was for 1 of 1 resident (Resident #62) reviewed for pain. An interview was conducted with the Nurse Practitioner on 06/25/25 at 9:05 AM. The Nurse Practitioner stated in hindsight she should have ordered something for Resident #62's pain when she assessed him on 03/17/25. She stated he continued to demonstrate signs of pain on 06/16/25 according to her progress note and she should have ordered pain medication then as well. The Nurse Practitioner stated Resident #62 did not always demonstrate signs and symptoms of pain when she inquired with the nursing staff, but she did neglect to treat his pain when she observed it. An interview with the Director of Nursing on 06/26/25 at 10:25 AM revealed Resident #62's pain was neglected and he should have had pain medications ordered to treat his pain to help with his activities of daily living care and to participate in therapy.

Based on observations, record reviews, staff interviews, and Wound Care Physician interviews, the facility failed to obtain orders, and to provide treatment on admission for a Stage 2 pressure ulcer wound that progressed to an unstageable wound for 1 of 1 residents (Resident # 64) reviewed for pressure ulcers. Finding included: A review of Resident #64's hospital Discharge summary dated [DATE] revealed no order for treatment to the right and left buttock and no documentation regarding the condition of the resident's skin upon discharge. Resident #64 was admitted to the facility from the hospital on 3/7/25 with diagnoses which included aftercare following femur (the long thigh bone) fracture, anemia, multiple myeloma (a severe form of cancer), and history of stroke. A nursing admission progress note completed by Nurse #2 on 3/7/25 at 3:43 PM indicated the resident had Stage 2 pressure ulcers (partial thickness skin loss) to the bilateral buttocks. The admission progress note did not indicate that the physician was notified of the pressure ulcers or that the physician was consulted for wound care treatment orders. A review of the admission skin assessment dated [DATE] by Nurse #2 revealed that Resident #64 was noted with the following areas on the skin: - left buttock pressure ulcer 1 centimeter (cm) length with 2 cm width - right buttock pressure ulcer 2 cm length with 2 cm width The admission skin assessment did not indicate that the physician was notified of the pressure ulcers or consulted regarding treatment of the Stage 2 pressure ulcers. A physician order in Resident #64's electronic health record dated 3/7/25 indicated to apply house barrier cream to the peri area after each incontinence episodes and as needed. A review of Resident #64's March 2025 electronic Medication and Treatment Administration Record revealed no entry for house barrier cream to the peri area after incontinence episodes and as needed. An interview was conducted with Nurse #2 on 6/24/25 at 3:00 PM. Nurse #2 stated that the floor nurse was responsible for completion of the admission assessment including a full body audit when a resident was admitted or readmitted . Nurse #2 stated that she completed the initial admission skin assessment for Resident #64, and she recalled that the resident had Stage 2 wounds to bilateral buttocks that did not have dressings covering them on admission. Nurse #2 indicated she did not think she needed to notify the physician of the 2 Stage 2 wounds and did not need to consult the physician for a wound care treatment orders. Nurse #2 indicated that she did not think the wounds were that serious, so she did not think she needed to do anything further other than the order for barrier cream. Nurse #2 stated she did not alert anyone that Resident #64 should be evaluated by the Wound Care Physician and was unaware that Resident #64's wound on the right buttock progressed to an unstageable wound that required debridement. A skin observation tool dated 3/8/25 completed by Nurse #5 indicated Resident #64 had Stage 2 pressure wounds to the right and left buttock. A review of an undated facility Standing Treatment Orders for Wounds revealed that Stage 2 wounds were to be cleansed with normal saline, calcium alginate and an island dressing was to be applied. The physician and the Wound Care Physician were to be notified. A review of Resident #64's electronic health record revealed that the standing treatment order for Stage 2 ulcers to cleanse the area with normal saline, apply calcium alginate and cover with an island dressing was not initiated until 3/13/25. A review of Resident # 64's nursing progress notes from 3//8/25 through 3/13/25 revealed there was no entry noting that the right buttock wound was an unstageable deep tissue wound ( a wound where the full extent of tissue damage cannot be determined due to eschar or dead tissue). There was no further entry regarding the left buttock wound. The first Wound Care Physician note for Resident #64 dated 3/13/25 indicated Resident #64 was evaluated at the request of the physician due to a wound on the right buttock. The note indicated a thorough assessment and evaluation was performed with the wound exam revealing an unstageable deep tissue injury to the right buttock measuring 6.5 cm x 5.3 cm. The wound care physician note did not indicate a pressure ulcer was observed on Resident #64's left buttock. An interview was conducted with the Wound Care Physician on 6/26/25 at 12:30 PM. The Wound Care Physician stated he evaluated Resident #64 on 3/13/25 due to a wound on the right buttock and his exam revealed that the resident had an unstageable deep tissue wound. The Wound Care Physician stated that the nursing staff had assessed the wound as a Stage 2 on admission however when he evaluated it the wound was unstageable due to necrotic or dead tissue. The Wound Care Physician stated the nursing staff should have informed Resident #64's physician of the Stage 2 pressure ulcer noted on admission to implement orders to prevent worsening of the ulcer. A pressure injury assessment dated [DATE] signed on 3/18/25 by Nurse #4 indicated Resident #64 had an unstageable deep tissue injury to the right buttock measuring 6.5 cm x 5.3 cm. The assessment indicated this was the first pressure injury assessment with no other assessments to compare to evaluate the progress of the wound. An interview was conducted with Nurse #4 on 6/25/25 at 3:49 PM. Nurse #4 stated there was not currently a Wound Care Nurse for the facility. Nurse #4 stated she was assigned to accompany the Wound Care Physician on 3/13/25 on rounds and to document the pressure injury assessments for each resident that was evaluated. Nurse #4 stated Resident #64 was on the list to be evaluated on 3/13/25 but she did not know who added the resident to the list. An interview was conducted with the Nurse Practitioner (NP) on 6/25/25 at 10:30 AM. The NP stated that she evaluated Resident #64's skin but was unable to recall on what date. The NP stated that she recalled that Resident #64's skin was broken with pressure areas on bilateral buttock. The NP stated that the treatment of barrier cream was a prevention for a Stage 1 wound but once the skin was broken as in Stage 2, 3 or 4 wounds, a dressing was required. The NP indicated that if a topical treatment such as barrier cream was used, it must be applied after each incontinence episode and must be recorded on the Treatment Administration Record. The nurses must apply the barrier cream and assess the skin if it was used for a pressure ulcer treatment. The NP stated that given Resident #64's overall condition and boney body habitus, she would have expected a wound care treatment other than barrier cream. The Stage 2 area on the buttock that Resident #64 was admitted with could have progressed due to not obtaining an order for a wound care treatment. A cushioned foam island dressing would have been a more appropriate order and could have prevented the wound from progressing. The NP stated that she expected that wounds would be thoroughly assessed and appropriate wound care orders implemented. A physician order written by the Wound Care Physician dated 3/13/25 indicated to apply calcium alginate and cover with an island dressing every day to the right buttock. Resident #64's admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a severe cognitive impairment and had 2 Stage 2 pressure ulcers present on admission. Skin observation tools completed on 3/15/25 and 3/22/25 indicated Resident #64 had no new areas of concern. A Wound Care Physician note dated 3/27/25 indicated Resident #64 was evaluated and a surgical debridement procedure to remove necrotic tissue and establish margins of viable tissue was completed. A post debridement assessment of the wound indicated that the previously unstageable necrotic wound revealed underlying deep tissue at the muscle/fascia level which had been obscured by the necrotic tissue. With the removal of the necrotic tissue the wound now presented as a Stage 4 full thickness pressure wound measuring 1.9 cm length by 3.2 cm width and 0.1 cm depth. An interview with the Director of Nursing (DON) on 6/26/25 at 3:45 PM revealed that she expected that the physician would be notified on admission of a pressure ulcer and appropriate treatment orders would be initiated. The DON indicated that the facility had an interdisciplinary team daily morning meeting that reviewed new admissions and changes in resident conditions from the previous day. The DON indicated that Resident #64 was reviewed in the meeting following her admission and a referral was made for the resident to be evaluated by the Wound Care Physician. The DON indicated it was an oversight that the appropriate wound treatment orders were not initiated on admission and education of the nursing staff was required.

Based on observations, record review, and staff, Nurse Practitioner and Physician interviews, the facility failed to provide pain management to include medications or non-pharmacological interventions for a resident who was observed by the Nurse Practitioner, the Nursing Aides and Occupational Therapist Assistant to have signs and symptoms of pain. This was for 1 of 1 resident (Resident #62) reviewed for pain. Findings included: Resident #62 was admitted to the facility on [DATE]. Diagnoses included stroke with right side weakness, aphasia (loss of ability to express speech), cognition deficit, vascular dementia, contracture to right elbow, anxiety, and depression. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired, exhibited no behaviors, and was coded as not receiving any scheduled or as needed pain medication. A review of Resident #62's care plan dated 02/06/25 revealed a plan of care was in place for at risk for alteration in musculoskeletal status related to stroke with right side weakness with a goal that the resident would remain free of injuries or complications through next review. Interventions included, in part, to monitor/document/report as needed signs or symptoms of complications related to joint pain, joint stiffness, usually worse on wakening, swelling, decline in self-care ability, contracture formation or changes, and pain after exercise. Review of an Occupational Therapist Assistant (OTA) note written on 02/10/25 revealed, in part, the therapist provided passive range of motion to the right upper extremity to reduce contracture and prevent loss of range of motion. Resident tolerated well with extra time required due to pain. An Occupational Therapist Assistant note written on 02/26/25 revealed resident agreed to passive range of motion to right upper extremity but was very limited due to pain response causing resident to pull away during light passive range of motion. A nursing progress note written by Nurse #3 on 03/07/25 at 12:54 PM revealed this nurse was called to Resident's room by staff at 7:30 AM. Resident observed lying on the floor beside his bed, on his right side, possibly trying to transfer without assistance from staff. A head to toe assessment was completed and there were no injuries, bruising, or bleeding noted. The Nurse Practitioner was notified at 7:35 AM with a new order to send Resident to the emergency room for evaluation. The emergency room (ER) note dated 03/07/25 at 8:46 AM revealed in part, per Emergency Medical Services (EMS), the resident arrived to the emergency room due to an unwitnessed fall. Resident reportedly was trying to get out of bed and falling and demonstrated actual or suspected pain (headache but no other pain). A Computed tomography (CT) Scan (medical imaging technique used to obtain detailed internal images of the body) of the head was conducted and showed an old left stroke. The ER note indicated Resident #62 was discharged back to facility. A review of the Occupational Therapist Assistant's note written on 03/11/25 revealed Resident was seen today following a fall on 03/07/25. The note revealed the therapist provided passive range of motion to the right upper extremity to reduce contracture and protect skin integrity, but resident only tolerated less than 10 minutes before refusing to continue. A Nurse Practitioner (NP) note dated 03/17/25 revealed she was seeing Resident #62 due to complaints of right arm pain. Resident had fallen on 03/07/25 from the bed to the floor landing on his right side and refused an initial assessment and became very agitated and swung at the staff with his left arm and yelled loudly. Resident was sent to the hospital where he was evaluated. A CT scan was taken of his head which was negative for any new findings and he was returned to the facility. The note indicated the staff have reported the resident was having increased pain when any manipulation of his right arm was attempted during care. When the NP attempted to examine his right arm, resident pulled away and resisted any attempt at inspection and/or movement. He was noted to have mild edema of his right wrist and the top of his right hand. Resident has had an increase of pain since his fall. The plan was noted as pain in right arm - uncontrolled. Will obtain x-rays 2 views of right arm to include hand, wrist and lower arm. Treatment as indicated after results obtained. A physician's order was written 4 days later on 03/22/25 for x-ray of right extremity 2 views to rule out fracture due to increased pain on movement to include right hand, wrist and lower arm due to increased pain since fall on 03/07/25 and swelling for 2 days. There was no x-ray ordered for the right shoulder. Review of the physician orders for Resident #62 revealed there were no medications ordered to manage or treat pain. The facility had no standing orders in place to administer pain relievers. Review of the nursing progress notes since 03/07/25 revealed there were no non pharmacological interventions done to treat Resident #62's pain. The x-ray results for Resident #62's right shoulder dated 03/24/25 were reviewed. The findings indicated no gross fracture or dislocation. The osseous (bone) structures appeared grossly intact. The conclusion of the x-ray indicated no gross osseous abnormality, limited study for which a fracture is not excluded and recommend repeat study with diagnostic views. The x-ray results for Resident #62's right hand dated 03/24/25 was reviewed. The findings indicated no gross fracture or dislocation. The osseous structures appear grossly intact. The conclusion of the x-ray indicated no gross osseous abnormality, limited study for which a fracture is not excluded and recommend repeat study with diagnostic views. There were no x-ray results for Resident #62s right wrist or lower arm per the physician order. The MDS quarterly assessment dated [DATE] revealed Resident was rarely or never understood and moderately cognitively impaired. He exhibited rejection of care behavior 1 to 3 days during this assessment. Resident had impairment to one side to upper extremity and no impairment to lower extremity. Resident #62 was not receiving scheduled or as needed pain medication. A progress note written by the Nurse Practitioner written on 06/16/25 revealed Resident has a contracture of his right arm and complaints of pain when right arm was moved or manipulated. An interview with Nurse Aide (NA) #1 on 06/23/25 at 3:45 PM revealed Resident #62 did not like to get out of bed and he would get very angry when she tried to get him out of bed. She stated when she repositioned him he would favor his right contracted arm and show signs of pain such as moaning and groaning and grimacing and guarding. She stated she had noticed that he used to keep his arm / elbow bent and rest across his abdomen but since the fall on 03/07/25 he has it raised (like drawn up) laying over his chest. NA #1 stated Resident #62 showed signs of pain whenever she would get him dressed and it was hard to put on his hospital gown; he would groan and pull away whenever she tried to put on his gown and she had to be very careful and ease it on his arm and shoulder very carefully. NA #1 stated he would refuse care a lot, but she did not know if that was because he was in pain. She stated as far as she knew he did not get pain medication and she did not tell the nurse that he was having pain during care because she thought it was related to the contracture and the nurses were already aware. NA #1 stated she had reported the observation of pain to the Nurse Practitioner a couple of times since his falls on 03/07/25 and 04/10/25 but she could not remember the exact dates. An interview with Nurse #3 on 06/24/25 at 2:30 PM revealed Resident #62 revealed Resident #62 was refusing to get out bed and did not want to be bothered since admission. She stated he wanted to be left alone. She stated he was cognitively aware and even though he was aphasic he could make his needs known by saying yes or no when asked and pointing to items/things. She stated he did not complain of pain and she would ask when she gave him his medications. Nurse #3 stated none of the Nurse Aides ever reported to her that Resident #62 was having pain. Nurse #3 stated on 03/07/25 at the beginning of the shift, she was notified that Resident #62 had a fall and was on the floor. Upon entering the room, she stated he was lying on the floor and she attempted to do a head to toe neurological assessment, but he was being very uncooperative and swung his arm at her and would not allow her to assess him. She stated she did not know if he was in pain or not, but he did not want to be touched. Nurse #3 stated it was an unwitnessed fall and since she could not do a neurological assessment she reported that to the EMS team and a CT scan of his head was done while he was at the hospital. Nurse #3 stated prior to the fall and after the fall she did not notice him having signs or symptoms of pain to his arm, but she knew that his right arm was contracted. An interview with the Rehabilitation (Rehab) Manager who was also the Occupational Therapist Assistant (OTA) on 06/24/25 at 4:00 PM revealed Resident #62 was nonverbal but he could make his need known with yes or no questions. She stated he was very difficult to evaluate since admission as he did not want to be touched and wanted to be left alone and would not allow her to do range of motion. She stated contractures can be very painful especially with movement, but not doing range of motion would cause more pain due to the joint and muscle stiffness that can occur with non-movement. The Rehab Manager/OTA stated Resident #62 refused care due to pain. The Rehab Manager/OTA stated the resident's refusal with therapy was discussed at the morning meetings and the nursing staff was made aware of his refusals due to pain. The Rehab Manager/OTA stated he demonstrated signs and symptoms of pain by wincing, groaning and pulling away and also verbally answering yes when asked if he was in pain. An interview with Nurse Aide #2 at 9:45 AM on 06/25/25 at 9:30 AM revealed since his admission, Resident #62 would refuse care often and would not allow her to touch him or change him at times. She stated whenever she would try to provide care, he would be combative and wince especially when trying to put on his hospital gown or getting him dressed. She stated his right arm was very tight and it was very difficult to get his gown on and he would try to pull away. NA #2 stated she did not report Resident #62's pain to the nurse because she thought the nurses were aware since he had a contracture to that right arm. An interview was conducted with the Nurse Practitioner (NP) on 06/25/25 at 11:00 AM. The NP stated she saw him on 03/17/25 related to his recent fall on 03/07/25. She stated Resident #62 was guarding his right arm and pushing her arm away and replied yes when asked if his right arm was in pain. The NP stated he was noted to have some swelling on his right wrist and hand and that was why she ordered the x-ray. The NP stated his pain could have been the reason he was refusing care and in hindsight she should have ordered something sooner for his pain. She stated up until 03/17/25, she had not been made aware he was having pain until NA #1 informed her that he was having pain whenever he was being provided care and was refusing to get up. The NP stated as far as she knew he always had that baseline pain due to his contracture since admission and it could have been the reason he was resistant to care and not participating in therapy, and that he did not want to be touched. It was reported to her again in June by NA #1 that Resident #62 was having pain and again she stated she should have ordered something for pain. The Nurse Practitioner stated she would start him right away on scheduled Tylenol (pain reliever). The Nurse Practitioner stated she would get another x-ray today on Resident #62's right arm to make sure a fracture could be ruled out. The emergency room note dated 06/25/25 revealed, in part, resident presented to the ER via EMS for right arm pain from contracture. The Medical Decision Making note revealed the physician was able to extend the right arm a little bit further down the chest so that it is was not in the way of neck and face after the baclofen and the diazepam (an antianxiety medication) were administered. The note indicated he would be sent back to the facility with a prescription for baclofen for muscle spasticity. Review of the x-ray of the right humerus (arm) revealed bone demineralization (reduction of minerals in tissue) and no evidence of acute fracture of dislocation. X-ray result of the right elbow and lower arm revealed a contracted elbow with no fracture or dislocation and mild osteoarthritis. A follow up interview was conducted with the Nurse Practitioner on 06/26/25 at 9:05 AM. The NP stated Resident #62 was sent to the ER on [DATE] to get an x-ray of his arm since the last x-ray did not get a full picture of his wrist and arm as ordered on 03/22/25 and that there was a recommendation for further diagnostic views. She stated when Resident #62 was sent back to the facility on [DATE] from the ER, the ER physician had ordered Baclofen (a medication to treat muscle spasticity) which she felt was a good idea for Resident #62. The Nurse Practitioner stated the Baclofen and the Tylenol may help him to be able to participate in therapy and be able to move his right arm more with less pain and he may not refuse care as much. An interview with the facility's Physician was conducted via phone on 06/26/25 at 2:15 PM. The Physician stated if Resident #62 was demonstrating signs and symptoms of pain when the Nurse Practitioner assessed him, then he would have expected the Nurse Practitioner to order a pain reliver for this resident and for the pain to be assessed. He stated 3 months or possibly longer of not getting pain medication was a long time and perhaps the resident would have been participating in his therapy and ADLS if he were medicated for his pain. The Physician also stated he would have expected the Nurse Aides to communicate with the Nurses of the signs and symptoms or pain they observed on this resident during care and for the Nurse to complete an assessment. An interview with the Director of Nursing (DON) on 06/26/25 at 2:35 PM revealed she was not made aware Resident #62 was having any pain. The DON stated she would have expected the Nurse Aides to report the pain to the Nurses and for the Nurses to assess the resident, document the assessment and notify the Physician for any new orders if there was pain. The DON stated she knew that Resident #62 was refusing care, but she did not remember the Rehab Manager/OTA reporting pain.

Based on record review and staff interviews, the facility failed to submit payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for federal fiscal year Quarter 1 (October through December 2024) and Quarter 2 (January through March 2025). This was for 2 of 3 quarters reviewed. Findings included: A review of the PBJ Staffing Data Report for Quarter 1 for the reporting period October 1, 2024, through December 31, 2024, revealed that the staffing data report identified an area of concern triggered for failed to submit data for the quarter. A review of the PBJ Staffing Data Report for Quarter 2 January 1, 2025, through March 31,2025 revealed that the staffing data report identified an area of concern triggered for failed to submit data for the quarter. An interview was conducted with the Administrator on 6/24/25 at 10:00 AM. The Administrator stated she was responsible for submitting the payroll-based data on the PBJ report to CMS. The Administrator stated the last time she submitted data was November 2024. The Administrator stated that after that, she was unable to log in to the PBJ system and did not know how to correct this. The Administrator indicated that she had reached out for assistance with her log-in but did not receive a response and she had not followed up on this. The Administrator stated she knew she was required to submit PBJ data and she had not done so.

Based on record review and staff and Nurse Practitioner interviews, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly to fulfill the responsibilities of the committee to identify and correct deficient practices in the facility effectively for 2 quarters and failed to have the Medical Director attend the meeting for 1 quarter. This deficient practice was observed for 3 of 3 quarters reviewed and had the potential to impact all facility residents. Findings included: A review of the facility Quality Assurance and Performance Improvement Program (QAPI) policy last revised January 2025 revealed that the following individuals serve on the committee: Administrator or designee Director of Nursing (DON) Medical Director Infection Preventionist Representatives of the following departments as requested by the Administrator: pharmacy, Social Services, Activity Services, Environmental Services, Human Resources and medical records. The policy stated that the committee meets at least quarterly. A review of the facility QAPI meeting minutes revealed the following: A review of the quarterly QAPI meeting minutes dated 11/12/24 at 10:30 AM revealed the following staff members were in attendance: Administrator, Rehabilitation Director, DON, Social Worker, Assistant Director of Nursing, Dietary Manager, Activities Services and Staff Development Coordinator. The Medical Director and Pharmacist were not listed in attendance. 1st Quarter 2025 the QAPI meeting did not take place. 2nd Quarter 2025 the QAPI meeting did not take place. An interview was conducted with the Nurse Practitioner (NP) on 6/25/25 at 10:30 AM. The NP indicated that she was not involved in the QAPI program and had not been invited to attend a QAPI meeting. The NP stated the Medical Director was not involved in the QAPI program. An interview with the Administrator on 6/26/25 at 4:30 PM revealed that the previous Medical Director that was in the position until the beginning of June 2025, worked remotely in another state and was unable to attend QAPI meetings on site. The Administrator stated that she did not extend an invitation to the Nurse Practitioner that worked on site daily to attend the QAPI meetings in the Medical Director's absence. The Administrator indicated she did not attempt to have the Medical Director attend the meetings virtually, instead she cancelled the meetings, and the committee had not met since November. The Administrator indicated the facility held a weekly at risk meeting of the interdisciplinary team. The Administrator revealed that the facility had not met expectations regarding weights, falls and grievances. She stated she had attempted to implement plans of correction in these areas however due to not following through in these areas with the QAPI process, the plans were not successful. The Administrator indicated she was responsible for the QAPI program in the facility and moving forward, she will make sure the Medical Director or his designee is present at all the QAPI committee meetings. The facility provided a corrective action plan that was not acceptable to the State Agency due to no evidence that education or a monitoring system was implemented prior to the entrance of the survey team for the recertification survey on 6/22/25.

Based on observations, record review, and staff, Nurse Practitioner and Physician interviews the facility failed to 1.) follow the physician's order to obtain an x-ray of a resident's right wrist and lower arm due to swelling and signs and symptoms of pain and failed to acknowledge recommendations on the x-ray results for further diagnostic reviews indicating a fracture could not be excluded for Resident #62. 2.) provide a TLSO (thoraco-lumbo-sacral orthosis, a type of spinal brace that supports the spine from the thoracic region down to the sacrum. It is used to limit movement, provide support and stabilization to the spine, and promote healing after injury) which was ordered by the hospital following a T3 (third thoracic vertebra) compression fracture for a resident (Resident #38) who experienced a fall in the facility. 3.) administer the full course of antibiotic therapy prescribed to a resident (Resident #48) for the treatment of a urinary tract infection. This occurred for 3 of 3 residents reviewed for quality of care (Residents #62, #38 and #48). Findings included: 1.) Resident #62 was admitted to the facility on [DATE]. Diagnoses included stroke with right side weakness, aphasia (loss of ability to express speech), cognition deficit, vascular dementia, contracture to right elbow, anxiety, and depression. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 and was moderately cognitively impaired. A review of Resident #62's care plan dated 02/06/25 revealed a plan of care was in place for at risk for alteration in musculoskeletal status related to stroke with right side weakness with a goal that the resident would remain free of injuries or complications through next review. Interventions included, in part, to monitor/document/report as needed signs or symptoms of complications related to joint pain, joint stiffness, usually worse on wakening, swelling, decline in self-care ability, contracture formation or changes, and pain after exercise. A nursing progress note written by Nurse #3 on 03/07/25 at 12:54 revealed this nurse was called to Resident's room by staff at 7:30 AM. Resident was observed lying on the floor beside his bed, on his right side, possibly trying to transfer without assistance from staff. A head to toe assessment was completed and there were no injuries, bruising, or bleeding noted. The Nurse Practitioner was notified at 7:35 AM with a new order to send Resident to the emergency room for evaluation. The emergency room (ER) note dated 03/07/25 at 8:46 AM revealed in part, per Emergency Medical Services, the resident arrived due to an unwitnessed fall. Resident reportedly was trying to get out of bed and falling and demonstrated actual or suspected pain (headache but no other pain). A Computed Tomography (CT) Scan (medical imaging technique used to obtain detailed internal images of the body) of the head was conducted and showed an old left stroke. Resident #62 was discharged back to facility on 03/07/25. A Nurse Practitioner (NP) note dated 03/17/25 revealed she was seeing Resident #62 due to complaints of right arm pain. Resident had fallen on 03/07/25 from the bed to the floor landing on his right side and refused an initial assessment becoming very agitated and swung at the staff with his left arm and yelled loudly. Resident was sent to the hospital where he was evaluated. A CT scan was taken of his head which was negative for any new findings and he was returned to the facility. The NP note indicated the staff have reported the resident was having increased pain when any manipulation of his right arm was attempted during care. When the NP attempted to examine his right arm, resident pulled away and resisted any attempt at inspection and/or movement. He was noted to have mild edema of his right wrist and the top of the right hand. Resident has had an increase of pain since his fall. The Nurse Practitioner's plan was noted as pain in right arm - uncontrolled. Will obtain x-rays 2 views of right arm to include hand, wrist and lower arm. Treatment as indicated after results obtained. A physician's order entered by the Nurse Practitioner was written 4 days later on 03/22/25 for x-ray of right extremity 2 views to rule out fracture due to increased pain on movement to include right hand, wrist and lower arm due to increased pain since fall on 03/07/25 and swelling for 2 days. There was no x-ray ordered for the right shoulder. Review of the physician orders revealed there were no medications ordered to manage or treat pain. An interview was conducted with the Nurse Practitioner (NP) on 06/25/24 at 11:00 AM. The NP stated she saw Resident #62 him on 03/17/25 related to his recent fall on 03/07/25. She stated Resident #62 was guarding his right arm and pushing her arm away and replied yes when asked if his right arm was in pain. The NP stated he was noted to have some swelling on his right wrist and hand and that was why she ordered the x-ray. The Nurse Practitioner stated she did not realize the order was not carried out to include Resident #62's right wrist and lower arm and she did not know why the x-ray included the right shoulder when she did not order that. The NP stated she did not follow through with the recommendations because she did not read the result of the x-ray in its entirety. She stated her eyes stopped at where the result read no gross fracture or dislocation. The NP stated she would get another x-ray today at the hospital. The NP stated the reason the x-ray was done 4 days after she originally ordered it on 03/17/25, was because she realized she had entered the order in the electronic record the wrong way and the nurses could not see the order. The NP stated when she realized the x-ray was not done, she reentered the order on 03/22/25 the correct way in the electronic record so the nurses could view the order and obtain the x-ray. The x-ray results for Resident #62's right shoulder dated 03/24/25 was reviewed. The findings indicated no gross fracture or dislocation. The osseous (bone) structures appeared grossly intact. The conclusion of the x-ray indicated no gross osseous abnormality, limited study for which a fracture is not excluded and recommend repeat study with diagnostic views. The x-ray results for Resident #62's right hand dated 03/24/25 was reviewed. The findings indicated no gross fracture or dislocation. The osseous structures appear grossly intact. The conclusion of the x-ray indicated no gross osseous abnormality, limited study for which a fracture is not excluded and recommend repeat study with diagnostic views. There were no x-ray results for Resident #62's right wrist or lower arm per the physician order on 03/22/25. The MDS quarterly assessment dated [DATE] revealed Resident was rarely or never understood and moderately cognitively impaired. He exhibited rejection of care behavior 1 to 3 days during this assessment. A progress note written by the Nurse Practitioner written on 06/16/25 revealed Resident has a contracture of his right arm and complaints of pain when right arm was moved or manipulated. A follow up interview was conducted with the Nurse Practitioner on 06/25/25 at 9:05 AM. She stated she agreed that another x-ray should be taken today to rule out any kind of fracture and it should have been done when the x-ray resulted on 03/24/25. A Nurse Practitioner order was written on 06/25/25 to be sent to the emergency room for x-rays of the lower right arm due to pain and contracture. The emergency room note dated 06/25/25 revealed, in part, resident presented to the ER via EMS for right arm pain from contracture. The Medical Decision Making note revealed the physician was able to extend the resident's right arm a little bit further down the chest so that it is was not in the way of neck and face after Baclofen (a medication to treat muscle spasms) and Diazepam (an antianxiety medication) were administered. The note indicated he would be sent back to the facility with a prescription for Baclofen for muscle spasticity. Review of the x-ray of the right humerus (arm) revealed bone demineralization (reduction of minerals in tissue) and no evidence of acute fracture of dislocation. X-ray result of the right elbow and lower arm revealed a contracted elbow with no fracture or dislocation and mild osteoarthritis. An interview with the Director of Nursing (DON) on 06/26/25 at 2:35 PM revealed she did not read the x-ray result from 03/24/25 in its entirety and she stopped reading the x-ray when she read no fracture or dislocation. She stated she should have read the entire result of the x-ray and notified the physician to obtain an order to complete the recommendations for further diagnostic views. An interview with the facility's Physician was conducted via phone on 06/26/25 at 2:15 PM. The Physician stated he would have expected the nursing staff and the Nurse Practitioner to read any and all x-rays results in their entirety. The Physician stated although the result of the x-rays were not indicative of any fractures, there would be no way of knowing this for sure without obtaining the additional diagnostic views that were recommended. 2.) Resident #38 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and dementia. A new diagnosis of a wedge compression fracture of the third thoracic vertebra was added on 6/23/25. A care plan dated 4/14/25 revealed Resident #38 had an extensive history of falls prior to admission and had injuries from falls. She was at risk for further falls with injury related to impaired balance, weight bearing issues, medication use, and a history of falls. Interventions included in part; to have no further falls with injury. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #38 was severely cognitively impaired and had no falls. A progress note dated 6/21/25 at 5:30 AM documented by Nurse #11 revealed Resident #38 was heard yelling from her bedroom. Resident #38 was found on the floor by the nurse and nurse aide. She had a laceration on her right eye which was bleeding. Resident #38 was confused and stated she was looking for her pillow. Resident #38 was transferred to the hospital with Emergency Medical Services. A hospital admission note dated 6/21/25 at 6:43 AM revealed Resident #38 was evaluated for an unwitnessed fall with an abrasion to the right temple. Resident #38 was at the nursing facility and was walking and slipped on a mat and fell onto her right cheek. There was no loss of consciousness, or blood thinner use, and no other pain or trauma reported during the evaluation. Resident #38 had a normal neurological exam and was stable to return to the nursing home. An order will be written for a TLSO brace. The discharge diagnoses included T3 (third thoracic vertebra) compression fracture. A written order dated 6/21/25 signed by the hospital physician for Resident #38 revealed TLSO for T3 compression fracture. An order dated 6/21/25 signed by the hospital physician for Resident #38 revealed Ultracet 37.5 milligrams (mg)/325 mg oral tablets. Give one tablet every six hours for 5 days as needed for pain. A progress note dated 6/21/25 at 11:18 AM documented by Nurse #4 revealed Resident #38 returned from the hospital this morning at approximately 11:00 AM following a fall during the night. Resident #38 was noted to have hit the right side of her head while walking in her room in the dark per report from the night shift nurse. Dried blood and bruising was noted above the right eye. Resident #38 was assisted into bed and was currently lying in bed with her eyes closed at this time. Resident #38 rated her pain as 6 out of 10 and pain medication was given. A new order was written for a TLSO brace for a 60% T3 compression fracture. The TLSO order was brought to the facility by Emergency Medical Services (EMS). The Director of Nursing (DON) was notified of the order. A phone interview was conducted on 6/26/25 at 3:30 PM with Nurse #4. She stated she was the admitting nurse when Resident #38 returned to the facility on Saturday 6/21/25 around 11:00 AM after a fall during the night. Nurse #4 stated the hospital sent the TLSO order with Emergency Medical Services (EMS) personnel. Nurse #4 stated she called the Director of Nursing (DON) once she received the order, and the DON instructed her to call the hospital to clarify the order. Nurse #4 called the hospital at that time and stated the hospital personnel did not communicate to her very well regarding who provided the TLSO but stated to her that they did not provide it indicating it was the responsibility of the facility. The hospital personnel instructed Nurse #4 that the TLSO was to be worn 24 hours a day and to follow up with the Orthopedist. Nurse #4 stated she notified the DON after speaking with the hospital and indicated they didn't know how to get the TLSO. Nurse #4 stated Resident #38 did return from the hospital with a pain medication order which she received during her shift on 6/21/25 and had also required pain medication during the week. She stated the pain medication administered for Resident #38 was effective in managing her pain. A progress note dated 6/23/25 at 10:37 AM written by the Nurse Practitioner revealed Resident #38 was evaluated for follow up after an emergency room visit on 6/21/25. Resident #38 was sent to the hospital after an unwitnessed fall. Staff entered the room after hearing Resident #38 yelling. She was found on the floor at the foot of her roommate's bed. She had bleeding from an area lateral to her right eye. Resident #38 told staff she was looking for her pillow. She was observed lying in bed this morning with a large ecchymosed (bruised) area surrounding the right eye with swelling, and a small abrasion on the right cheek. Resident #38 was at baseline regarding mentation, and was confused, and oriented to self only. Resident #38 denied pain. Diagnostics at the hospital showed a 60% T3 compression fracture of the spine with mild compromise to the adjacent spinal canal. The examination revealed Resident #38 was able to move all extremities without verbal or non-verbal indicators of pain. Resident #38 is at high risk for falls due to dementia and Parkinson's disease. Resident #38 was stable and denied pain at this time. She has Ultracet (pain medication) every 6 hours as needed for pain. Follow up with neurosurgery. TLSO brace to be worn while out of bed. During an observation on 6/26/25 at 9:30 AM Resident #38 was observed sitting up on the side of her bed. She was oriented to person. She was observed with a large, bruised area around her right eye with facial grimacing. There was no TLSO in place. When the surveyor asked her if she had pain, Resident #38 stated yes her back and her head hurt. During an interview on 6/26/25 at 9:35 AM Nurse #2 stated she was the assigned nurse. Nurse #2 stated Resident #38 had pain medication ordered after having the fall on 6/21/25 and she continued to receive the pain medication as needed. Nurse #2 stated Resident #38 had complaints of back pain or pain all over at times, but the medication was effective in relieving her pain. She stated she would administer pain medication at this time. Nurse #2 stated Resident #38 did not have a TLSO that she was aware of, and she did not know the reason she didn't have the brace. During an interview on 06/26/25 at 10:33 AM the Rehabilitation Director stated she was surprised that Resident #38 came back from the hospital without the TLSO which was a brace that covered the entire torso. The Rehabilitation Director stated therapy was not equipped to fit Resident #38 for the TLSO and that would have to be done from an outside service and required proper fitting. She stated the TLSO for Resident #38 was discussed in the Monday morning meeting on 6/23/25 following the fall over the weekend and the Director of Nursing was informed during the meeting that the therapy department could not provide the TLSO. The Rehabilitation Director stated Resident #38 was seen by the Orthopedist yesterday 6/25/25 and she thought maybe they would fit her there, but they didn't. She reported therapy services had been held for Resident #38 pending the results from the Orthopedist appointment to clear her for further services. During an interview on 06/26/25 at 1:24 PM the Nurse Practitioner stated she evaluated Resident #38 on Monday 6/23/25 following the fall over the weekend. She stated she was aware that the hospital wrote an order for the TLSO but thought the facility had obtained it. The Nurse Practitioner stated she was not aware Resident #38 still did not have the TLSO but stated she should have had it in place by now because it had been 5 days without one. During a phone interview on 06/26/25 at 2:00 PM the Physician stated he was made aware today of Resident #38's fall with compression fracture that occurred on 6/21/25. He indicated the Nurse Practitioner would have followed up with Resident #38 following the fall on 6/21/25 and therefore he was not aware of the fall or the order for the TLSO. The Physician stated he spoke with the DON today and ordered Resident #38 to be sent back to the hospital today due to having continued complaints of pain and until the hospital could get the TLSO placed. He stated the order for the TLSO should have been obtained sooner than 5 days following hospitalization. The Physician stated the TLSO was used for stabilization of the spine and Resident #38 should have had one provided upon return from the hospital or sent back to the hospital until she could get one. The Physician indicated that once the facility realized they could not obtain the TLSO upon return from the hospital they should have sent Resident #38 back to the hospital at that time. During an interview on 6/26/25 at 3:00 PM the Director of Nursing (DON) stated Nurse #4 notified her of the TLSO for Resident #38 upon return from the hospital on 6/21/25. She stated she had Nurse #4 call the hospital back, but they did not get clear information as to how to get the TLSO. She stated on Monday 6/23/25 the Nurse Practitioner was notified and evaluated Resident #38. The DON stated Resident #38 had a follow up appointment scheduled on Thursday 6/25/25 and the Orthopedist wrote to continue the TLSO and follow up with neurosurgery. She stated she just spoke with the facility Physician and was instructed to call a medical supply company today to come out and fit for the brace and if the medical supply company could not get there today to send Resident #38 back to the hospital. She indicated she was awaiting a call back from the medical supply company and would know something soon and if they could not come out today they would send Resident #38 back to the hospital until she could get the TLSO placed. 3.) Resident #48 was admitted to the facility on [DATE] with diagnoses of a gastrostomy tube placement and a history of urinary tract infections. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #48 was severely cognitively impaired. She received medications through the gastrostomy tube and received antibiotics. A care plan revised 3/20/25 for Resident #48 included a history of urinary tract infections and Resident #48 remained at risk for further urinary tract infections. A nursing progress note dated 3/20/25 at 2:05 AM documented by the Unit Manager revealed a report was given from the off going nurse that Resident #48 had foul smelling urine and vaginal discharge. A urine sample was obtained per standing orders. The urine sample was sent to the lab for urinalysis with culture and sensitivity (a urine test obtained to identify the presence of bacteria. A urine culture identifies the presence and type of bacteria causing an infection. Sensitivity tests determine which antibiotics are effective against the bacteria per standing orders). A physician's order with a start date of 3/22/25 at 9:00 PM for Resident #48 revealed Sulfamethoxazole-Trimethoprim (antibiotic) oral suspension 800-160 milligrams per 20 milliliters (ml). Give 20 milliliters via gastrostomy tube two times a day for urinary tract infection for 7 days (Total of 14 doses). A progress note dated 3/23/25 at 5:27 PM documented by the Nurse Practitioner revealed Resident #48 was evaluated to follow up on a urinary tract infection. The recent culture and sensitivity grew greater than 100,000 cfu/mls (colony forming units per milliliter- a measurement used to quantify the number of viable bacteria in a sample. Greater than 100,000 is indictive of a urinary tract infection). Review of the Medication Administration Record (MAR) for Resident #48 dated March 2025 revealed Sulfamethoxazole-Trimethoprim (antibiotic) oral suspension was scheduled for administration at 9:00 AM and 9:00 PM. Resident #48 received only 10 of the 14 doses. The dates and times of when the medication was not given were as follows: 3/22/25 at 9:00 PM the medication was documented as not administered by the Unit Manager. 3/23/25 at 9:00 AM the medication was documented as not administered by Nurse #8. 3/23/25 at 9:00 PM the medication was documented as not administered by the Unit Manager. 3/26/25 at 9:00 PM the medication was documented as not administered by Nurse #9. Review of Resident #48's progress notes from 3/22/25 through 3/26/25 revealed no documentation as to why the Sulfamethoxazole-Trimethoprim was not administered. During an interview on 06/26/25 at 1:07 PM the Unit Manager stated the antibiotic was not administered to Resident #48 on 3/22/25 at 9:00 PM or 3/23/25 at 9:00 PM due to waiting for the liquid suspension to come from the pharmacy. She stated the liquid form was needed to administer through the gastrostomy tube and the liquid suspension would not have been available in the Omnicell (the medication dispensing system in the facility). The Unit Manager stated she he had a resident assignment on 3/22/25 and 3/23/25 on night shift and indicated she did not call the pharmacy regarding the medication due to it being after hours. She did not attempt to get the medication from the back up pharmacy. She indicated that she did not notify the Nurse Practitioner or the Physician that the antibiotic was not available. Attempts were made on 06/27/25 at 1:15 PM to contact Nurse #9. There was no response. During a phone interview on 6/26/25 at 5:00 PM Nurse #8 stated the antibiotic was not administered to Resident #48 by her on 3/23/25 at 9:00 AM due to waiting for the medication to come from the pharmacy. Nurse #8 stated she did not recall reaching out to the pharmacy regarding the medication. She stated the medication would not have been available in the Omnicell and indicated she did not try to get it from the back up pharmacy. Nurse #8 confirmed she did not notify the Nurse Practitioner or the Physician regarding not having the medication available for administration. During a phone interview on 6/26/25 at 3:30 PM the Nurse Practitioner stated she was not aware that the full course of the antibiotic Sulfamethoxazole-Trimethoprim was not administered to Resident #48. She stated Resident #48 had a history of urinary tract infections and should have received the full course totaling 14 doses. The nursing staff had not reported any further signs or symptoms of a urinary tract infection to her since that time. The Nurse Practitioner stated there had been no significant outcome from not receiving the missed doses but indicated it was important that she received the full course of treatment to effectively treat the infection. During an interview on 06/26/25 at 3:08 PM the Director of Nursing (DON) stated she was not aware that Resident #48 did not receive the full course of the prescribed antibiotic (Sulfamethoxazole-Trimethoprim). The DON stated when it was realized that the medication was not available in the facility and nursing staff were waiting on the pharmacy to send the medication, the administration dates and times should have been extended in the electronic medical record so that the order wouldn't have been discontinued after 7 days. The nurse on duty when the medication was received in the facility should have accounted for the missed doses and extended the discontinue date on the MAR and that did not occur and that was why the full course of treatment was not administered. She stated education would be provided on ensuring the full course of antibiotic therapy was administered. The DON stated she expected the nurses to call the pharmacy if the medication was not delivered or utilize the backup pharmacy and that did not occur.

Based on record review and staff interviews, the Consultant Pharmacist failed to identify and report a medication irregularity during the monthly medication regimen review. Resident #62 received the anticonvulsant medication Depakote 250 milligrams after the order was written for a gradual dose reduction and to discontinue after 14 days. Resident #62 received 25 additional tablets of Depakote and the wrong dose. There was no significant outcome. This occurred for 1 of 5 residents reviewed for medication administration. Findings included. Resident #62 was admitted to the facility on [DATE] with diagnoses including major depressive disorder. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderately impaired cognition. He received anticonvulsant and antidepressant medications. A Psychiatrist's order dated 5/14/25 for Resident #62 revealed Depakote 250 milligrams (mg). Give one tablet by mouth twice a day for mood disorder. The Psychiatrist's note dated 5/29/25 for Resident #62 revealed to start a gradual dose reduction and discontinue Depakote for mood due to Resident #62 was currently receiving Keppra (an anticonvulsant) following recent hospitalization. The Psychiatrist's order dated 5/29/25 for Resident #62 revealed to start Depakote 125 milligram tablets. Give 1 tablet by mouth two times a day for recurrent major depressive disorder for 14 days then discontinue due to taking Keppra (discontinue 6/12/25). Review of the Medication Administration Record (MAR) dated 5/29/25 through 6/25/25 revealed Resident #62 was administered Depakote 125 milligram tablets twice a day. Resident #62 continued to receive the medication twice a day from 6/13/25 through the morning dose administered on 6/25/25. Review of Resident #62's electronic medical record revealed the order for Depakote 125 milligram tablets was entered by the Director of Nursing on 5/29/25 at 4:36 PM. There was no 14 day stop date entered on the order. The Consultant Pharmacist's medication regimen review note dated 6/18/25 documented that Resident #62 had medication changes. On 5/29/25 Depakote was decreased to 125 milligrams twice a day due to recently starting Keppra. There were no recommendations made regarding the Depakote order. An attempt was made on 6/26/25 at 1:50 PM to contact the Consultant Pharmacist, with no response. The Director of Nursing reported the Pharmacist was on leave and unavailable for interview. A phone interview was conducted on 6/25/25 at 2:00 PM with the Psychiatrist who ordered Depakote. She stated the Depakote order dated 5/29/25 for Resident #62 should have been discontinued after 14 days. She stated Resident #62 was prescribed Keppra during a recent hospitalization due to seizure activity so therefore the Depakote dose was to be decreased to 125 milligrams for a 14-day period and then discontinued. She stated she was in the facility today and evaluated Resident #62 and there had been no outcome from continuing to receive the additional doses or the increased dose of the medication. She stated that a 250-milligram dose was considered a low dose, and it was prescribed to Resident #62 for mood and behaviors. The potential outcome would be increased sedation, and no adverse symptoms had been reported to her. She stated she would send an order to discontinue the Depakote today. She indicated the facility should have identified the medication error and she would continue to monitor Resident #62. During an interview on 06/26/25 at 3:04 PM the Director of Nursing (DON) stated she entered the Depakote order on 5/29/25 and did not enter a 14 day stop date. Therefore, the order continued to remain active after the 14-day period. She stated the Consultant Pharmacist's monthly medication review was a part of their oversight to catch medication discrepancies. She stated the Consultant Pharmacist had completed her medication review for the facility for the month of June 2025 and there were no recommendations made regarding the Depakote order for Resident #62. She stated the medication error was missed by the staff and by the Consultant Pharmacist. During a phone interview on 06/26/25 at 3:15 PM the Physician stated the Depakote order for Resident #62 should have been entered correctly and then discontinued according to the Psychiatrist's order. He stated potential adverse symptoms would include increased sedation and there had been no reports of any adverse signs or symptoms reported to him. He indicated that the medication error should have been identified by the facility staff and the Consultant Pharmacist.

Based on observations, record review, the Psychiatrist, Nurse Practitioner, the Physician, and the dispensing pharmacy Quality Assurance Representative interviews, the facility failed to discontinue the anticonvulsant medication Depakote prescribed to a resident (Resident #62) for mood disorder. This resulted in the resident receiving 25 additional tablets of Depakote and the wrong dose. There was no significant outcome. This occurred for 1 of 5 residents reviewed for medication administration. Findings included. Resident #62 was admitted to the facility on [DATE] with diagnoses including major depressive disorder. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderately impaired cognition. He received anticonvulsant and antidepressant medications. A Psychiatrist's order dated 5/14/25 for Resident #62 revealed Depakote 250 milligrams (mg). Give one tablet by mouth twice a day for mood disorder. The Psychiatrist's note dated 5/29/25 for Resident #62 revealed to start a gradual dose reduction and discontinue Depakote for mood due to Resident #62 was currently receiving Keppra (an anticonvulsant) following recent hospitalization. The Psychiatrist's order dated 5/29/25 for Resident #62 revealed to start Depakote 125 milligram tablets. Give 1 tablet by mouth two times a day for recurrent major depressive disorder for 14 days then discontinue due to taking Keppra. (discontinue 6/12/25) During a medication pass observation on 6/25/25 at 10:00 AM Nurse #3 administered one Depakote 250 milligram oral tablet to Resident #62. During an observation on 6/25/25 at 10:00 AM Resident #62 was observed lying in bed with his eyes closed. He aroused when his name was called. He was able to respond with yes or no appropriately. Review of the Medication Administration Record (MAR) dated 5/29/25 through 6/25/25 revealed Resident #62 was administered Depakote 125 milligram tablets twice a day. Resident #62 continued to receive the medication twice a day from 6/13/25 through the morning dose administered on 6/25/25. Review of Resident #62's electronic medical record revealed the order for Depakote 125 milligram tablets was entered by the Director of Nursing on 5/29/25 at 4:36 PM. There was no 14 day stop date entered on the order. During an interview on 6/25/25 at 12:00 PM Nurse #3 stated Resident #62 was aphasic (difficulty with speech) due to a history of stroke, but he could communicate his needs to staff. She stated she was not aware the Depakote should have been discontinued. She stated she administered the 250-milligram tablet in error although the order on the MAR was to administer 125 milligrams. She stated she was routinely assigned to Resident #62, and she was uncertain how long the 250 milligram tablets had been available for use on the medication cart. She stated Resident #62 had not had any symptoms such as increased sedation from receiving the additional doses including the wrong dose of Depakote. A phone interview was conducted on 6/25/25 at 2:00 PM with the Psychiatrist who ordered Depakote. She stated the Depakote order dated 5/29/25 for Resident #62 should have been discontinued after 14 days. She stated Resident #62 was prescribed Keppra during a recent hospitalization due to seizure activity so therefore the Depakote dose was to be decreased to 125 milligrams for a 14-day period and then discontinued. She stated she was in the facility today and evaluated Resident #62 and he had no outcome from continuing to receive the additional doses or the increased dose of the medication. She stated a 250-milligram dose was considered a low dose and there were no Depakote levels ordered during the time he received the medication because he was not Bipolar (a mental health condition causing severe mood swings) and she was not trying to reach a therapeutic range. It was prescribed to Resident #62 for mood and behaviors. She stated potential outcome would be increased sedation and no adverse symptoms had been reported to her. She stated she would send an order to discontinue the Depakote today and there would be no need to check his Depakote level at this time due to him being on a low dose. She stated she would continue to monitor Resident #62. A phone interview was conducted on 6/25/25 at 2:30 PM with the facility's dispensing Pharmacy Quality Assurance Representative. She stated the pharmacy dispensed 60 tablets of Depakote 250 milligrams on 5/14/25 and 28 tablets of Depakote 125 milligrams (14-day supply) on 5/29/25. She stated no other Depakote tablets had been dispensed since that time. During an interview on 6/25/25 at 3:00 PM Nurse #1 stated she routinely provided care to Resident #62. She stated she had administered Depakote to Resident #62 daily and had never split the tablet therefore he received the full 250 milligram dose that was currently on the medication cart. She was not certain of how long he had been receiving the 250 milligram tablets. During an interview on 6/26/25 at 9:20 AM the Nurse Practitioner stated she was in the facility daily Monday through Friday. She was not aware the Depakote order should have been discontinued for Resident #62. The Nurse Practitioner stated Resident #62 was followed by the Psychiatrist who wrote the order. During the last evaluation on 6/16/25, her note included that Resident #62 had no signs of sedation. She stated there had been no reports of Resident #62 having any adverse symptoms from receiving the additional doses or the wrong dose of Depakote. An attempt was made on 6/26/25 at 1:50 PM to contact the Consultant Pharmacist, with no response. The Director of Nursing reported the Pharmacist was on leave and unavailable for interview. During an interview on 06/26/25 at 3:04 PM the Director of Nursing (DON) stated she entered the Depakote order on 5/29/25 and did not enter a 14 day stop date. Therefore, the order continued to remain active after the 14-day period. She stated the 250 milligram tablets from the previous order on 5/14/25 should have been returned to the pharmacy when the new order was written on 5/29/25 for the lower dose. This would have prevented the 250-milligram dose being available for administration on the medication cart. She stated the order entry was done in error and education would be provided to all nursing staff. During a phone interview on 06/26/25 at 3:15 PM the Physician stated the Depakote order for Resident #62 should have been entered correctly and then discontinued according to the Psychiatrist's order. He stated potential adverse symptoms would include increased sedation. He stated there had been no reports of any adverse signs or symptoms reported to him.

Based on manufacturer instructions, observations and staff interviews the facility failed to record an opened date on a multi-dose oral inhaler that had a shortened expiration date on 1 of 3 medication carts (300 hall) and to discard expired medications on 2 of 2 wound treatment carts (100/200 hall, 400/500 hall) and in 1 of 2 medication storage rooms (400/500 hall) and maintain a locked wound treatment cart (100/200 hall) that were reviewed for medication storage. Findings included. a.) An observation of the 300-hall medication cart on 6/23/25 at 1:00 PM revealed the following medications: Trelegy Ellipta oral inhaler 200 micrograms with no opened date. The manufacturer's instructions listed on the label read to discard 6 weeks after opening. During an interview on 06/23/25 at 1:03 PM Nurse #2 stated all nurses were responsible for checking the medication carts for expired medications. She indicated that she had not administered the Trelegy Ellipta inhaler today and had not checked for an expiration date. She stated the inhaler should have been labeled with a date when it was opened. b.) An observation of the 100/200 hall wound treatment cart on 6/23/25 at 1:30 PM revealed the following: The wound treatment cart was observed on the 100 hallway and was noted with the lock out which indicated the cart was unlocked. There were no staff members observed using the cart. An observation of the wound treatment cart on the 100 hallway revealed the following: Biofreeze pain relief spray with an expiration date of March 2025. During an interview on 06/23/25 at 1:35 PM Nurse #6 stated the nurses were responsible for wound care and for checking the treatment cart for expired medications. Nurse #6 stated she had not used the wound treatment cart and was uncertain who left the cart unlocked. She stated she was not aware of the expired medication on the cart. During an interview on 6/23/25 at 1:40 PM Nurse #1 the 100/200 hall assigned nurse stated she had not used the wound treatment cart. Nurse #1 reported she was uncertain who left the cart unlocked. She stated all nurses were responsible for checking expiration dates and she had not checked the cart today (06/23/25). c.) An observation of the 400/500 hall wound treatment cart on 6/23/25 at 1:50 PM revealed the following: Minerin cream (used to treat skin irritations) with instructions on the label to discard after 6/17/23. During an interview on 06/23/25 at 1:35 PM Nurse #6 stated the nurses were responsible for wound care and for checking the treatment cart for expired medications. Nurse #6 stated she was not aware of the expired Minerin cream on the cart. d.) An observation of the 400/500 hall medication storage room on 6/23/25 at 2:00 PM revealed the following expired medications: Potassium Chloride 20 milliequivalents (used to treat low potassium levels) 1000 milliliter intravenous (IV) solution with an expiration date of May 2025. 2 vials of Gentamicin (antibiotic) 80 milligrams per 2 milliliters for injection with an expiration on each vial of May 2025. One Normal Saline Syringe (used for flushing IV catheters) 10 milliliters with an expiration date of September 2024. Lisinopril (an antihypertensive) 2.5 milligram oral tablets labeled to discard after 4/29/25. During an interview on 6/23/25 at 2:15 PM Nurse #1 stated the IV supplies currently being used for residents were located in the medication storage room. Nurse #1 was not aware of any expired medications. She stated all nurses were responsible for checking expiration dates in the medication storage rooms. During an interview on 6/23/25 at 2:30 PM Nurse #6 stated all nurses were responsible for checking expiration dates as well as the Unit Manager who was responsible for restocking the medication storage room. Nurse #6 was not aware there were expired medications in the storage room. Nurse #6 stated there were currently no residents with orders for IV fluids. During an interview on 6/23/25 at 3:30 PM the Unit Manager stated she was also responsible for checking the medication storage rooms for expired medications. She stated she checked the medications rooms weekly. The Unit Manager was not aware of the expired medications and indicated it was an oversight. During an interview on 06/23/25 at 4:00 PM the Director of Nursing (DON) stated the assigned nurse was responsible for checking medication carts for expired medications and to ensure all medications were labeled with an opened date. She stated the nursing staff including the Unit Manager were responsible for checking the medication storage rooms for expired medications. The assigned nurse performed wound care and should check the cart daily for expired medications, or creams prior to doing wound treatments, and ensuring the wound treatment cart was locked when not in use.

Based on record review, and staff, resident, and Physician interviews, the facility failed to notify the physician that the scheduled medication gabapentin, a medication ordered for nerve pain that is not to be stopped abruptly, was not administered. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24 and had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms and the physician was not notified of this. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The physician was not notified that Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, the facility failed to notify the physician that 14 doses of the antibiotic Amoxicillin 875 mg was administered to Resident #39 instead of the antibiotic Augmentin (Amoxicillin-Clavulanate 875 mg-125 mg) that was ordered by the physician on discharge from the hospital. This deficient practice affected 3 of 10 residents reviewed for notification. Immediate Jeopardy began for Resident #51 on 5/9/24 when the resident reported a pain scale of 10, had not been receiving gabapentin, and the physician was not notified, and on 5/12/24 for Resident #46 when the resident had increased pain, difficulty sleeping, had not been receiving gabapentin, and the physician was notified. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Example #3 was cited at scope and severity D. Findings included: 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. The May 2024 Medication Administration Record (MAR) indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. This MAR and the medication administration notes revealed Resident #51's gabapentin was not administered on 5/8/24 at 5:00 PM and 9:00 PM and on 5/9/24, 5/10/24, 5/11/24, 5/12/24 and 5/13/24 at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM. A pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse #9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse #9 stated Resident #51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse #9 indicated Resident #51 refused her shower on 5/9/24 which was not normal for her, reporting she was in too much pain. Nurse #9 stated she was not aware that she should have notified the physician of Resident #51's increased pain and the ordered medication gabapentin that was not administered. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 indicated she did not notify the physician that Resident #51 had not received the scheduled gabapentin. Nurse #8 stated she did not realize that she should have notified the physician that the medication was not available and not administered as ordered. Nurse #8 stated she did not report Resident #51's increased pain to the physician. A nursing progress note by Nurse #13 on 5/10/24 at 3:24 AM stated Resident #51 reported her legs were numb. The note stated the nurse informed Resident #51 there were no interventions for that and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room . Attempts were made to interview Nurse #13 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not notify the physician that the medication gabapentin was not available and not administered and had increased pain. Unit Manager #1 was unable to explain why she did not notify the physician that the ordered medication gabapentin was not administered to Resident #51. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated due to acute pain and received gabapentin. The discharge instructions were to take prescription medications as ordered including gabapentin 800 mg 4 times per day and to not stop taking prescription medication for pain suddenly. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM and was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider of the resident's change in condition and requested to be sent to the hospital. Resident #51 was sent to the hospital per her request. Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. Nurse #14 worked at the facility through an agency. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received Gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. An ED Summary dated 5/13/24 indicated Resident #51 was evaluated due to acute pain. Resident #51 received gabapentin in the emergency room and the emergency room physician sent a new prescription for gabapentin to the pharmacy. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51 and why the physician was not notified. The DON stated she expected the nurses to notify the physician when medications were not available for administration. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be available and administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identify that a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated she was in the position at the facility since 6/7/24. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered and if the ordered medication was not obtained the physician should be notified. Attempts were made via phone to interview the previous physician with messages left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. Resident #46's May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR revealed on 5/10/24 at 9:00 PM, and on 5/11/24, 5/12/24, 5/13/24, 5/14/24, 5/15/24, 5/16/24 and 5/17/24 at 9:00 AM and 9:00 PM, the nursing staff documented the gabapentin was not administered. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin the medication was not administered due to it being unavailable. Nurse #3 stated she did not notify the physician that she had not administered the prescribed medication gabapentin and was unaware that she should have done this. An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that worked at the facility for several months. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart and she did not notify the physician that the gabapentin was not administered. Nurse #6 stated she was not aware that she was supposed to notify the physician. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse #17 indicated she was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #17 stated she did not notify the physician that she did not administer the scheduled gabapentin on 5/13/24, 5/14/24 and 5/15/24. Nurse #17 did not have an explanation why she did not notify the physician. An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 was unable to explain why she had not notified the physician of Resident #46's medication gabapentin not administered and resident's increased pain. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident had increased pain and she did not notify the physician. An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM. Nurse #5 stated she did not notify the physician the medication was unavailable or of the missed doses. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and she did not notify the physician. Attempted to interview Nurse #11, nurse assigned to Resident #46 on 5/16/24 7:00 PM to 7:00 AM. Messages were left on 6/11/24 and 6/12/24 with no return call received. An interview was conducted with Resident #46 on 6/13/24 at 9:30 AM. Resident #46 stated she had gone without gabapentin for days at a time on several occasions. Resident #46 reported staff stated the medication was coming from the pharmacy and then it didn't come in. Resident indicated she was familiar with her medications and gabapentin was prescribed for nerve pain. Resident #46 stated she had increased pain, trouble sleeping, was anxious, irritable, nauseous and unable to get up out of bed or complete her usual routine during the time when she did not receive her gabapentin. Resident #46 stated it was horrible and the staff told her she would just have to wait it out until the medication came in. Resident #46 stated she was not aware if the physician was notified of her medication not being administered as ordered. An in-person interview with the Director of Nursing (DON) on 6/12/24 at 4:15 PM revealed the nurses on the medication cart were expected to notify the physician when a medication was not available and administered as ordered. The DON stated she started at the facility at the end of March 2024. The DON stated she was not aware the physician was not notified. The DON expected the nurses to notify the physician of changes in condition including uncontrolled pain, medications not administered, and residents transferred to the hospital for evaluation. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected the physician to be notified when medications were not available and administered as ordered. The Administrator stated nursing staff did not understand what to do when they identified a medication was not available for administration and this included notification of the physician for further orders. An interview was conducted by phone with the Physician on 6/18/24 at 1:20 PM. The Physician stated she had been in the position since 6/7/24. The Physician indicated the dose of gabapentin ordered, 800 mg twice per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the risk of withdrawal and increased pain. Withdrawal symptoms can occur within 12 hours and can be severe. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered. She stated it was the responsibility of the facility to notify the physician when a scheduled medication was not available. Attempts were made via phone to interview the previous physician with messages left on 6/12/24 at 3:33 PM and 6/13/24 at 3:00 PM with no return call received. The Administrator was notified of Immediate Jeopardy on 6/13/24 at 2:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to notify the provider when two residents (Resident #51 and Resident #46) were not administered their ordered gabapentin for multiple doses. Resident #51 was not administered her routine order for gabapentin 800 mg 4 times a day from 05/08/2024 - 05/13/2024. A licensed nurse stated she did not notify the physician when the medication was not available. The nurse stated that if medication was not available for a few days, then she would call the pharmacy. The facility Unit Manager #1 was aware of the gabapentin not being available but did not recall what happened or what she did about obtaining the medication. The documentation in the electronic health record (EHR) showed no evidence that the physician was notified. On 05/09/2024 Resident #51 refused a shower due to too much pain. On 05/10/2024 Resident #51 complained of her legs feeling numb. On 05/12/2024 Resident #51 complained of pain and spasming in which Resident #51 requested to go to the emergency room (ER). Resident #51 returned from the ER where the resident was treated for acute pain and received gabapentin at the hospital. In the evening on 05/12/2024 Resident #51 complained of agitation and anxiety due to not receiving gabapentin and requested to go to the ER. Resident #51 received gabapentin in the ER. The physician in the ER sent a new prescription for gabapentin to the pharmacy. Resident #46 was not administered her routine order for gabapentin 800 mg 2 times a day from 05/10/2024 - 05/17/2024. Unit Manager #2 stated there had been delays in receiving refills of gabapentin and resident had been without the ordered gabapentin. She stated she did not notify the physician. Resident #46 had a pain level of 8 or 9 constantly during the time the facility failed to obtain and administer the medication. Resident #46 complained of not receiving pain medication which caused her more pain and made it hard to sleep. Resident #46 complained of irritability, being anxious, and nausea. Resident #46 had not felt well and had not been able to get out of bed to participate in activities and perform a daily routine due to pain in her legs. Residents with missed medications, changes in conditions, and residents who have had a documented risk management report are at a greater risk of the physician not being notified. Therefore, effective 06/13/2024, the Administrator, Director of Nursing, and Unit Managers (UMs) completed an audit for the past 90 days of all residents in the facility who had missed medications, changes in conditions, and/or a documented risk management report to ensure the physician had been notified. On 06/15/2024 it was determined by this audit that the physician had not been notified of every missed medication, change in condition, and documented risk management report. The concerns were identified and reported to the physician to ensure the notification of change. A documented risk management report is a report that a nurse completes to document resident incidents such as medication errors, falls, skin tears, pressure ulcers, etc. Any resident incident that occurs in the facility is documented in the electronic health record. It includes general details of the incident, a description of the incident, any statements from the resident or witnesses and any follow-up action to be taken by the nursing staff. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be complete: On 06/13/2024 the Director of Nursing educated Floor Nurses and Unit Managers (UMs) on the process to notify the physician when there are missed medications, changes in conditions, and/or a resident who has a documented risk management report. Nurses will notify the physician immediately via phone call to the on-call service provider that is posted at each nursing station. This process will happen if the nurse is working in the facility and witnesses a missed medication, change in condition, and/or if the nurse completes a documented risk management report on any resident. The Director of Nursing and Unit Managers (UMs) will begin in person education on 06/13/2024 with all nurses and medication aides which will include all full-time, part-time, as needed, and agency staff. This education will be on the importance of notifying the physician of any missed medications, changes in conditions, and documented risk management reports. No nurses or medication aides will work after 06/13/2024 until they have received the above noted education. The Director of Nursing will be responsible for keeping up with those nurses and medication aides who have and have not been educated. The Director of Nursing is responsible for completing the education or assigning the UM to complete the education for any staff who has not been educated by 06/13/2024. The UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure staff notify the provider when there are missed medications, changes in conditions, and/or if a resident has a documented risk management report. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. On 06/14/2024 the Director of Nursing and provider reviewed the facility provider communication log. Effective 06/13/2024 the Director of Nursing will provide education to ensure all nurses and medication aides (full-time, part-time, as needed, and agency) have comprehensive knowledge of how to utilize the provider communication log. The provider communication log is located in a white binder at each nursing station in the facility. The Floor Nurses and UMs will utilize this provider communication log daily to document any reason for why the provider should see a resident such as for a sick visit, readmission, new admission, orders to be signed, at the resident's request, at the resident's families request, medication refills, changes in conditions, and/or documented risk management reports. Effective as of 06/13/2024 Floor Nurses and UMs will be responsible for ensuring this provider communication log is updated daily. The Floor Nurses and UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure staff notify the provider when there are missed medications, changes in conditions, and/or a resident who has a documented risk management report. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. All newly hired nurses and medication aides, (full-time, part-time, as needed, and agency) will be educated as noted above. This will be completed by the Director of Nursing. The Director of Nursing will be responsible for keeping up with new hires who have and have not been educated. The Director of Nursing is responsible for completing the education with new hires. The Director of Nursing was notified of this responsibility on 06/13/2024 by the Administrator. Alleged date of immediate jeopardy removal: 6/16/24 The removal plan of the Immediate Jeopardy was validated on 06/19/24. The audit conducted for all residents who had missed medications, changes in conditions, and/or a documented risk management report to ensure the physician had been notified was verified and confirmed any identified concerns were reported to the physician. A sample of staff including the Administrator, Unit Manager, nurses and medication aides were interviewed regarding in services they received related to the deficient practice. All staff interviewed stated they had been in serviced regarding the process of notifying the physician when there are missed medications or changes in condition. The IJ removal date of 06/16/24 was validated. 37673 3. Resident #39 was admitted to the facility on [DATE] with a diagnosis of a urinary tract infection (UTI). The hospital discharge summary dated 05/02/24 revealed the following physician order: Amoxicillin-Clavulanate 875 mg-125 mg tablet oral every 12 hours for 7 days, (Augmentin). Amoxicillin-Clavulanate is a combination penicillin-type antibiotic used to treat a wide variety of bacterial infections. The facility MAR (Medication Administration Record) for May 2024 revealed Resident #39 was administered Amoxicillin 875 mg-give 1 tablet by mouth every 12 hours for a UTI x 7 days. He received the Amoxicillin 875 mg on the following dates for a total of 14 doses: 05/03/24, 05/04/24, 05/05/24, 05/06/24, 05/07/24, 05/08/24, 05/09/24, and 05/10/24. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had intact cognition. He had an indwelling urinary catheter. He had undergone recent genitourinary surgery (refers to the urinary organs of the body) that required skilled nursing care. He was administered antibiotic medication. Review of the Consultant Pharmacist ' s Medication Regimen Review dated 05/27/24 revealed the following recommendation: This resident was admitted with an order for Amoxicillin/Clavulanate 875 MG BID (twice a day) for 7 days. This was entered into the computer as Amoxicillin 875 MG. This is what the pharmacy sent. Please notify the provider of the medication error to clarify if any additional treatment is needed. Please review with the nurses to ensure they read orders carefully and double check entries. In an interview with the Consultant Pharmacist on 6/12/24 at 9:50 AM she stated the difference between Amoxicillin and Amoxicillin-Clavulanate was that the Clavulanate drug helped the Amoxicillin work better and more types of bacteria were affected by the addition of Clavulanate. She would have expected the provider to be notified to report the medication error and determine if additional treatment was necessary. In an interview with the Director of Nursing (DON) on 06/12/24 at 4:40 PM she stated she had not followed up on the pharmacy recommendation and had not notified the provider that the wrong antibiotic had been administered to Resident #39 to determine if further treatment was necessary. In an interview with the facility physician on 06/19/24 at 9:30 AM she stated she had not been notified that Resident #39 was given the wrong antibiotic. She noted she started at the facility last week and was not his doctor when this occurred. However, she reported she had seen Resident #39 yesterday and he was not having any symptoms of a UTI at this time. She did not feel any further intervention was required. She stated she would expect to be notified whenever there was a pharmacy recommendation or a medication error so that it could be addressed when it occurred.

Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Psychiatrist, Physician, and Wound Clinic Physician, the facility failed to protect the residents' right to be free of neglect when the facility failed to obtain significant medications (Resident #51, Resident #46, and Resident #8), administer significant medications (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8), notify the physician that scheduled medication for nerve pain that was not to be stopped abruptly was not administered (Resident #51 and Resident #46), and provide effective pain management (Resident #51 and Resident #46). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51's scheduled gabapentin was not obtained and administered for 21 doses resulting in ineffective pain management as evidenced by complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. The physician was not notified. Resident #51 was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46's scheduled gabapentin was not obtained and administered for 14 doses resulting in ineffective pain management as evidenced by increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. The physician was not notified. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized and the discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). This deficient practice affected 9 of 10 residents reviewed for neglect. Immediate Jeopardy began on 3/14/24 when the facility neglected to administer Resident #269's haloperidol and carvedilol as ordered and the resident required ED evaluation due to shortness of breath and an elevated pulse. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Residents #8, #10, #32, #39, and #50 were cited at scope and severity E. The findings included: This tag is cross referenced to: F580: Based on record review, and staff, resident, and Physician interviews, the facility failed to notify the physician that the scheduled medication gabapentin, a medication ordered for nerve pain that is not to be stopped abruptly, was not administered. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24 and had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms and the physician was not notified of this. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The physician was not notified that Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, the facility failed to notify the physician that 14 doses of the antibiotic Amoxicillin 875 mg was administered to Resident #39 instead of the antibiotic Augmentin (Amoxicillin-Clavulanate 875 mg-125 mg) that was ordered by the physician on discharge from the hospital. This deficient practice affected 3 of 10 residents reviewed for notification. F697: Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. F755: Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Physician interview, the facility failed to ensure scheduled medication was obtained and available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication. She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication. F760: Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant). An interview was conducted via phone with the Physician on 6/18/24 at 1:20 pm. The Physician indicated it was the facility's responsibility to provide the services necessary for the residents. An interview was conducted in person with the Director of Nursing (DON) on 6/14/24 at 4:10 PM. The DON indicated that staff not providing services needed to the resident was a form of neglect. She indicated education was provided to nursing staff to educate them on providing services the residents required. The Administrator was notified of immediate jeopardy on 6/13/24 at 5:00 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to protect Residents #46, #51, #269, and #419 from neglect as evidenced by the following deficient practices: 580: The facility failed to notify the physician when two residents (Resident #51 and #46) were not administered their ordered gabapentin for multiple doses. 697: The facility failed to effectively manage Resident #51's and Resident #46's pain. 755: The facility failed to ensure routine pain medication was obtained and available for administration for Resident #51 and Resident #46. 760: The facility failed to prevent significant medication errors for Resident #269, Resident #419, Resident #51, and Resident #46. The facility became aware of this neglect allegation for Resident #51 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #46 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #269 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The facility became aware of this neglect allegation for Resident #419 on 06/13/2024. The neglect allegation was reported to the Health Care Personal Registry on 06/14/2024 and has been reported to law enforcement and Adult Protective Services on 06/16/2024. The Administrator and Director of Nursing identified that all current residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be complete: On 06/13/2024 the Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) began educating all staff on the facility abuse and neglect policy. This education will be on the importance of staff understanding that all residents have a right to be free of neglect and that failing to provide the necessary care and services to residents constitutes neglect. All staff will have a comprehensive understanding that the following are necessary care and services: obtaining and administering medications as ordered by provider, effectively managing pain, and notifying the physician of significant changes to include any issues with administering significant medications as ordered. The Administrator, Director of Nursing, Social Worker, and Unit Managers (UMs) will begin in person education on 06/13/2024 with all staff which will include all full-time, part-time, as needed, contract staffing departments, and agency staff. No staff member will work after 06/13/2024 until they have received the education. The Social Worker and Director of Nursing will be responsible for keeping up with staff who have and have not been educated. The Social Worker, the Director of Nursing, and UMs are responsible for completing the education with all staff including any staff who have not been educated by 06/13/2024. The UMs were notified of their responsibility on 06/13/2024 by the Director of Nursing. The Social Worker and the Director of Nursing will be responsible for tracking the education and ensuring it is completed so that the facility has an effective system in place to ensure the facility implements effective systems so that residents receive the necessary care and services that are needed. The Social Worker and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator. All newly hired staff (full-time, part-time, as needed, contract staffing departments and agency) will be educated as noted above. This will be completed by the Social Worker, Human Resources Coordinator, and/or Director of Nursing. The Social Worker, Human Resources Coordinator, and the Director of Nursing will be responsible for keeping up with new hires who have and have not been educated. The Social Worker, Human Resources Coordinator, and the Director of Nursing are responsible for completing the education with new hires. The Social Worker, Human Resources Coordinator, and the Director of Nursing were notified of this responsibility on 06/13/2024 by the Administrator. Alleged date of immediate jeopardy removal: 6/16/24 The removal plan of the Immediate Jeopardy was validated on 06/19/24. A sample of staff including the Administrator, Unit Manager, nurses and medication aides were interviewed regarding in-services they received related to the deficient practice. All staff interviewed stated they had been in-serviced regarding the importance of staff understanding that all residents have a right to be free of neglect and understood that failing to provide the necessary care and services to residents constitutes neglect such as obtaining and administering medications as ordered, managing pain, and notifying the physician of significant changes. The IJ removal date of 6/16/24 was validated.

Based on record review, staff, resident, Consultant Pharmacist, and Physician interview, the facility failed to provide effective pain management and manage symptoms of withdraw for 2 of 10 residents (Resident #51 and Resident #46) reviewed for pain management. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not available to administer and resulted in a total of 21 doses of the prescribed medication not administered from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain at up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) per her request on 5/12/24 in the middle of the night where she was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening per her request for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not available to administer on 5/10/24 and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in increased pain at a sustained 8-9 pain level, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Immediate Jeopardy began when the facility failed to provide effective pain management for Resident #51 on 5/9/24 resulting in a pain level of 10 out of 10, and for Resident #46 on 5/12/24 when the resident had increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Findings included: Gabapentin is an anticonvulsant medication prescribed for seizures and nerve pain. Manufacturer instructions indicated gabapentin caused physical dependence and stopping the medication results in withdrawal symptoms. Within 12 hours after stopping gabapentin, withdrawal symptoms may start and may be severe. Withdrawal symptoms include nausea, insomnia, anxiety, tremors, body aches, increased pain, hallucinations and seizures. 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's physician orders revealed an order dated 4/10/24 for methadone 5 mg 2 times per day for pain and an order dated 4/18/24 for baclofen 20 mg 3 times per day for muscle spasms. Review of Resident #51's care plan revealed a focus dated 11/7/23 of pain due to chronic back pain. The goal indicated resident's pain will be relieved with use of pain medications. Interventions included provide/ administer pain medications as ordered, monitor for complaint of pain and report the need for further interventions. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated the 92 gabapentin pills from the 4/25/24 supply for Resident #51 were returned to the pharmacy while Resident #51 was in the hospital from 5/5/24 through 5/8/24. The hospital discharge summary dated 5/8/24 indicated Resident #51 was hospitalized from 5/5/24 through the morning of 5/8/24. The hospital discharge summary indicated the order for gabapentin for Resident #51 was unchanged when she returned on 5/8/24. The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and the documentation of a 9 indicated to see the nursing notes. This MAR did not include routine monitoring of pain using a 0-10 pain scale rating. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. A pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse # 8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 reported increased pain when she did not receive her gabapentin. Nurse # 8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as order. Nurse #8 stated she did not report Resident #51's concerns about not receiving the medication gabapentin to administration and did not have an explanation for why she did not report the concerns. A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the writer (Nurse #8) informed Resident #51 there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room . The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse # 9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. An interview was conducted via phone with Nurse # 9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51 and the resident reported pain in her legs. Nurse #9 indicated it was normal for Resident #51 to refuse her shower. An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 revealed she was assigned to Resident #51 on 5/10/24 from 7:00 PM to 7:00 AM. Nurse #13 indicated the ordered medication gabapentin 800 mg was unavailable for the scheduled dose at 9:00 PM. Nurse #13 recalled that Resident #51 normally did not complain of pain other than discomfort from her suprapubic catheter (a tube inserted through the abdomen to drain urine from the bladder). The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51 and did not assess Resident #51 for pain. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks and prior to that she worked the 7:00 PM to 7:00 AM shift. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall any further details of the situation. Unit Manager #1 stated she did not recall if she had been involved in obtaining the medication gabapentin for Resident #51. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to the emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE] at 6:11 AM. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM. Nurse #2 stated she was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital during the night on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Nurse #2 stated it looked like Resident #51 was exhibiting withdrawal symptoms. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility, and she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available. A progress note written by Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51's gabapentin was not available in the facility and the resident was sent to the emergency room during the night on 5/12/24 to obtain it. The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM). Attempts were made via phone to interview Nurse #14, a nurse that worked through an agency as needed. Messages left on 6/13/24 and 6/14/24 with no return call received. An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received Gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. The emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/13/24 - The MAR for 9:00 AM indicated Nurse # 15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 12:00 PM indicated Nurse # 15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 5:00 PM indicated Nurse # 15 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24. A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 reported pain due to not receiving gabapentin but stated gabapentin was ordered for pain so running out of the medication would cause increased pain. An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated she was familiar with Resident #51. NA #1 stated Resident #51 complained of pain at times, but this was not common for her. An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident #51 complained of leg pain at times. A follow up interview was conducted via phone with Nurse #8 on 6/27/24 at 6:15 PM. Nurse #8 stated she was aware of the potential for withdrawal and adverse effects that Resident #51 may sustain because of not receiving the ordered doses of gabapentin. Nurse #8 stated muscle aches and spasms were signs of withdrawal. An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51 resulting in missed doses of the medication ordered for pain. The DON indicated there was confusion regarding the requirements to order and reorder gabapentin and she did not understand the requirements herself. The DON revealed the Consultant Pharmacist had informed her of the problem with gabapentin running out but being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills, especially medications for pain. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected pain medication to be administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identified a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications, especially pain medications, so they could be administered as ordered. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident reported no pain in the previous 5 days. A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8. Gabapentin 800 mg was administered twice per day from 5/1/24 through 5/9/24. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked through an agency and was assigned to work at the facility on 5/6/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this. An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident # 46. Nurse #2 recalled the gabapentin was delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Resident #46 would do it. The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication: 5/10/24 - The MAR for 9:00 PM indicated Nurse # 3 documented a 9 and there was no corresponding nursing note. - The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain. Nurse #3 documented the PRN dose was effective. 5/11/24 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 7. Nurse #3 documented the PRN dose was effective. 5/12/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for a pain level of 9. Nurse #3 documented the PRN dose was effective. 5/13/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9. A pain level of 8 was recorded at 10:50 PM. The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy. - The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for pain. Nurse #17 documented the PRN dose was effective. 5/14/24 - The MAR for 9:00 AM indicated Nurse # 7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:25 PM Nurse # 17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen. Nurse #17 documented the PRN dose was effective. 5/15/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. 5/16/24 - The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 AM indicated waiting for delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse # 11 documented a 9. The corresponding nursing note on 5/17/24 at 12:40 AM indicated awaiting medication delivery from pharmacy. 5/17/24 - The MAR for 9:00 AM indicated Nurse #5 documented a 9. An administration note dated 5/17/24 at 10:09 AM indicated awaiting medication delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:04 PM. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented 9 on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin and indicated the medication was not administered due to it being unavailable. Nurse #3 stated Resident #46 had pain and was unable to sleep when she did not receive the medication gabapentin. Nurse #3 reported she did not relay Resident #46's reports of increased pain to the physician. An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that had worked at the facility for several months. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart. Nurse #6 indicated Resident #46 was upset about not receiving her scheduled gabapentin due to having increased pain. Nurse #6 did not report the resident's concerns about pain and did not have an explanation for why. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse # 17 stated she was assigned to Resident #46 from 7:00 PM to 7:00 AM shift on 5/13/24, 5/14/24, and 5/15/24. Nurse # 17 stated she looked for the medication on the medication cart and when she did not see it, she documented it 9, not available. Nurse #17 indicated medications were frequently missing and ran out from the medication cart. Nurse #17 revealed gabapentin was prescribed for pain and Resident #46 exhibited increased pain, irritability and anxiety from not receiving the medication. Nurse #17 did not report Resident #46's symptoms to the physician or administration and did not have an explanation for why. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #16. Nurse #16 was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #16 stated she worked at the facility through an agency for about 6 weeks. Nurse #16 stated 9 on the electronic MAR indicated the medication was not available. Nurse #16 indicated she documented 9 for unavailable on Resident #46's MAR on 5/13/24, 5/14/24 and 5/15/24 at 9:00 PM for the scheduled doses of gabapentin. Nurse #16 stated gabapentin was prescribed for pain and Resident #46 reported increased pain and inability to sleep from not receiving her scheduled pain medication. An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 stated she signed for the dose on the electronic MAR on 5/15/24 at 9:00 AM in error. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not attempt to obtain it or notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 stated she was aware that gabapentin was prescribed for nerve pain and not receiving the medication would cause the resident to have increased pain. Nurse #7 was unable to explain why she did not report Resident #46's increased pain from not receiving the scheduled doses of gabapentin. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident reported increased pain. Unit Manager #2 stated she did nothing about Resident #46's medication not being available and did not have an explanation for why. An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated there was a problem with running out of medications and administration was aware of the problem with medication not coming in from pharmacy. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM and did not call the pharmacy to obtain it. Nurse #5 stated Resident #46 reported increased pain. Nurse #5 stated she the medication was on order, so she did not attempt to obtain it. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and the resident reported pain. Nurse #2 stated she did not call the pharmacy to obtain the prescribed gabapentin for Resident #46. Nurse #2 stated medications were frequently unavailable, and she was informed by other nurses, although she did not recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done. Attempted to interview Nurse #11, nurse assigned to Resident #46 on 5/16/24 7:00 PM to 7:00 AM. Messages were left on 6/11/24 and 6/12/24 with no return call received. An interview was conducted with Resident #46 on 6/13/24 at 9:30 AM. Resident #46 stated the facility frequently had trouble obtaining medications. Resident #46 stated she had gone without medications for days at a time on several occasions. Resident #46 reported staff would state the medication was coming from the pharmacy and then it didn't come in. Resident indicated she was familiar with her medications and gabapentin was prescribed for nerve pain. Resident #46 stated she had increased pain, trouble sleeping, was anxious, irritable, nauseous and unable to get up out of bed or complete her usual routine during the time when she did not receive her gabapentin. Resident #46 stated it was horrible and the staff told her she would just have to wait it out until the medication came in. An interview was conducted via phone with Nursing Assistant (NA) #1 on 6/27/24 at 4:17 PM. NA #1 stated she was familiar with Resident #46. NA #1 stated Resident #46 complained of pain at times, but this was not common for her. An interview was conducted via phone with NA #9 on 6/27/24 at 4:40 PM. NA #9 stated Resident # 46 was pleasant, quiet and did not usually complain of pain. NA #9 stated Resident #46's normal routine was to get up out of bed to the wheelchair and attend activities daily. An interview was conducted via phone with Nurse #5 on 6/27/24 at 6:44 PM. Nurse #5 stated she was aware that suddenly stopping gabapentin could lead to withdrawal symptoms including insomnia, nausea, tremors and anxiety. Nurse #5 stated the symptoms Resident #46 reported could have been withdrawal symptoms. Review of a 5/27/24 Medication Record Review by the Consultant Pharmacist indicated a medication error was identified in Resident #46's electronic health record. The note indicated gabapentin was marked out of stock for 13 doses in May 2024. The Pharmacist indicated on the note that she checked the pharmacy records and found the pharmacy sent a 30-day supply of the medicatio [TRUNCATED]

Based on record review, staff, resident, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, and Physician interview, the facility failed to ensure scheduled medication was obtained and available for administration for 3 of 10 residents (Resident #51, Resident #46, and Resident #8) reviewed for medications. Resident #51 was prescribed gabapentin 800 milligrams (mg) four times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #51 missed a total of 21 doses of the medication from 5/8/24 through 5/13/24. Resident #51 had complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the Emergency Department (ED) on 5/12/24 in the middle of the night after missing 14 doses of the medication. She was treated for acute pain with gabapentin and returned to the facility the same day. Resident #51 missed 3 more doses of gabapentin on 5/12/24 and returned to the ED that evening for worsening muscle spasms. She was again treated for acute pain with gabapentin and returned to the facility where she proceeded to miss 4 more doses of the medication prior to the facility obtaining the medication for administration. Resident #46 was prescribed gabapentin 800 mg two times daily for nerve pain. The medication was not obtained from the pharmacy and Resident #46 missed 14 doses of the medication from 5/10/24 through 5/17/24 resulting in trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Additionally, Resident #8 was prescribed Oxycodone/Acetaminophen (opioid medication) 10/325 mg and this medication was not obtained from the pharmacy resulting in multiple missed doses of the medication. Immediate Jeopardy began on 5/9/24 for Resident #51 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in a reported pain scale of 10 out of 10. Immediate Jeopardy began on 5/12/24 for Resident #46 when the facility failed to obtain the ordered medication gabapentin from the pharmacy resulting in increased pain and difficulty sleeping. Immediate Jeopardy was removed on 6/16/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Example #3 was cited at scope and severity E. Findings included: 1. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The pharmacy records indicated a supply of 120 gabapentin 800 mg pills was sent to the facility for Resident #51 on 4/25/24. The pharmacy record indicated 92 gabapentin pills from the 4/25/24 supply for Resident #51 were returned to the pharmacy while Resident #51 was in the hospital from 5/5/24 through 5/8/24. The hospital discharge summary dated 5/8/24 indicated Resident #51 was hospitalized from 5/5/24 through the morning of 5/8/24. The hospital indicated the order for gabapentin for Resident #51 was unchanged when she was discharged on [DATE]. A nursing progress note written by Nurse #8 on 5/8/24 at 4:22 PM revealed Resident #51 returned to the facility from the hospital on 5/8/24 at 2:40 PM. Resident #51's May 2024 Medication Administration Record (MAR) indicated there was no routine pain monitoring. The May 2024 MAR indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. Following readmission to the facility on [DATE], a pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/9/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 indicated she did not know the process for obtaining medications from the pharmacy and had been informed by other nurses, although she did not recall which nurses, that if a medication was not available, they just had to wait for it to come in. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse # 8 stated frequently medications were not available. Nurse #8 stated a written or electronic prescription was not required to reorder gabapentin. Nurse # 8 stated Resident #51 was frustrated about not receiving the medication gabapentin as order. A nursing progress note by Nurse #13 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed Resident #51 there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room . The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from pharmacy. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse #9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse #9 stated Resident #51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse #9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse #9 indicated Resident #51 refused her shower on 5/9/24 which was not normal for her, reporting she was in too much pain. Nurse #9 stated the facility frequently ran out of medications and did not receive medications on time. Nurse #9 stated she did not attempt to obtain medication for Resident #51 and did not know the process for obtaining gabapentin. Attempts were made to interview Nurse #13 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51. She stated she was unclear the requirements for reordering gabapentin and did not assess Resident #51 for pain. Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE] at 6:11 AM. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM and was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. Nurse #2 stated medications were frequently not available in the facility. Nurse #2 stated she had been told by other nurses, although she was not able to recall which nurses, that they just had to wait until the medications came in from the pharmacy and there was nothing that could be done about the medications not being available. A progress note written by Agency Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51 had not received her medications from the pharmacy. Unit Manager #1 wrote down the medication that was needed from the pharmacy. The resident was sent to the emergency room last night to obtain gabapentin. The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM). Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. Nurse #14 worked at the facility through an agency. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received Gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her Gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for Gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/13/24 - The MAR for 9:00 AM indicated Nurse #15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 12:00 PM indicated Nurse #15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 5:00 PM indicated Nurse #15 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on the night of 5/13/24. A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks. Unit Manager #1 stated she thought gabapentin required a written or electronic prescription to be refilled but it had been a while since she ordered it so she was not sure. Unit Manager #1 stated she knew gabapentin had to be kept in the narcotic locked box and signed for. Unit Manager #1 stated she was aware that Resident #51 ran out of gabapentin and required emergency room evaluation due to increased pain but did not recall when or how she became aware. Unit Manager #1 indicated she did not recall if she had been involved in obtaining the medication gabapentin for Resident #51. An in-person interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 stated she thought a written or electronic prescription was required to obtain a refill of gabapentin, but she was not sure. Unit Manager #2 stated there had been delays in receiving refills of gabapentin for the past several months and Resident #51 had gone without medication. Unit Manager #2 was unable to recall if Resident #51 had pain due to not receiving gabapentin. Unit Manager #2 stated she had not contacted the pharmacy to obtain the ordered medication gabapentin for Resident #51. An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist indicated there was a system process problem with the facility and the ordering and reordering of medications, including gabapentin. The Consultant Pharmacist stated there was confusion in the facility regarding the requirements for ordering and reordering gabapentin and this placed the residents at risk of adverse effects. The Consultant Pharmacist stated she discussed the problems with obtaining medications for administration when the current Director of Nursing (DON) came into the position at the facility (DON started position in the end of March) and made her aware of the concerns. Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate). The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. The Consultant Pharmacist indicated the pharmacy considered gabapentin a controlled medication for storage and accounting purposes but did not require a written or electronic prescription for refills. An interview was conducted by phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Pharmacy Quality Assurance Specialist indicated the pharmacy treated gabapentin as a controlled medication in terms in the storage and accounting for it. She stated a written or electronic prescription was not required to obtain the medication from the pharmacy. The Pharmacy Assurance Specialist stated the process for obtaining a refill of the medication gabapentin was the facility sent the refill sticker via fax or completed a refill request in the computer. An in-person interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated she did not know why the medication gabapentin was not available for Resident #51. The DON indicated there was confusion regarding the requirements to order and reorder gabapentin and she did not understand the requirements herself. The DON revealed the Consultant Pharmacist had informed her when she started at the facility at the end of March of the problem with gabapentin not being available. Being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills. An in-person interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be available and administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identify that a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician further indicated it was not right to withhold medication from a resident and it had the potential for adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered. 2. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident # 46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact with no behaviors. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident had no pain in the previous 5 days. A physician order dated 1/18/24 indicated Resident #46 had a PRN (as needed) order for hydrocodone acetaminophen 5-325 milligrams (mg) every 6 hours as needed for pain. A review of the Medication Administration Record (MAR) for 5/1/24 through 5/9/24 revealed Resident #46 was administered the PRN hydrocodone acetaminophen 10 doses with the highest pain level recorded as 8. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM and was assigned to Resident #46. Nurse #3 indicated a card of gabapentin was delivered for Resident #46 on 5/6/24 but the medication did not have a controlled substance sign out sheet, so she asked Nurse #2 what to do. Nurse #3 indicated Nurse #2 returned the card of gabapentin for Resident #46 to the pharmacy with the delivery driver. Nurse #3 stated she did not inform the Unit Manager, Director of Nursing (DON), or pharmacy that the medication was returned as she thought Nurse #2 would have done this. An interview was conducted with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she worked on 5/6/24 from 7:00 PM to 7:00 AM but she was not assigned to Resident #46. Nurse #2 recalled the gabapentin was delivered from the pharmacy for Resident #46 on 5/6/24 but it did not have a controlled drug sheet attached. Nurse #2 stated she was told by someone, but she could not recall who, to return the medication to the pharmacy with the delivery driver due to no controlled drug sheet. Nurse #2 indicated she did not inform the Unit Manager, DON or pharmacy that the medication was returned as she thought the nurse assigned to Resident #46 would do it. Review of a Controlled Drug Record for Resident #46 revealed the last dose from the supply of gabapentin delivered on 4/8/24 was signed out by Nurse #7 on 5/10/24 at 8:00 AM bringing the count to 0 pills remaining. Resident #46's May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM. The MAR further indicated there was no routine monitoring of Resident #46's pain level. The May 2024 MAR specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication: 5/10/24 - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. - The MAR at 9:51 PM indicated Nurse #3 administered a PRN dose of hydrocodone acetaminophen 5-325 mg for pain. 5/11/24 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:43 PM. - The MAR indicated at 9:43 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen. 5/12/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:09 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. A pain level of 9 was recorded at 9:37 PM. - The MAR indicated at 9:37 PM Nurse #3 administered a PRN dose of 5-325 mg hydrocodone acetaminophen. 5/13/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:44 AM indicated awaiting pharmacy delivery of gabapentin. - The MAR for 9:00 PM indicated Nurse #17 documented a 9. A pain level of 8 was recorded at 10:50 PM. The corresponding nursing note at 10:53 PM indicated the medication on order from pharmacy. - The MAR indicated at 9:50 PM Nurse #17 administered a PRN dose of 5-325 mg hydrocodone acetaminophen for pain. 5/14/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 17 documented a 9 and there was no corresponding nursing note. - The MAR indicated at 9:25 PM Nurse #17 administered an as needed dose of 5-325 mg hydrocodone acetaminophen. 5/15/24 - The MAR for 9:00 AM indicated Nurse #7 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #17 documented a 9 and there was no corresponding nursing note. 5/16/24 - The MAR for 9:00 AM indicated Unit Manager #2 documented a 9. The corresponding nursing note at 9:17 AM indicated waiting for delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse #11 documented a 9. The corresponding nursing note on 5/17/24 at 12:40 AM indicated awaiting medication delivery from pharmacy. 5/17/24 - The MAR for 9:00 AM indicated Nurse #5 documented a 9. An administration note dated 5/17/24 at 10:09 AM indicated awaiting medication delivery of gabapentin from pharmacy. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. A pain level of 7 was recorded at 9:04 PM. An interview was conducted with Nurse #3 on 6/13/24 at 1:45 PM. Nurse #3 stated she was assigned to Resident #46 on 5/10/24, 5/11/24, and 5/12/24 from 7:00 PM to 7:00 AM. Nurse #3 stated she documented 9 on 5/10/24, 5/11/24, and 5/12/24 at 9:00 PM for the scheduled doses of gabapentin and indicated the medication was not administered due to it was unavailable. Nurse #3 stated she was unaware of the process to obtain the medication and she did not follow up to obtain the medication. Nurse #3 stated Resident #46 had pain and was unable to sleep which was a change from the norm when she did not receive the medication gabapentin. An interview was conducted with Nurse #6 on 6/13/24 at 12:30 PM. Nurse #6 stated she was an agency nurse that had worked at the facility for several months. Nurse #6 stated she administered the prescribed dose of gabapentin on 5/11/24 at 9:00 AM from the emergency medication delivery system as it was not available on the medication cart. Nurse #6 stated she was told by someone, unable to recall who, after she gave the dose from the emergency medication delivery system that she was not to do so since it was not the correct dose. The emergency medication delivery system contained gabapentin 100 mg tablets and Resident #46's physician order was for 800 mg. Nurse #6 stated she was assigned to Resident #46 on 5/12/24 and 5/13/24 and documented 9 on the electronic MAR for the scheduled 9:00 AM doses of gabapentin. Nurse #6 stated the medication was not available on the medication cart and she did not obtain it from the emergency medication delivery system on 5/12/24 or 5/13/24. Nurse #6 stated she was not aware of the process for obtaining a medication that was not available. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #17. Nurse #17 stated she worked at the facility through an agency for about 6 weeks. Nurse # 17 stated she was assigned to Resident #46 from 7:00 PM to 7:00 AM shift on 5/13/24, 5/14/24, and 5/15/24. Nurse #17 stated she looked for the medication on the medication cart and when she did not see it, she documented it 9, not available. Nurse #17 indicated medications were frequently missing and ran out from the medication cart. Nurse #17 stated she did not notify the pharmacy or the provider that the medication was not available. Nurse #17 revealed gabapentin was prescribed for pain and Resident #46 exhibited increased pain, irritability and anxiety from not receiving the medication. An interview was conducted on 6/13/24 at 3:47 PM with Nurse #16. Nurse #16 was assigned to Resident #46 on 5/13/24, 5/14/24 and 5/15/24 from 7:00 PM to 7:00 AM. Nurse #16 stated 9 on the electronic MAR indicated the medication was not available. Nurse #16 indicated she documented 9 for unavailable on Resident #46's MAR on 5/13/24, 5/14/24 and 5/15/24 at 9:00 PM for the scheduled dose of gabapentin. Nurse #16 stated gabapentin was not on the medication cart for Resident #46, Nurse #16 stated she worked at the facility through an agency for about 6 weeks. Nurse #16 stated medications were frequently missing from the medication cart. Nurse #16 stated she did not call the pharmacy to obtain the medication. Nurse #16 stated gabapentin was prescribed for pain and not receiving the medication caused Resident #46 increased pain. An interview was conducted with Nurse #7 on 6/13/24 at 11:30 AM. Nurse #7 revealed she was an agency nurse at the facility since March. Nurse #7 was assigned to Resident #46 on 5/14/24 and 5/15/24 from 7:00 AM to 7:00 PM. Nurse #7 stated she did not administer the ordered dose of gabapentin on 5/14/24 and 5/15/24 at 9:00 AM due to it not being available. Nurse #7 stated she signed for the dose on the electronic MAR on 5/15/24 at 9:00 AM in error. Nurse #7 recalled gabapentin was not available on the medication cart, but she did not attempt to obtain it or notify the physician. Nurse #7 stated Resident #46 was upset and had increased pain when she did not receive the ordered gabapentin. Nurse #7 stated she was aware that gabapentin was prescribed for nerve pain and not receiving the medication would cause the resident to have increased pain and should be monitored for this. Nurse #7 was unaware of the process for obtaining a medication that was not available. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated she thought a written or electronic prescription was required to obtain a refill of gabapentin. Unit Manager #2 stated there had been delays in receiving refills of gabapentin, but she did not know why and Resident #46 had gone without the medication. Unit Manager #2 indicated she was assigned to Resident #46 on 5/16/24 from 7:00 AM to 3:00 PM. Unit Manager #2 stated gabapentin was unavailable for Resident #46 on 5/16/24 at 9:00 AM as ordered, resident had increased pain and she did not attempt to obtain it. Unit Manager #2 stated she did nothing about Resident #46's medication not being available. An interview was conducted with Nurse #5 on 6/14/24 at 9:00 AM. Nurse #5 stated there was a problem with running out of medications and medications not being available. Nurse #5 stated she used the computer to reorder medications, but they frequently did not come in and she did not know why. Nurse #5 stated administration was aware of the problem with medication not coming in from pharmacy. Nurse #5 stated she did not know if a written or electric prescription was needed to reorder gabapentin. Nurse #5 stated she was assigned to Resident #46 on 5/17/24 for the 7:00 AM to 7:00 PM shift. Nurse #5 stated she did not administer the scheduled gabapentin on 5/17/24 at 9:00 AM, did not call the pharmacy to obtain the medication and observed Resident #46 to have increased pain which was abnormal for the resident. Nurse #5 stated she the medication was on order, so she did not attempt to obtain it. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:25 PM. Nurse #2 stated she was the nurse assigned to Resident #46 on 5/17/24 from 7:00 PM to 7:00 AM. Nurse #2 stated gabapentin was not available for the prescribed dose for Resident #46 on 5/17/24 and resident had increased pain. Nurse #2 stated she did not call the pharmacy to obtain the prescribed [TRUNCATED]

Based on record review and interviews with resident, staff, Consultant Pharmacist, Pharmacy Quality Assurance Specialist, Physician, and Wound Clinic Physician, the facility failed to prevent significant medication errors for 9 of 10 residents reviewed (Resident #269, Resident #51, Resident #46, Resident #419, Resident #39, Resident #32, Resident #10, Resident #50, and Resident #8). Resident #269 was administered 6 doses of haloperidol (antipsychotic medication) 20 milligrams (mg) instead of the ordered dosage of 2 tablets of 2 mg at bedtime and was not administered carvedilol (a medication used to treat heart failure, high blood pressure and chest pain) for 25 of the ordered doses. Resident #269 experienced an elevated pulse and shortness of breath requiring Emergency Department (ED) evaluation on 3/14/24. Resident #51 was not administered 21 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/8/24 through 5/13/24 resulting in complaints of constant pain up to a 10 (on a scale of 0 to 10 with the 10 being the worst pain possible), numbness in her legs, and spasms. She was transferred to the ED twice on 5/12/24 where she was treated for acute pain with gabapentin and returned to the facility. Resident #46 was not administered 14 doses of gabapentin (prescribed for nerve pain) 800 mg from 5/10/24 through 5/17/24 resulting in increased pain, trouble sleeping, anxiety, irritability, nausea, and being unable to complete her normal routine due to pain in her legs. Resident #419 was not administered 6 doses of intravenous (IV) (delivered into the vein) Rocephin (antibiotic) and 7 doses of IV Daptomycin (antibiotic) for treatment of his infected stage 4 sacral (triangular bone at the base of the spine) pressure ulcer. The resident was hospitalized on [DATE] and the 4/26/24 discharge summary indicated they suspected Resident #419's sepsis likely centered around his large stage 4 pressure ulcer with likely chronic osteomyelitis (bone infection). In addition, the facility: administered 14 doses of Amoxicillin (antibiotic) to Resident #39 instead of the ordered Amoxicillin-Clavulanate; did not administer 34 doses of Resident #32's ordered mirtazapine (antidepressant medication); did not administer 23 doses of Resident #10's ordered tetrabenazine prescribed for the treatment of tardive dyskinesia (involuntary movements such as tongue thrusting, rapid eye blinking, repetitive chewing, that can occur with long term psychotropic use); did not follow the parameters indicated in the physician's order for Resident #50's blood pressure medication resulting in 8 doses not administered as ordered; and did not administer 12 doses of Resident #8's Oxycodone/Acetaminophen (opioid pain medication), 3 doses of Ozempic (anti-diabetic medication), 1 dose of Glipizide (anti-diabetic medication), and 1 dose of Rivaroxaban (anticoagulant). Immediate Jeopardy began on: 3/14/24 for Resident #269 when haloperidol and carvedilol were not administered as ordered and the resident required ED evaluation due to shortness of breath and an elevated pulse; 5/9/24 for Resident #51 when gabapentin not being administered as ordered resulted in a 10 out of 10 pain scale; 5/12/14 for Resident #46 when gabapentin not being administered as ordered resulted in increased pain and difficulty sleeping, and on 3/15/24 for Resident #419 when the resident's IV dislodged (came out of her vein) and the nurse was unable to restart the IV to administer the ordered antibiotic. Immediate Jeopardy was removed on 6/15/24 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Examples #5, #6, #7, #8, and #9 were cited at scope and severity E. Findings included: 1. Review of Resident #269's hospital discharge summary dated 3/7/24 indicated the resident was to receive haloperidol 2 tablets of 2 milligrams (mg) at bedtime for mood and carvedilol 12.5 mg twice per day. Resident #269 was admitted on [DATE] with diagnoses which included congestive heart failure, atrial fibrillation and toxic encephalopathy (a neurological disorder caused by exposure to toxic substances). Resident #269's admission physician orders entered on 3/7/24 included haloperidol 20 mg at bedtime for mood. The order was entered into the computer by the previous Director of Nursing (DON). Resident #269's admission physician orders entered on 3/7/24 did not include carvedilol 12.5 mg as indicated in his hospital discharge summary. Review of Resident #269's medical record revealed the admission assessment was completed by Nurse #9 on 3/7/24 at 3:22 PM. Review of Resident #269's March 2024 Medication Administration Record (MAR) revealed haloperidol 20 mg was scheduled to be administered at 8:00 PM. The MAR was blank on 3/7/24 for the scheduled 8:00 PM dose. The MAR revealed the medication was electronically signed as administered on 3/8/24, 3/9/24, 3/10/24, 3/11/24, 3/12/24, and 3/13/24. The MAR further revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily from admission on 3/7/24 through the morning of 3/14/24 as indicated in the hospital discharge summary. This resulted in 14 missed doses of the medication from admission on 3/7/24 through the morning of 3/14/24. Resident #269's admission Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and received antipsychotic medication. Review of Resident #269's March 2024 MAR revealed vital signs were to be obtained every shift. On 3/14/24 day shift (7:00 AM to 3:00 PM) the following were recorded: Blood pressure 162/90 (elevated), pulse 113 (elevated), respirations 20 and temperature 97.0 degrees Fahrenheit. Review of Resident #269's electronic health record revealed a nursing progress note written by Nurse #9 dated 3/14/24 at 12:10 PM which indicated resident complained of shortness of breath and stated he did not feel right. Resident #269's vital signs were: blood pressure 136/90, pulse 113 (elevated), respirations 22, temperature 97.5 and oxygen saturation of 98% on 3 liters of oxygen. Resident #269 requested to go to the hospital. On 3/14/24 at 12:25 PM Resident #269 went out of the facility to the emergency department. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:00 PM. Nurse # 9 stated she was no longer employed at the facility. Nurse #9 stated she was assigned to Resident #269 on 3/14/24 when he requested to be sent to the emergency room for evaluation. Nurse #9 stated Resident #269 was not doing well that day. Nurse #9 further stated Resident #269 complained of not feeling well, stating he knew something was wrong, his pulse was elevated, he was short of breath and reported he did not feel good all over. Nurse #9 stated after she sent Resident #269 to the hospital, she reviewed his medications and saw the dose of haloperidol was 20 mg. Nurse #9 stated she did not administer Resident #269 haloperidol on her shift as it was ordered to be given on night shift. Nurse #9 indicated if she saw a dose of 20 mg of haloperidol on the MAR to be given, she would not have given it since it was a higher dose than normally ordered. Nurse #9 stated she would clarify a dose that was higher than normal with the doctor. An Emergency Department (ED) Provider Report dated 3/14/24 at 4:24 PM indicated Resident #269 was evaluated with a chief complaint of shortness of breath. Chest x ray and laboratory tests were obtained with no further treatment required. Vital signs upon discharge from the emergency department were blood pressure 138/88, respirations 18 and oxygen saturation 94 percent. The discharge medication list indicated Resident #269 was to receive in part the medication haloperidol 2 tablets of 2 mg at bedtime and carvedilol 12.5 mg twice per day. There was no indication in the ED report of the significant medication errors with haloperidol or carvedilol. Review of the electronic health record for Resident #269 revealed the resident returned to the facility on [DATE] at 6:44 PM. Review of Resident #269's physician orders revealed an order dated 3/14/24 for haloperidol 2 mg give 1 tablet at bedtime for mood. The order was entered by the previous DON and was discontinued on 3/15/24. Review of the March 2024 MAR for Resident #269 revealed haloperidol 2 mg give 1 tablet at bedtime on 3/14/24 at 8:00 PM was documented with a 9 indicating to see nurses notes. Review of Resident #269's nursing progress notes revealed there was no corresponding note on 3/14/24 at 8:00 PM. Review of Resident #269's physician orders revealed an order dated 3/15/24 for haloperidol 2 mg give 2 tablets at bedtime for mood. Review of Resident #269's electronic health record revealed an incident note written by Nurse #4 on 3/15/2024 at 3:58 PM. The note indicated Resident #269's order for haloperidol was transcribed in the computer incorrectly. The progress note indicated Resident #269 received the incorrect dose of haloperidol on 3/8, 3/9, 3/10, 3/11, 3/12, and 3/13/24. Attempts were made to interview Nurse #4 via phone with messages left on 6/11/24 and 6/12/24 with no return call received. Nurse #4 no longer worked at the facility. The order for carvedilol 12.5 mg indicated in the 3/14/24 ED discharge summary was not entered into Resident #269's physician orders when the resident returned to the facility. The March 2024 MAR revealed that Resident #269 did not receive carvedilol 12.5 mg twice daily on the evening of 3/14/24 through the morning of 3/20/24 as indicated in the ED discharge summary. This resulted in 12 missed doses of the medication. A nursing progress note dated 3/20/24 at 11:50 AM written by Nurse #7 stated resident was discharged home. An interview was conducted with Nurse #13 via phone on 6/27/24 at 12:50 PM. Nurse #13 was assigned to Resident #269 on 3/8/24 from 7:00 PM to 7:00 AM and administered the haloperidol 20 mg on 3/8/24 at 9:00 PM. Nurse #13 stated she administered the medication as ordered and documented on the MAR. Nurse #13 did not recall any further information regarding the dose of haloperidol. An interview was conducted via phone with Nurse #8 on 6/13/24 at 5:12 PM. Nurse #8 confirmed she was assigned to Resident #269 from 7:00 PM to 7:00 AM on 3/9/24 and she administered haloperidol 20 mg according to the physician order and as documented on the MAR. Nurse #8 stated she did not think about it at the time to clarify or hold the haloperidol due to an excessive dose. An interview was conducted with Unit Manager #1 on 6/13/24 at 9:30 AM. Unit Manager #1 stated she was assigned to Resident #269 on 3/11/24, 3/12/24 and 3/13/24. Unit Manager stated she administered the ordered doses of haloperidol to Resident #269 at 9:00 PM on 3/11/24, 3/12/24 and 3/13/24. Unit Manager #1 stated she did not question the dose or obtain a clarification of the dose prior to administering it. An interview was conducted with Unit Manager #2 on 6/13/24 at 8:15 AM. Unit Manager #2 indicated normally, the floor nurses entered the orders in the computer without verifying the orders with the Physician when a resident was admitted . Unit Manager #2 stated she was not sure who was supposed to fax the orders from the hospital, that she did not do it and she thought it must be someone from administration. Unit Manager #2 confirmed she was assigned to Resident #269 on 3/10/24 and her electronic signature on the MAR indicated she administered the 9:00 PM dose of haloperidol 20 mg. Unit Manager #2 stated it did not occur to her to clarify the dose or hold the haloperidol due to the dose of 20 mg ordered being higher than a usual dose ordered. An interview was conducted via phone with the previous Director of Nursing (DON) on 6/13/24 at 1:20 PM. The previous DON stated she entered the orders into the computer for Resident #269 on 3/7/24 when he was admitted to the facility from the hospital. She stated she entered the order for haloperidol incorrectly. She indicated she did not know why she put the order in incorrectly and couldn't say what happened. The previous DON revealed she was not aware she omitted the order for carvedilol and she did not have an explanation for why other than human error. The previous DON indicated she did not recall if she sent the discharge summary to the pharmacy. The previous DON stated she recalled Resident #269 went to the emergency room but did not know why or the outcome. The previous DON stated she left the position at the facility shortly after the resident was sent to the hospital. An interview was conducted via phone with the Pharmacy Quality Assurance Specialist on 6/12/24 at 11:50 AM. The Quality Assurance Specialist indicated the pharmacy dispensed 30 tablets of haloperidol 20 mg on 3/7/24 for Resident #269. The Quality Assurance Specialist indicated the pharmacy did not receive the hospital discharge summary dated 3/7/24 for Resident #269. The Quality Assurance Specialist stated normally the pharmacist compared the discharge summary and the orders that were entered and would call the facility for clarification or to report discrepancies. The Quality Assurance Specialist indicated documentation in the pharmacy record indicated the pharmacy did not receive a discharge summary for Resident #269. The pharmacy record indicated the pharmacist called the facility on 3/7/24 and was informed by the previous Director of Nursing (DON) to send all Resident # 269's medications as they were entered into the computer. Precautions indicated to use haloperidol with extreme caution with residents with cardiac arrhythmia. The Quality Assurance Specialist stated there was no dosage warning in the computer for the haloperidol dosage. An interview was conducted via phone with the Consultant Pharmacist on 6/12/24 at 9:15 AM. The Consultant Pharmacist indicated haloperidol 20 mg was a high dose which was usually only prescribed in an acute setting with a major psychiatric diagnosis. The Consultant Pharmacist indicated the high dose of haloperidol had the potential for adverse effects including harm and receiving the medication at that dose for a sustained period increased the likelihood of effects. The Consultant Pharmacist stated adverse effects could include but were not limited to sedation, somnolence, movement disorders, drooling and severe respiratory difficulty. The Consultant Pharmacist stated the haloperidol error was a significant medication error. The Consultant Pharmacist reported the omission of carvedilol could result in harm due to potential for exacerbation of atrial fibrillation (irregular heart rate) and congestive heart failure. The Consultant Pharmacist indicated there was a systemic problem with medication administration in the facility for some time and she addressed this with the current DON when she started in March. The Consultant Pharmacist indicated the pharmacy was supposed to receive a copy of the discharge orders to reconcile that with what was entered into the computer by the facility. An interview was conducted via phone with the Physician on 6/11/24 at 1:00 PM. The Physician stated she was new to the facility having started on 6/7/24. The Physician stated in her career as a physician she had never prescribed a dose of 20 milligrams of haloperidol. The Physician indicated the recommended dose that she would prescribe was 2.5 milligrams to 5 milligrams as a one-time dose for an acute psychotic episode. The Physician further stated 6 doses of 20 mg of haloperidol had the potential for serious adverse effects such as sedation, increased tiredness, and respiratory difficulty. The Physician reported the omission of carvedilol from Resident #269's medication list from admission on 3/7/24 through discharge on 3/20/24 was concerning and had the potential for serious adverse effects including changes in blood pressure, heart rate, shortness of breath and worsening of congestive heart failure. An interview was conducted with the current Director of Nursing (DON) on 6/12/24 at 2:15 PM. The DON indicated the incorrect dose of haloperidol administered to Resident #269 was a significant medication error. The DON stated she was aware of the error with the transcription of Resident #269's orders and stated the error was made by the previous DON. The DON stated she did not recall how she was made aware of the error. The DON stated she expected orders to be transcribed correctly and the discharge summary to be faxed to the pharmacy by the floor nurse. An interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated it was her expectation that medications would be transcribed and administered correctly. She stated she was unaware of the error that occurred with the transcription of Resident #269's medications. 2. Resident #51 was admitted on [DATE] with diagnosis which included in part: chronic pain syndrome, chronic back pain, rheumatoid arthritis, pressure ulcers, and spastic paraplegia (a disorder that causes progressive weakness, stiffness, tightness, pain and muscle spasms of the lower extremities). Review of Resident #51's physician orders revealed an 11/21/23 order for gabapentin 800 milligrams (mg) 4 times per day for nerve pain. Review of Resident #51's quarterly Minimum Data Set (MDS) dated [DATE] indicated resident was cognitively intact and exhibited no behaviors. The MDS assessment was coded as received scheduled and as needed pain medication. The pain interview was not assessed. The May 2024 Medication Administration Record (MAR) indicated Resident #51's gabapentin was scheduled to be administered at 9:00 AM, 12:00 PM, 5:00 PM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/8/24 - The MAR for 5:00 PM indicated Nurse #8 documented a 9 and the corresponding administration record note at 5:23 PM indicated the facility was awaiting the arrival of gabapentin 800 mg from the pharmacy. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. 5/9/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #8 documented a 9 and there was no corresponding nursing note. Following readmission to the facility on [DATE], a pain assessment dated [DATE] was completed by Nurse #9. The pain assessment indicated Resident #51 had pain almost constantly with a pain rating of 10 and the pain made it hard to sleep and day to day activities were limited due to pain. A nursing progress note by Nurse #9 on 5/9/24 indicated Resident #51 refused a shower due to too much pain. An interview was conducted via phone on 6/13/24 at 5:12 PM with Nurse #8. Nurse #8 stated she was assigned to Resident #51 on 5/8/24 and 5/10/24. Nurse #8 stated she was familiar with Resident #51. Nurse # 8 stated Resident #51 had increased pain when she did not receive her gabapentin. Nurse #8 stated 9 documented on the MAR indicated the medication was not available. If a medication was not available, she stated she would wait a few days and then notify Unit Manager #1. Nurse #8 stated she did not recall when, but she knew she notified Unit Manager #1 that Resident #51's gabapentin was not available. Nurse #8 stated Resident # 51 was frustrated about not receiving the medication gabapentin as ordered. A nursing progress note written by Nurse #8 on 5/10/24 at 3:24 AM indicated Resident #51 reported her legs were numb. The note indicated the nurse informed there were no interventions for this and offered emergency room evaluation. Resident #51 declined to be sent to the emergency room . The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/10/24 - The MAR for 9:00 AM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #9 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse #13 documented a 9 and the corresponding administration record note at 10:12 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. An interview was conducted via phone with Nurse #9 on 6/13/24 at 2:15 PM. Nurse # 9 was assigned to Resident #51 on 5/9/24 and 5/10/24 from 7:00 AM to 7:00 PM. Nurse # 9 stated Resident # 51's gabapentin was not available on 5/9/24 and 5/10/24 for the scheduled doses at 9:00 AM, 12:00 PM and 5:00 PM. Nurse # 9 revealed she documented 9 which indicated the medication was not available for the doses. Nurse # 9 stated she did not attempt to obtain medication for Resident #51. An interview was conducted via phone with Nurse #13 on 6/27/24 at 12:50 PM. Nurse #13 stated Resident #51's gabapentin was unavailable, and she had not administered it. Nurse #13 stated she did not attempt to obtain the medication for Resident #51. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/11/24 - The MAR for 9:00 AM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 12:00 PM indicated Unit Manager #1 documented a 9 and there was no corresponding nursing note. - The MAR for 5:00 PM indicated Nurse #14 documented a 9 and the corresponding progress note on 5/11/24 at 4:15 PM indicated gabapentin 800 mg was pending from the pharmacy and the nurse pass on information to next shift to follow up. - The MAR for 9:00 PM indicated Nurse #2 documented a 9 and there was no corresponding nursing note. An in-person interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 revealed she was assigned to Resident #51 on 5/11/24 from 7:00 AM to 3:00 PM and she documented the medication gabapentin was not available for the scheduled doses at 9:00 AM and 12:00 PM. Unit Manager #1 stated she did not recall if she made any attempt to obtain the medication for Resident #51. Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. A progress note written by Nurse #2 on 5/12/2024 at 3:48 AM indicated Resident #51 complained of pain and spasming and requested to be sent to emergency room . Resident #51 was alert and oriented and stated that symptoms were due to gabapentin withdrawal from not receiving her medication as ordered. An Emergency Department (ED) Summary dated 5/12/24 at 6:11 AM indicated Resident #51 was evaluated for a chief complaint that the facility had been out of her gabapentin for a couple of days and now she was experiencing full body cramps. The ED Summary stated Resident #51 presented to the ED on 5/12/24 at 4:22 AM and reported she had not had her gabapentin and thought she was in gabapentin withdrawal. While in the ED, at 4:43 AM on 5/12/24 Resident #51 was administered gabapentin 800 mg. The discharge instructions were to restart gabapentin 800 mg 4 times per day, to follow up with her primary care physician and to not stop taking prescription medication for pain suddenly. Resident #51 was discharged back to the facility on [DATE] at 6:11 AM. An interview was conducted via phone with Nurse #2 on 6/14/24 at 2:24 PM. Nurse #2 stated she was an agency nurse at the facility and worked from 7:00 PM to 7:00 AM. Nurse #2 was assigned to Resident #51 on 5/11/24 into 5/12/24. Nurse #2 recalled sending Resident #51 to the hospital on 5/12/24 due to uncontrolled pain and not having her prescribed gabapentin on hand in the facility. Resident #51 kept complaining of pain during the shift and was shaking and stating she did not feel well. Resident #51 requested to be sent to the hospital for evaluation and to receive her prescribed medication gabapentin for pain. Nurse #2 stated she notified the provider and sent Resident #51 to the hospital. A progress note written by Nurse #14 on 5/12/24 at 10:09 AM indicated Resident #51 returned from the hospital at approximately 8:00 AM. Unit Manager #1 was made aware on 5/11/24 that Resident #51 had not received her gabapentin and was sent to the emergency room last night to obtain it. The MAR for 5/12/24 revealed Nurse #14 inaccurately documented a 6 for the 9:00 AM, 12:00 PM, and 5:00 PM doses of Resident #51's gabapentin which indicated the resident was in the hospital. (Resident #51 returned from the ED on 5/12/24 at approximately 8:00 AM [per Nurse #14's progress note] and the next scheduled dose of gabapentin was due at 9:00 AM). Attempts were made to interview Nurse #14 via phone with messages left on 6/13/24 and 6/14/24 with no return call received. A progress note written by Nurse #8 on 5/13/24 at 2:40 AM revealed on 5/12/24 at 7:50 PM the nurse was called to resident's room. Resident #51 complained of worsening muscle spasms all over and requested to go to the emergency department. 911 was called for transfer to the emergency room . Resident #51 returned to the facility having received gabapentin at the emergency room . Resident #51 told the emergency room staff that until she received her gabapentin at the facility, she would continue to go to the emergency room every time she was supposed to get it or at least daily. emergency room physician sent a new prescription for gabapentin 800mg four times per day to facility pharmacy. Resident #51 returned to the facility at 9:41 PM. An ED Summary dated 5/12/24 at 8:50 PM indicated Resident #51 presented with muscle spasms and reported she was unable to get her gabapentin prescription refilled at the nursing facility and was having breakthrough pain. The Medication Administration Record for the ED indicated Resident #51 was administered gabapentin 800 mg on 5/12/24 at 9:12 PM. Resident #51 was discharged back to the facility on [DATE] at 9:41 PM with instructions to continue with gabapentin 800 mg 4 times per day. The MAR and the medication administration notes revealed the following related to Resident #51's gabapentin: 5/13/24 - The MAR for 9:00 AM indicated Nurse #15 documented a 9 and the corresponding administration record note at 10:05 AM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 12:00 PM indicated Nurse #15 documented a 9 and the corresponding administration record note at 1:41 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy. - The MAR for 5:00 PM indicated Nurse # 15 documented a 9 and there was no corresponding nursing note. - The MAR for 9:00 PM indicated Nurse # 11 documented a 9 and the corresponding administration record note at 10:52 PM indicated the facility was awaiting delivery of gabapentin 800 mg from the pharmacy Pharmacy records indicated a supply of 120 gabapentin pills was sent to the facility for Resident #51 on 5/13/24. A 6/7/24 nursing progress note indicated Resident #51 was transferred to the hospital due to a change in condition. Resident #51 remained in the hospital as of 6/19/24 and was unavailable for interview. An interview was conducted with Unit Manager #1 on 6/13/24 at 8:00 AM. Unit Manager #1 stated she was in the role of Unit Manager for 3-4 weeks. Unit Manager #1 recalled Resident #51 ran out of gabapentin and required emergency room evaluations due to not receiving the medication. Unit Manager #1 did not recall when or how she became aware of the medication errors of Resident #51 not receiving the ordered medication gabapentin. An interview by phone was conducted with the Consultant Pharmacist on 6/12/24 at 9:14 AM. The Consultant Pharmacist stated she discussed the problems with obtaining medications for administration in March when the current Director of Nursing (DON) came into the position at the facility. The Consultant Pharmacist indicated not receiving gabapentin as ordered could cause increased pain, withdrawal symptoms, and tachycardia (a heart rhythm problem causing elevated heart rate) and was a significant medication error. The Consultant Pharmacist indicated withdrawal symptoms may start within 12 hours and may be severe. An interview was conducted with the Director of Nursing (DON) on 6/12/24 at 2:00 PM. The DON stated Resident #51 not receiving the prescribed medication gabapentin from 5/8/24 through 5/13/24 was a significant medication error. The DON revealed the Consultant Pharmacist had informed her of the problem with gabapentin not being available but being new to the DON position, she had not investigated the problem. The DON stated a system was required in the facility to track medication refills to prevent further significant medication errors due to not obtaining refills. An interview was conducted with the Administrator on 6/14/24 at 4:10 PM. The Administrator stated she expected medications would be administered as ordered by the physician. The Administrator stated nursing staff did not have a comprehensive understanding of what to do when they identified that a medication was not available for administration. An interview via phone was conducted with the Physician on 6/18/24 at 1:20 PM. The Physician indicated the dose of gabapentin ordered, 800 mg 4 times per day was a high dose of medication and it was not recommended to abruptly stop taking the medication due to the potential for withdrawal and severe pain. The Physician stated increased pain was a definite concern due to not receiving the scheduled gabapentin as ordered and it could start within 12 hours. The Physician indicated omission of an ordered medication was a medication error and had the potential for serious adverse outcome. The Physician revealed Resident #51 being sent to the hospital for evaluation due to increased pain was the outcome of not receiving the scheduled doses of the medication gabapentin as ordered by the physician. She stated it was the responsibility of the facility to obtain the medications so they could be administered as ordered. 3. Resident #46 was admitted on [DATE] with diagnosis which included diabetes and neuropathy. Review of Resident #46's physician orders revealed a 12/6/23 order for gabapentin 800 milligrams (mg) 2 times per day for nerve pain. Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact with no behaviors. Resident #46 received scheduled and as needed pain medication, pain interview should be conducted, and resident had no pain in the previous 5 days. Review of a Controlled Drug Record for Resident #46 revealed the last dose from the supply of gabapentin delivered on 4/8/24 was signed out by Nurse #7 on 5/10/24 at 8:00 AM bringing the count to 0 pills remaining. The May 2024 Medication Administration Record (MAR) indicated gabapentin 800 mg was to be administered at 9:00 AM and 9:00 PM and specified the documentation of a 9 indicated to see the nursing notes. This MAR and the medication administration notes revealed the following related to Resident #46's pain medication: 5/10/24 - The MAR for 9:00 PM indicated Nurse # 3 documented a 9 and there was no corresponding nursing note. 5/11/24 - The MAR for 9:00 AM indicated Nurse #6 documented as the medication was administered. - The MAR for 9:00 PM indicated Nurse #3 documented a 9 and there was no corresponding nursing note. 5/12/24 - The MAR for 9:00 AM indicated Nurse #6 documented a 9. The corresponding nursing note at 9:0 [TRUNCATED]

Based on observation, staff interviews, Physician interview, and record review the facility failed to provide supervision to prevent a cognitively impaired resident who displayed wandering and exit seeking behaviors from exiting the facility unsupervised for 1 of 1 residents (Resident #6) reviewed for accidents. Resident #6 was found unsupervised outside of the facility by facility staff on two separate occasions (08/11/18 and 11/17/18) and returned inside with no injuries. Additionally, the facility failed to monitor Resident #6's Wanderguard each shift for placement and each night for function and on 12/18/18 when she was attempting to make another unsupervised exit from the facility staff discovered she was not wearing her Wanderguard. Immediate Jeopardy began on 08/11/18 when Resident #6 was found outside of the facility without supervision by Nursing Assistant (NA) #1 at the end of the street approximately 325 feet away from the facility. Resident #6 exited the facility unsupervised again on 11/17/18 through the front door, crossed the sidewalk and walked on to the paved driveway before staff (who were alerted by the door alarm) reached her. Immediate Jeopardy was removed on 01/19/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. Findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's plan of care from the resident's admission to the facility on [DATE] until 08/13/18 revealed there was no care plan for wandering or exit seeking behaviors. Review of the admission assessment completed on 06/06/18 revealed behaviors were not triggered in the Care Area Assessment (CAA) section and there was no documentation that behaviors would be carried forward to the care planning phase. Review of Resident #6's nursing progress notes revealed staff documented that Resident #6 displayed the following behaviors in (MONTH) (YEAR): Review of a note written, by Nurse #5 on 06/06/18 at 2:41 PM, revealed Resident #6 complained of not wanting to stay at the facility and wanting to stay with family. Review of a note written, by Nurse #5 on 06/08/18 at 4:39 PM, specified Resident #6 was restless and agitated, complained she was supposed to go home, and wanted money and directions out. Review of a note written, by Nurse #6 on 06/18/18 at 2:05 AM, revealed she came out of her room asking to call a cab so she could get help. Review of a note written, by Nurse #5 on 06/28/18 at 2:45 PM, revealed she repeatedly complained of wanting to go home at the shift start. Review of the 30 day Minimum Data Set Assessment ((MDS) dated [DATE] revealed that Resident #6 had severely impaired cognition. She used a wheelchair for ambulation. She required supervision only for locomotion in her room and was independent for locomotion off the unit. She did not display any behaviors and was not resistant to care. The assessment further revealed Resident #6 did not have wandering behaviors during the assessment period. Review of Resident #6's medical record revealed a Wander Risk Assessment was not completed by staff until after the resident's first unsupervised exit from the facility which occurred on 08/11/18. Review of the progress note written by Nurse #1 on 08/11/18 at 3:42 PM documented Resident #6 was found at the stop sign at the end of the street beside the church by an aide (Nurse Aide #1) who was returning from her break. (The stop sign is approximately 325 feet from the facility. The street is a residential 2 lane paved road with uneven shoulders on both sides.) During an interview conducted with Nurse Aide (NA) #1 on 1/18/19 at 11:10 AM she stated she went out for lunch between 12:30 PM and 1:00 PM on 08/11/18. When she was driving back to the facility she noticed one of the facility residents alone, with her rolling walker at the stop sign at the end of the street. She stated she immediately put the car in park, got out and talked to Resident #6 and convinced her to get back into her car with her. NA #1 stated she called the facility and told them she found Resident #6 down the road at the stop sign, but before she could inform them Resident #6 was in her car and safe they hung up. By the time she got back to the facility with Resident #6 staff were outside looking for her. NA #1 stated she asked Resident #6 where she was going and she told her she wanted some red nail polish. She stated she was able to convince Resident #6 to go back into the building by promising her that she would personally bring her some red nail polish. NA #1 stated the weather wasn't rainy or cold and she remembered Resident #6 had on pants, shoes and a shirt and was appropriately dressed for the day. On 01/17/19 at 1:30 PM an observation was made of the street where Resident #6 was found by Nurse Aide (NA) #1 on 08/11/18. This observation revealed the street was a residential 2 lane paved road with uneven shoulders on both sides. Where the resident was found was 350 feet away from the facility (walked off by the survey team). The temperature outside the facility on 08/11/18 at 11:50 AM was 88.7 degrees Fahrenheit according to the National Weather Service-Raleigh. Review of the facility incident report dated 08/11/18 at 2:45 PM written by the Director of Nursing recorded the following interview with Resident #6: I have been asking over and over all week to go to the store to get some nail polish, scissors and earrings and they haven't let me go yet. I was trying to go to the store to get my stuff. I normally can go to the store and do the things I want to on my own. Resident #6 was crying. Description of the immediate action taken: She was assessed and a Wanderguard bracelet was placed on her right ankle. No injuries were noted. Review of an elopement incident note written by Nurse #1 on 08/11/18 at 3:42 PM and attached to the incident report revealed that a wandering assessment was completed and the resident was determined to be not safe to leave the facility on her own. A Wanderguard was placed on the resident to alert staff if the resident tried to go outside so that staff could assist her. Activities was going to check with the resident on planned trips to the store to see if she wanted to go as she had exited the facility to go to the store. The mental health group also assessed the resident on 08/11/18 and wrote new orders for [MEDICATION NAME] 25 milligrams (mg) daily, a medication used for anxiety and depression because the resident had been noticed with episodes of crying. The resident's care plan was updated for elopement. In an interview conducted with the Director of Nursing (DON) on 01/17/19 at 6:35 PM she stated a Wander Risk Assessment was not completed when the Resident #6 was admitted to the facility. The DON commented that staff had not recognized the exit seeking behaviors displayed by the resident before her unsupervised exit from the facility on 08/11/18 and staff did not consider her to be an elopement risk. The DON stated Resident #6 was not wearing a Wanderguard prior to 08/11/18 which allowed her to exit the front door of the facility unsupervised and undetected on 08/11/18. Review of the facility incident report dated 11/17/18 at 7:35 AM written by the Director of Nursing documented the following incident description: Resident #6 had an attempted elopement around 7:00 AM but was redirected by staff and brought to the 400 hall day room. At approximately 7:30 AM the alarms were going off, by the time staff got to resident she was in the parking lot. The resident description was documented as: Resident stating she was leaving because staff was doping her sister up. Talking about her roommate. The immediate action taken as documented on the incident report: Resident assisted back in the building x1 and brought back to the 400 hall day room for breakfast. Review of the nurse progress note written on 11/17/18 at 10:22 AM by Nurse #2 specified she intercepted Resident #6 trying to elope out the front door at 7:00 AM on 11/17/18 when she was reporting for work. She put the resident in the 400 hall day room and went to take report from the third shift nurse. At 7:35 AM the alarm sounded but by the time staff could reach the resident she had crossed the threshold and got into the parking lot. She notified the physician and the family. At that time the granddaughter told her that the resident had stated the weekend before that she was going to run away. An observation on 01/18/19 at 1:45 PM of where staff located Resident #6 on 11/17/18 revealed the resident in the facility's front parking lot approximately 20 feet from the facility's front entrance (walked off by survey team). Observations of both the sidewalk and parking lot revealed they were evenly paved. The temperature outside the facility on 11/17/18 at 7:40 AM was 36.5 degrees Fahrenheit according to the National Weather Service-Raleigh. In an interview conducted with Nurse #2 on 01/17/19 at 5:42 PM she described Resident #6's unsupervised exit that occurred on 11/17/18. She stated she heard the alarm go off at the front door and she went immediately to the door but Resident #6 had made it across the sidewalk and into the paved driveway in front of the facility before she could get to her. She stated there was no traffic in the drive way because most employees reporting for work had already parked and were in the facility. She said the weather wasn't cold and it was not raining that morning and she could not remember what the resident was wearing. She stated earlier during the morning of 11/17/18 at 7:00 AM Resident #6 made an attempt to elope from the facility and she put the resident in the day room. Nurse #2 explained she did not assign anyone to watch Resident #6 in the day room because when she went into the chart room and she thought if the resident tried to exit the facility's front door again she would be able to see her through a window in the chart room. Nurse #6 stated she did not see Resident #6 go past the window in the chart room and the resident successfully exited the facility's front door unsupervised at 7:35 AM. Review of the elopement incident follow up note written by the Social Worker on 11/19/18 (no time recorded) revealed she documented she had been made aware Resident #6 attempted to exit the building because her sister was being doped up. The note stated Resident #6 was having increased confusion and delusions. The mental health team was contacted and assessed the resident that morning. A nursing progress note date 12/18/18, written by Nurse #3, revealed Resident #6's Wanderguard alarm did not sound when she attempted to exit or reenter the facility's front door and it was discovered that she was not wearing a Wanderguard bracelet. During an interview conducted with Nurse #3 on 1/18/19 at 10:25 AM she stated that she was able to intercept Resident #6 on 12/18/18 as she attempted to exit the facility's front door unsupervised. She said she saw the resident as she opened the door before she crossed the threshold. Nurse #3 stated she did not hear the door alarm go off when the resident exited the door or when she re-entered the building. She said she found that Resident #6 was not wearing a Wanderguard bracelet. Review of Resident #6's care plan revealed that on 08/13/18, after the resident exited the facility unsupervised on 08/11/18, the Social Worker updated the care plan to include a goal for the resident to remain safe and not leave the facility unattended through the next review date. New care plan interventions initiated on 8/13/18 included: Check the function of the Wanderguard each night (nursing), Check placement of the Wanderguard each shift (nursing), and Wanderguard in place to ankle (nurse aides). Review of Resident #6's medical record revealed no documentation from 8/13/18 to 12/18/18 that nursing staff implemented the care plan interventions to checking the function of the resident's Wanderguard each night and to check the placement of the Wanderguard each shift as specified on the resident's care plan. On 01/17/19 at 5:42 PM an interview was conducted with Nurse #2, who cared for Resident #6. Nurse #2 confirmed there was no indication on the Medication Administration Record, [REDACTED]. During an interview conducted with the Director of Nursing on 01/17/19 at 6:35 PM she stated that she expected interventions documented on the plan of care to be communicated to and implemented by staff. On 01/19/19 at 9:52 AM Physician #1 was interviewed by phone. She stated she was made aware that Resident #6 had been outside the building on multiple occasions. She reported she was told the resident went out the doors with other visitors and was found unharmed and without injury. She commented she was assured by the facility that they had put interventions in place to protect the residents. She also remarked that the Medical Director had been informed and involved in dealing with elopements. Physician #1 stated she felt Resident #6 was safe in the building because there had been no reports of trouble in the last month. She reported she was involved with the facility in developing policies about how to deal with newly admitted residents who present with wandering tendencies or later began exhibiting exit seeking behaviors. On 01/19/19 at 5:25 PM the Medical Director was interviewed by phone. He stated he was aware the facility had issues with residents leaving the building unsupervised. He did not remember if they specifically spoke about Resident #6. He stated he felt Resident #6 was safe because there was not a lot of traffic where the facility was located. He stated he felt Resident #6 would have the problem of trying to leave a facility wherever she was placed. The facility Administrator and Director of Nursing were notified of Immediate Jeopardy on 01/18/19 at 3:55 PM. On 01/19/19 at 12:54 PM the facility provided the following credible allegation of immediate jeopardy removal: The plan to correct specific deficiency and facts that led to the alleged deficient practice: Summary of events: Resident #6, an [AGE] year old female, was admitted from home where she lived with daughter to [MEDICATION NAME] Living and Rehab Center (PLRC) on 5/24/18 with [DIAGNOSES REDACTED]. Resident was alert, verbal with clear speech, and used wheel chair for locomotion, propelling herself. On 5/27/18, she was assessed by physical therapy to have high fatigue and difficulty walking and was able to ambulate 8 feet with minimal assist using a front wheel walker. She was discharged from physical therapy on 7/10/18 having met the goal of being able to ambulate 300 feet with stand by assistance and occasional verbal cues. Summary of events that led to alleged deficient practice: On 8/11/18, resident left facility and was approximately 200 yards from front door when spotted by a Certified Nursing Assistant (CNA) and brought back in through front doors. Resident was assessed by Registered Nurse (RN) to be alert and oriented to person, place, time and situation. She had no injuries. When describing what occurred, she was tearful and she stated she had been doing things on her own all her life and she was just going to the store to get some things she needed. On 11/17/18, resident demonstrated some confusion and was trying to leave through the front doors. Licensed Practical Nurse (LPN) redirected her and helped her to the Day Room for breakfast. About 30 minutes later, the alarm sounded and she had crossed over the threshold of the front door and stepped approximately 4 feet past front doors (per camera footage review). When resident was describing what had occurred, she told the nurse that she was leaving because they were doping up her sister (referring to her roommate). On 12/18/18, Resident #6 was observed exiting front door of facility by RN who was leaving out of side exit after completion of her shift. RN initiated Code Pink and resident was easily redirected back into building. Resident was visualized throughout entire incident and no injuries were incurred. The resident was found to be missing her secure care bracelet (SCB). Root Cause Analysis (RCA) discovered 2 system failures: No wandering assessment had been completed despite resident having verbalized a desire to go home on one occasion as well as requesting to call a cab in order to get help related to pain in her knees (after topical pain medication had been applied). Therefore, there was no trigger for a wandering/elopement care plan. The Care Plan was developed on 8/13/18 to include applying SCB, checking function and placement; however, there was no communication with the staff to check placement or function of SCB. Corrective action for involved resident: For 8/11/18 event: On 8/11/18, wandering assessment was completed and a SCB was applied. On 8/12/18, staff brought in some red nail polish to satisfy resident's request and provide an activity that was meaningful for the resident. On 8/13/18, care plan was updated and implemented by Activities Director to include the opportunities for her to go shopping and on other outings of her choice to satisfy her desire to be independent. On 8/13/18, mental health services visited with resident and recommended psychotherapy 1-4 times per month as well as adding an anti-depressant to her medication regimen. All staff (including nursing, therapy, social services, activities, housekeeping/environmental services, dietary, maintenance and administrative departments) were in-serviced on CODE PINK/Missing Resident emergency procedure by 8/23/18. Initiated Admission assessment schedule on 9/11/18 to ensure no assessments were omitted from admission process. For 11/17/18 event: 'Dealing with behaviors / Verbal de-escalation' in-service was scheduled and provided to staff by mental health hospital staff on 11/29/18. 'Effective Communication with Residents' in-service was provided to staff on 12/11/18. Staff re-in-serviced on CODE PINK with special emphasis on recognizing resident's exit seeking behaviors. Nursing Home Administrator contacted wandering resident/access control system company on 11/19/18 with concerns. New upgrades to wandering resident/access control system to increase transmitter signal reception installed on 11/30/18. On 11/19/18, mental health services visited with resident. For 12/18/18 event: Replaced SCB 12/19/18. Order was entered into electronic medical record (EMR) to ensure function is validated each night shift by nurse. Task was entered into EMR to ensure placement is validated each shift by CNA. Wandering list updated. Ensured picture was available to staff of all wandering/elopement risk residents. IDT discussed alternate placement in skilled facility with locked dementia unit. Ombudsman contacted via email for assistance in finding alternate placement on 1/2/19. Representative from skilled facility with locked unit came to facility to assess resident for appropriateness of admission 1/9/19. Measures put in place to ensure deficient practice does not occur: Facility wide audit completed to ensure all residents have been assessed for wandering within past quarter and that any residents at risk have been evaluated for the necessity of an SCB on 1/18/19. SCB Audit completed on 1/18/19 including: Order entered into EMR to ensure function is validated each night shift by nurse. Task is entered into EMR to ensure placement is validated each shift by CNA. Care plan reviewed for inclusion of wandering issues. Wandering list up-to-date. Pictures available to staff of all wandering/elopement risk residents. Staff in-services started on 1/19/19 to re-educate nurses on using function checking device. Anyone who has not received this in-service will not be allowed to clock in until they have signed that they received in-service. Staff in-services started on 1/19/19 to re-educate CNAs on the importance of accurate documentation in EMR. Anyone who has not received this in-service will not be allowed to clock in until they have signed that they received in-service. Staff in-services to be scheduled for mental health services to educate regarding behaviors that signal a potential for an attempted elopement as well as behavior interventions and management. Care plan for Resident #6 was updated on 1/19/19 and implemented by Social Worker and DON to include placement of additional SCB on rollator because she has successfully removed the SCB from her body in the past and is dependent on rollator for ambulation. Audit performed by Registered Nurse on 1/19/19 to ensure no objects that could be utilized to remove SCB are readily accessible to residents wearing these bracelets. Nail clippers were removed from resident's possession by Social Worker on 1/19/19. Weekly task was added to each resident who wears a SCB's EMR to check possessions for any objects that could potentially be utilized to remove the SCB. How facility will monitor performance so solutions are sustained: SCB Audit completed by Social Worker for 100% of residents assessed to be at risk for elopement weekly for 3 months to include: Order entered into EMR to ensure function is validated each night shift by nurse. Task is entered into EMR to ensure placement is validated each shift by CNA. Care plan reviewed for inclusion of wandering issues. Wandering list up-to-date. Pictures available to staff of all wandering/elopement risk residents. Possessions checked for any objects that could potentially be utilized to remove the SCB. Admission Assessment Audit performed weekly by Minimum Data Set (MDS) to ensure all newly admitted residents have been assessed for wandering within 24 hours of admission. All audits will be forwarded to Quality Assurance Performance Improvement Committee for further recommendations. Date of Compliance for Credible Allegation of Compliance: 1/19/19 Person Responsible for implementing Credible Allegation of Compliance: Director of Nursing The credible allegation of Immediate Jeopardy removal was validated on 01/19/19 at 3:38 PM. A sample of staff that included nurses, nurse aides, and non-clinical employees were interviewed regarding in-servicing related to the deficient practice. All interviewed staff members stated they had been in-serviced regarding elopement and the facility procedure for checking alarmed or locked doors. A review of all documents developed to correct the deficient practice was completed. All facility policies and procedures that were revised to address the deficient practice were reviewed. A review of audit forms that were developed to ensure that in-services presented to all staff were understood and allowed an opportunity for staff to interact with dialogue were also reviewed. All doors that were alarmed were checked and verified to be working properly.

Based on record review and staff interviews, the facility failed to prevent physical abuse for 1 of 1 residents reviewed for abuse (Resident #1) during the provision of incontinence care a nursing assistant smacked Resident #1's hand. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #1 required extensive assistance from two staff members with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #1 had no impairments and was always incontinent of bowel and bladder. Resident #1 was noted to exhibit physical behaviors toward others such as hitting, kicking, pushing, scratching, and grabbing. A review of the care plan for Resident #1 initiated on 07/18/18 indicated Resident #1 had episodes of combative behavior during care such as hitting at staff and pushing staff away. Interventions included assess and anticipate resident's needs including food, thirst, toileting needs, comfort level and positioning, provide explanation to the resident regarding task that was being done before and while providing care, and when resident became combative, stop the task and try again in a few minutes; do not force. A review of a 24-hour report regarding the employee to resident abuse revealed the report was faxed to the State of North Carolina (NC) on 08/06/18 at 5:05 PM. A review of the 5-day investigation report regarding the employee to resident abuse revealed the report was faxed to the State of NC on 08/10/18 at 4:09 PM. The investigation stated Nursing Assistant (NA) #1 was assisting Resident #1 with incontinent care with the help of NA #2 and NA #3. The report stated NA #2 and NA #3 reported to the nurse on duty that NA #1 had slapped Resident #1 ' s right hand during incontinent care. A review of a statement written by NA #2 on 08/06/18 revealed NA #2 and NA #3 went into Resident #1 ' s room to do care with NA #1. The statement stated as the NAs were doing care, the next thing NA #2 knew was that NA #1 popped the resident on the right hand and said something to the resident about the patient had pinched her. NA #2 finished helping with care and reported her observation to the nurse. A review of a statement written by NA #3 on 08/06/18 revealed NA #1 stated Resident #1 pinched her, however, NA #3 did not see Resident #1 pinch NA #1. The next thing NA #3 saw was NA #1 pop the resident on the right hand and said You done pinch me one time, and you are not going to do it again. NA #2 and NA #3 finished giving care and left the room. The incident was reported to the nurse. A review of a written statement by NA #1 on 08/06/18 revealed NA #1 asked NA #2 and NA #3 to help her change Resident #1. NA #1 stated Resident #1 gave me 3 busted lips and a bruise on my ribs a week ago which was still sore. NA #1 stated NA #3 was at the foot of the bed and NA #2 and herself were on the sides of the bed. NA #1 stated we turned the resident toward NA #2 and the resident swung. NA #1 started to clean the resident and got bowel movement on her hand from wiping her. When NA #2 guided her arm and turned her my way, the resident pinched me on my side and held it. NA #1 reported that her reflex was to pop or swat her hand away and stated I barely hit her hand, my fingertips touched her. NA #1 did not want to grip the resident ' s hand because the resident puts her hand in her mouth and nose and she still had bowel movement on her gloved hand. NA #1 stated That ' s all that happened. A review of NA #1 ' s personnel record revealed she had received abuse prevention training during orientation on 04/25/18. A course completion history confirmed NA #1 completed the abuse and neglect in service via the computer on 04/25/18. A review of the Social Worker ' s (SW) statement written on 08/09/18 revealed the SW was notified by the DON of the incident involving Resident #1 and NA #1 on 08/06/18. The note indicated the DON stated she was made aware on 08/06/18 at approximately 2:45 AM that NA #1 had made physical contact with Resident #1 on her hand. Nurse #1 asked NA #1 to clock out and leave the facility until an investigation was completed. The SW ' s statement reported the two witnesses (NA #2 and NA #3) that were in the room at the time of the incident were interviewed. The statement reported NA #2 stated they were providing incontinent care when Resident #1 started to push the staff away and pinched at NA #1. NA #2 stated NA #1 popped Resident #1 ' s hand as if you would pop a toddler to tell them no. NA #2 reported NA #1 said something to Resident #1, however, NA #2 stated she was so stunned NA #1 had just done that she didn ' t process what NA #1 said to the resident. NA #2 stated she thought to herself did that just go down? The statement reported both witnesses stated NA #1 did not move her arm back to hit Resident #1, but popped the top of her hand. NA #2 also stated Resident #1 had a surprised look on her face and did not try to pinch or push staff away during the remainder of her care. Both NA #2 and NA #3 stated they all left the room together after finishing care. NA #2 and NA #3 discussed the incident and decided NA #2 would tell the charge nurse. The statement reported Nurse #1 contacted the DON and NA #1 had been put on suspension. The SW ' s statement reported Resident #1 ' s hand had been reassessed for any redness or bruising and there were no developing injuries. The statement revealed that after reviewing all the witnesses ' statements (NA #2 and NA #3) and speaking with the NAs, the DON and SW felt that this behavior by NA #1 was unacceptable and therefore would be terminating NA #1 ' s employment. The DON and SW called the employee and terminated her effective immediately. An interview was conducted with NA #3 on 08/23/18 at 6:58 AM. NA #3 reported during the night of 08/06/18 she and NA #2 assisted NA #1 with doing incontinent care on Resident #1. NA #3 stated NA #2 wanted her to observe care with Resident #1 to see how to do care on an incontinent resident with physical behaviors. NA #3 stated she was at the foot of the bed observing NA #1 and NA #2. NA #1 was on the right side of the bed and NA #2 was on the left side of the bed near the wall. NA #3 stated they were attempting to put the brief on Resident #1 who was incontinent of urine only and NA #1 turned the resident toward NA #2. NA #3 stated she witnessed NA #1 smack Resident #1 ' s right hand and stated you ' ve done pinched me once, you are not going to do that again. NA #3 stated the resident appeared to be stunned in her expression. NA #3 stated she did not see Resident #1 pinch NA #1. NA #3 reported the resident was cooperative through the remainder of the incontinent care and when they were done she left the room and discussed the incident with NA #2. NA #3 stated that NA #2 reported the incident to Nurse #1. An interview was conducted with NA #2 on 08/23/18 at 7:10 AM. NA #2 stated the night of 08/06/18 she worked the night shift with Resident #1 and was orienting NA #3. NA #2 stated she told NA #1 when she was ready to do care on Resident #1 to let her know because she wanted NA #3 to observe. NA #2 stated she was on the left of the resident and NA #1 was on the right side of the resident. NA #2 stated Resident #1 was known to be uncooperative and combative during care and we were informing the resident what we were going to do with her care. NA #2 stated sometimes we have to wait and come back a few minutes later if we are unable to redirect the resident. NA #2 stated she and NA #1 unfastened the brief and NA #1 attempted to turn the resident toward her to clean the resident. Resident #1 started to become combative and NA #2 noted she was incontinent of urine. NA #2 stated Resident #1 was known to become combative the moment staff attempted to turn her. Resident #1 began thrashing about and resisting care. NA #2 stated once Resident #1 was facing me while lying on her side, NA #1 tucked the brief under the resident and NA #2 then turned the resident back toward NA #1. NA #2 stated Resident #1 started hollering and fussing and swinging her arms around and she observed NA #1 pop Resident #1 ' s right hand. NA #2 stated she was shocked and thought to herself Did this just go down? NA #2 reported all she heard was NA #1 say something about pinching. NA #2 stated the resident had no redness or bruising on her hand and added, NA #1 did not move her arm back to hit the resident. NA #2 stated Resident #1 did not cry out or yell in pain. NA #2 stated when we were done, she and NA #3 left the room. NA #2 stated she spoke with NA #3 and told her that staff was not supposed to do that and it had to be reported to the nurse. NA #2 stated she told Nurse #1. NA #2 stated she was not aware of any injuries that were caused by Resident #1 on NA #1. An attempt to interview NA #1 was made via phone on 08/23/18 at 10:59 AM. The voice mail of NA #1 ' s phone was full and no message was able to be recorded. An interview with Nurse #1 was conducted on 08/23/18 at 3:03 PM via phone. Nurse #1 stated NA #2 reported to her what happened with NA #1 and Resident #1. Nurse #1 stated she followed the protocol and notified the DON and sent NA #1 home. Nurse #1 stated she checked on the resident and she had no redness, no swelling and no complaints of pain to her right hand. An interview was conducted with the DON on 08/23/18 at 3:24 PM. The DON reported she had NA #1 sent home and on suspension per the abuse protocol until the investigation was completed. The DON reported she called NA #1 and had her come to the facility to write a statement on 08/06/18. The DON stated after the investigation was completed, it was determined NA #1 should be terminated due to employee to resident abuse. The DON reported her expectation of all the staff was to adhere to the abuse policy and procedures and any staff member that did not follow the policy and was found guilty of any abuse would be terminated.