Every finding on record at Vineyard Court Nursing Center

Based on observations, interviews, record review and facility policy review, the facility failed to properly store an oxygen nasal cannula when not in use for one (1) of 20 sampled residents. Resident #43Findings Include:Record review of the facility policy titled Oxygen-Administration, Concentrator, Storage, and Assemblage revealed To provide adequate tissue oxygenation by providing supplemental oxygen.Supplies.Container for delivery device when not in use (plastic bag).Record review of Resident #43's Order Summary Report revealed a physician order with a start date of 2/23/2026, O2 (oxygen) @ (at) 2 (two) Liters via nasal cannula as needed for as needed (prn) shortness of breath (SOB) related to chronic obstructive pulmonary disease, unspecified.Observation and interview on 8/11/2026 at 9:27 AM revealed Resident #43's nasal cannula lying on the floor under the bed and not stored in a protective bag. Resident #43 stated that he does use oxygen as needed. He stated that his nasal cannula is often on the floor and that staff pick the nasal cannula up from the floor and apply it to him.Observations on 8/12/2026 at 11:00 AM and 8/13/2026 at 10:02 AM revealed Resident #43's nasal cannula lying on his unmade bed and not stored in a protective bag.During an interview on 8/13/2026 at 10:04 AM, Certified Nursing Assistant (CNA) #1 confirmed that Resident #43's nasal cannula was lying on his unmade bed and was not stored in a protective bag. CNA #1 stated that she did not know how the nasal cannula should be stored when not in use.During an interview on 8/13/2026 at 10:05 AM, Registered Nurse (RN) #2 confirmed that Resident #43's nasal cannula was not stored in a protective bag, and that Resident #43 receives oxygen as needed. RN #2 stated that she applies the nasal cannula to Resident #43 when needed. RN #2 acknowledged that the nasal cannula is supposed to be stored in a protective bag when not in use. RN #2 confirmed that failure to store the nasal cannula in a protective bag placed Resident #43 at risk for infection.During an interview on 8/13/2026 at 12:00 PM, the Director of Nursing (DON) stated that while not in use, the oxygen nasal cannula should be stored in a protective bag. She stated that not doing so is an infection control concern.Record review of Resident #43's Face Sheet revealed that Resident #43 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, unspecified.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/2026 revealed a Brief Interview for Mental Status (BIMS) summary score of 14, indicating that Resident #43 was cognitively intact.

Based on observations, interviews, record review and facility policy review, the facility failed to ensure food was served at an acceptable temperature for two (2) of 20 sampled residents. Resident #2 and Resident #58Findings Include:Review of the facility policy titled, Monitoring Temperature of Cooked Foods, dated 10/2017, revealed, The temperature of TCS (Time/Temperature Control for Safety) cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 degrees Fahrenheit and below 135 degrees Fahrenheit). 1, Cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher. 2 b. When the food is placed in the hot holding equipment. The temperature of the food should be 135 degrees Fahrenheit or higher . Resident #2During an interview on 8/11/2026 at 11:45 AM, Resident #2 stated that her food is often cold.During an observation on 8/12/2026 at 12:20 PM, meal trays were delivered to the [NAME] Hall on a covered cart. Resident #2 received her lunch meal in her room. The meal consisted of a hamburger patty on a bun with toppings, onion rings, strawberry cake, water, and coffee. The Dietary Manager (DM) was in the room at the same time to perform temperature checks of the food in Resident #2's room. The hamburger patty was tested by the DM, and the temperature measured 100 degrees Fahrenheit.Record review of Resident #2's Face Sheet revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Foot Ulcer and Chronic Obstructive Pulmonary Disease, Unspecified.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/12/2026 revealed a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact.Resident #58During an interview on 8/11/2026 at 9:22 AM, Resident #58 stated that the food served by the facility is always cold.During an observation on 8/12/2026 at 12:23 PM, Resident #58 received her lunch meal tray in her room. The tray consisted of a single hamburger patty and onion rings on the plate. An interview with the resident at that same time revealed that Resident #58 stated, It's cold! The DM was in the room at the same time to perform a temperature check of the food. The hamburger patty measured 85 degrees Fahrenheit, and the onion rings measured 78 degrees Fahrenheit.Record review of Resident #58's Face Sheet revealed Resident #58 was admitted to the facility on [DATE] with a diagnosis of Multiple Fractures of Ribs, Right Side, Subsequent Encounter for Fracture with Routine Healing.Record review of the MDS with an ARD of 8/11/2026 revealed a BIMS summary score of 15, indicating Resident #58 was cognitively intact. During an interview on 8/12/2026 at 12:25 PM, the DM confirmed that the temperatures of Resident #2's and Resident #58's food were too cold and did not maintain the temperature of the160 degrees when it was checked at the time of plating the food. She confirmed that the food was also served late to the residents. The DM stated that the lunch meal was ready by 11:00 AM and dietary staff started the tray line at 11:15 AM. She stated that Resident #2 and Resident #58 were located on the [NAME] Hall and their trays were served last. She stated that trays should be on the [NAME] Hall no later than 12:00 PM. The DM stated that Resident #58's tray was the first tray prepared and placed on the cart, but it was the last tray served from the cart. She stated that cold food has been an issue as long as I have worked here. The DM stated that she had been employed at the facility for eight (8) years. She stated that the plates were cold when the food was plated and that there was no room in the kitchen for a plate warmer. She also stated that the cook was slow at plating the food, resulting in the meals taking longer to reach the hall.

Based on observation, record review, interview and facility policy review, the facility failed to label six (6) of 12 multidose insulin pens observed which lacked the date opened and applicable discard date, affecting six (6) residents. Resident #3, Resident #4, Resident #37, Resident #44, Resident #47, and Resident #48Findings include:Review of the facility's undated policy titled, Insulin Injections revealed, .Check the date the vial is opened and discard if greater than 28 days or per manufacturer guidelines. When opening a new vial, date and initial.On 08/13/2026 at 9:42 AM, during an observation of the East Hall Medication Cart with Licensed Practical Nurse (LPN) #1, the cart contained 12 multidose insulin pens. 6 of the 12 pens had been opened and previously used but were not labeled with an open date or applicable discard date. The 6 pens were labeled for use for Residents #3, #4, #37, #44, #47, and #48. In an interview at that same time, LPN #1 confirmed the insulin pens should have been dated when first opened and used. LPN #1 stated the pens would have to be discarded and replaced because staff could not determine when they had been opened.Resident #3Record review of Resident #3's Order Summary Report revealed an active physician order dated 08/10/2026 for insulin glargine 100 units/mL (milliliter), inject 15 units subcutaneously once daily. The insulin pen had 80 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #3 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications.Resident #4Record review of Resident #4's Order Summary Report revealed an active physician order dated 04/08/2026 for Lantus SoloStar 100 units/mL, inject 26 units subcutaneously at bedtime and hold if the blood glucose was less than 150. The insulin pen had 140 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia.Resident #37Record review of Resident #37's Order Summary Report revealed an active physician order dated 08/19/2025 for Lantus SoloStar 100 units/mL, inject 40 units subcutaneously at bedtime and hold if the blood glucose was less than 150. The insulin pen had 222 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #37 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with hyperglycemia.Resident #44Record review of Resident #44's Order Summary Report revealed an active physician order dated 03/18/2026 for Lantus SoloStar 100 units/mL, inject 20 units subcutaneously at bedtime. The insulin pen had 160 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #44 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with unspecified complications.Resident #47Record review of Resident #47's Order Summary Report revealed an active physician order dated 04/29/2026 for Lantus SoloStar 100 units/mL, inject 15 units subcutaneously at bedtime. The insulin pen had 240 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #47 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without complications.Resident #48Record review of Resident #48's Order Summary Report revealed an active physician order dated 04/22/2026 for insulin glargine 100 units/mL, inject 10 units subcutaneously at bedtime. The insulin pen had 240 units remaining and did not contain an open date or discard date.Record review of the Face Sheet indicated Resident #48 was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus with unspecified complications.During an interview on 08/13/2026 at 9:58 AM, the Director of Nursing confirmed multidose insulin pens should be labeled with the date opened and the applicable discard date. The Director of Nursing stated insulin could lose potency if kept beyond the permitted period after opening and, without an open date, staff could not determine whether the medication remained within that period.

Based on record review and interview the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (ABN) of Non-Coverage when the facility initiated the termination of Medicare Part A services before exhaustion of available benefit days and the resident remained in the facility for one (1) of three (3) residents reviewed for beneficiary-protection notifications. Resident #24Findings include:Review of a statement on facility letterhead, signed and dated by the Administrator on [DATE], revealed, This facility does not have a policy for issuing Advanced Beneficiary Notices.Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed the facility initiated the termination of Resident #24's Medicare Part A services before the resident exhausted the available Medicare benefit days.Record review of the Notice of Medicare Non-Coverage revealed Resident #24 was notified that Medicare-covered services would end on [DATE] and Resident #24 signed the notice on [DATE] and remained in the facility until he expired at the hospital on [DATE].Further review of the facility's records revealed Resident #24 was not provided a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) of Non-Coverage, Form CMS-10055, before the termination of Medicare Part A services. Therefore, the resident was not provided with written notice of potential financial liability or the right to request that a claim be submitted to Medicare for an official coverage determination.During an interview on [DATE] at 11:17 AM, the Administrator confirmed Resident #24 was not provided with an SNF ABN for review or signature. The Administrator stated that the Social Worker did not give it to him. The Administrator confirmed Resident #24 should have received both the Notice of Medicare Non-Coverage and the SNF ABN.Record review of the Face Sheet indicated Resident #24 was admitted to the facility on [DATE] with medical diagnoses that included Dysphagia, Pneumonia, history of falling and heart failure and the resident remained in the facility after [DATE].

Based on observation, resident and resident representative interviews, staff interviews, record review, and facility policy review, the facility failed to ensure each resident was treated with dignity and respect by the use of inappropriate language and by not providing privacy during care for two (2) of five (5) residents sampled. Resident #1 and Resident #4Findings include:Record review of facility policy titled, Resident Rights with date of 2022, revealed, The resident has the right to a dignified existence . 4. The resident has a right to be treated with respect and dignity. Resident #1An observation of facility's video footage with the Administrator and an interview with the Administrator on 9/22/25 at 1:05 PM revealed Resident #1 in her wheelchair in the hallway and Certified Nursing Assistant (CNA) #1 leaned the resident forward in her wheelchair and looked in the back of the resident's brief in a common area where other residents were present. The Administrator stated this treated the resident like she was a child.A phone interview on 9/22/25 at 1:12 PM with Certified Nursing Assistant (CNA) #1 revealed that while she and Resident #1 were in the hallway, she looked in the back of the resident's brief to see if she had diarrhea. She stated she felt that the resident was far enough in the doorway of the room to not be visible to anyone in the hall. She acknowledged that each resident should receive their care in privacy, and checking Resident #1's brief in the hallway did not respect her dignity. She confirmed that she had been in-serviced on dignity, respect, resident rights, and the need to provide care in privacy.During an interview on 9/23/25 at 11:30 AM, the Administrator acknowledged it was her expectation that resident care be done in privacy. She confirmed the facility failed to ensure each resident was treated with dignity and respect when the care of Resident #1 was provided in the hallway.Record review of CNA #1's Resident Rights training dated 2/27/24.Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE], with medical diagnoses that included Congestive Heart Failure, Type 2 Diabetes Mellitus, and Encephalopathy. Record review of Resident #1's Brief Interview for Mental Status (BIMS) score dated 7/22/25, revealed a score of 6 which indicated a severe cognitive impairment. Resident #4During a phone interview on 9/22/25 at 3:20 PM, the resident's representative stated she and her sister brought the resident back to the facility after an outing and the resident was near the nurses' station when Certified Nursing Assistant (CNA) #2 came up to her and told her to, Back your a** up. She stated this was disrespectful and unprofessional and upset the resident. She acknowledged that caregivers in a nursing facility should be held to a higher standard and that should be upheld. On 9/22/25 at 8:30 PM, CNA #2 returned phone call for an interview with the State Agency (SA) and during the interview, she acknowledged that when Resident #4 returned to the facility with her food, she asked her if she had brought her some food and the resident said she did not. She stated she told the resident, Then just turn your a** around and get out of here. She stated she was joking and did not mean to cause any bad feelings to the resident with her language, but she now realized that speaking to a resident that way was disrespectful. She stated she did not know that a** was a curse word and should not be used in the facility. She acknowledged that she was in-serviced by the Administrator about not using profanity at work. She stated she had been in-serviced on dignity, respect, and resident rights and she was wrong to use disrespectful language to a resident.An interview with Resident #4 on 9/23/25 at 9:20 AM, revealed the incident occurred when she and her daughters returned to the facility from going out to eat and she had a bag of food with her. She was near the nurses' station and CNA #2 asked, Did you bring me some food and when I said I did not, CNA #2 told her, Well get your a** back out of here. This was heard by staff members, other residents, and her [AGE] year-old and [AGE] year-old daughters. She stated that this employee uses inappropriate language frequently when speaking with her. Once, she had not eaten much of her food and CNA #2 came to pick it up and commented that she did not eat much. She told her that she did not have much of an appetite and CNA responded with, I know the h*** you don't. You're not eating any d*** food. She stated she was a minister and [NAME] and did not use curse words. She acknowledged it was not respectful, and it was embarrassing to be spoken to that way, especially when her children were with her. She acknowledged that bad language was heard in other places, but for a care giver at work in a nursing facility to curse so easily and use such disrespectful language when speaking to residents was not appropriate or professional. She stated the staff members at a nursing facility were held to a higher standard and they should not curse in front of the residents or residents' families. During an interview on 9/23/25 at 11:30 AM, the Administrator acknowledged that it was her expectation that each resident be treated with dignity and respect. She confirmed the facility failed to honor the resident's right to be treated with dignity and respect when a staff member used profanity to a resident. Record review of CNA #2's Resident Rights training dated 7/15/25.Record review of admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included End Stage Renal Disease and Type 2 Diabetes Mellitus.Record review of BIMS dated 7/14/25, revealed a score of 15 which indicated the resident was intact cognitively.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to adequately supervise residents during smoking breaks which allowed residents to smoke marijuana for two (2) of three (3) residents reviewed for smoking. Resident #1 and #2Findings include:Record review of facility policy titled, Resident Smoking dated 10/24/22, revealed, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. 8. Any resident who is deemed safe to smoke will be allowed to smoke under supervision in designated smoking areas .During an interview on 8/26/25 at 3:35 PM, Resident #1 revealed he was a smoker and would smoke during scheduled smoke breaks. He stated he was outside smoking with other residents and Resident #2 was smoking marijuana and gave the joint to him to smoke. He stated he had a drug problem in the past and did not refuse the joint even though he knew he should not have smoked it. He revealed the facility should have kept it out, so he was not tempted to use it.Attempted to interview Resident #2 on 8/26/25 at 4:05 PM, resident was alert and able to nod head to answer questions, but speech was limited at the time of interview. Nodded yes to the question of whether he was a smoker and was able to smoke during the scheduled times. When asked about an incident involving marijuana, he smiled but did not respond in any other way. During an interview with Certified Nursing Assistant (CNA) #1 on 8/27/25 at 10:50 AM, it was revealed that she and CNA #2 were outside supervising the smoking residents, and she smelled marijuana. She saw Resident #2 passing a joint to Resident #1 who put it to his mouth and took puffs of it. She did not see how Resident #2 lit this since his back was towards her. CNA #2 stated that she went inside to immediately to report this incident.An interview with CNA #2 on 8/27/25 at 11:00 AM revealed she and CNA #1 were outside with the smokers and she smelled marijuana. She saw Resident #2 passing the marijuana to Resident #1, but since Resident #2's back was towards her, she did not see him light this. She stated she went inside to report and have additional staff in the area, and they convinced Resident #2 to give the joint to them. During an interview on 8/27/25 at 9:45 AM and an interview and observation on 8/27/25 at 1:30 PM, the Administrator revealed that Resident #1 and Resident #2 were smoking marijuana during smoke break and from questioning the residents and staff and watching camera footage, it was determined that Resident #2 had the marijuana joint and lit it from his cigarette and he shared this with Resident #1 who took several puffs of it. Resident #1 told her he was an addict, and he would take what was offered to him. She stated from the camera view, only Resident #2's back was showing, so they could not see what he was doing in front of him, but they were able to see that Resident #2 passed the lit joint to Resident #1 and Resident #1 put it to his mouth and took a few puffs from it. The staff members then approached those residents and Resident #2 gave it to them. During the smoke break observation, the Administrator pointed out that Residents #1 and #2 were on the far end of the smoking area with Resident #2 positioned facing the parking lot with his back towards the other residents, staff, and camera. Resident #1 was on the side and facing Resident #1. The staff were positioned in the center of the area and only had a view of Resident #2's back. The Administrator confirmed the staff should have been positioned on each end of the rectangular area to offer a better view of all of the residents to ensure safety. She confirmed the facility failed to provide adequate supervision during smoking break and due to this a resident was able to light a marijuana joint, smoke it, and pass it to another resident who also smoked it. Review of Resident #1's Safe Smoking Evaluation dated 3/21/25, 4/10/25, and 6/6/25 revealed the box by Resident is safe to smoke unsupervised at this time was not checked.Record review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and pain.Record review of Resident #1's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 6/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.Review of Resident #2's Safe Smoking Evaluation dated 4/10/25, 8/14/25, and 8/27/25 revealed the box by Resident is safe to smoke unsupervised at this time was not checked.Record review of Resident #2's admission Record revealed resident was admitted to facility on 3/3/25 with diagnoses that included cerebral infarction.Record review of Resident #2's MDS Section C with ARD of 6/4/25 revealed a BIMS score of 14 which indicated the resident was cognitively intact.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to provide an ordered pain medication for a resident who had pain for one (1) of four (4) residents reviewed. Resident #1Findings include:Record review of facility policy titled, Pharmacy Services dated 3/14/24, revealed, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Record review of facility policy titled, Medication Shortages/Unavailable Medications with revision date of 1/1/13, revealed, Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from Pharmacy.2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. During an interview and observation on 8/26/25 at 3:35 PM, Resident #1 appeared comfortable in his room lying in his bed. He stated he had pain in his back and his feet, but was comfortable at that time. He stated he recently requested pain medication for the pain in his back and feet and he was told by the nurse that he did not have pain medication and he would have to wait until it arrived at the facility. During a phone interview on 8/27/25 at 11:15 AM, Licensed Practical Nurse (LPN) #1 revealed she was working the medication cart on the evening that Resident #1 requested pain medication, and it was unavailable. She informed him that the medication was unavailable, and he could not receive it at that time, but he did receive his other medications as scheduled. She stated she had another resident with a medical concern and got distracted by that issue and failed to follow through with obtaining the medication as needed and ordered. She acknowledged she dropped the ball and that it was my mistake and took full responsibility for not obtaining the medication as needed. Interviews with the Administrator on 8/27/25 at 9:45 AM and at 1:30 PM revealed the facility had a procedure in place to ensure each resident received the medications needed and ordered, but this procedure was not followed by LPN #1. She stated the resident had an active prescription and the nurse should have contacted the pharmacy for a code to the medication dispensing system to obtain the medication to administer to the resident. She confirmed the facility failed to provide an ordered pain medication for a resident who had pain. She confirmed the medication system was in place, but the staff member did not follow the procedure, therefore, the medication was not administered. Record review of Resident #1's Order Summary Report revealed an order for Hydrocodone-Acetaminophen tablet 7.5-325 milligrams - give one tablet by mouth every four hours as needed for severe pain. Record review of Resident #1's Controlled Substances Proof of Use with received date of 6/19/25 revealed resident completed a card of Hydrocodone 7.5-325 on 8/9/25 at 8:48 PM. Record review of Resident #1's Controlled Substances Proof of Use with received date of 8/12/25 revealed the facility received Hydrocodone 10-325 on that date.Record review of Resident #1's Electronic Medication Administration Record (EMAR) for August 2025 revealed resident received his as needed Hydrocodone on 8/9/25 at 8:48 PM then did not receive again until 8/11/25 at 12:50 PM.Record review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and pain.Record review of Resident #1's Minimum Data Set (MDS) Section C with Assessment Reference Date (ARD) of 6/16/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide the services to ensure a resident maintained/improved his/her highest level of range of motion (ROM) as evidenced by failure to apply an anti-contracture device for (1) one of (5) five residents reviewed for positioning and mobility. (Resident #6) Findings include: Review of the facility policy titled, Prosthesis and Splint Policy, with no revision date revealed, Procedure: Applied and removed as ordered. On 2/18/25 at 10:00 AM, an observation of Resident #6 revealed a contracture to the left hand, no device in place. Record review of the Order Summary Report for Resident #6 revealed an order dated 9/25/24, remove the anti-contracture device from the left hand at least five minutes every shift and observe the skin for any impaired integrity . An observation and interview on 2/19/25 at 8:45 AM, with Licensed Practical Nurse (LPN) #1 he confirmed that Resident # 6 did not have an anti-contracture device on her left hand. He also confirmed the resident was supposed to have a device on the left hand to prevent worsening of the contracture. He stated he also worked 2/18/25 on the day shift and knew the resident had an order for a device but confirmed he did not check to see if the resident had the ant-contracture device on. In continued observation, it was revealed by LPN #1 that he was unable to locate an anti-contracture device in the resident's room. In an interview with the Certified Occupational Therapy Assistant (COTA) on 2/19/25 at 10:48 AM, she confirmed Resident # 6 should have a splinting device on her left hand related to her contracture. She stated if the resident was not wearing it that it could lead to worsening of the contracture. In an interview with the Director of Nursing (DON) on 2/19/25 at 10:50 AM, she confirmed that Resident #6 should have been wearing an anti-contracture device on the left hand to prevent worsening of the contracture. Review of the Admission Record revealed the facility admitted Resident # 6 on 8/06/2009 with a diagnosis that included Polyosteoarthritis Unspecified. Record review of Resident #6's Section GG: 0115 of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 was coded impairment on both sides of the upper and lower extremities.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a care plan for the use of an anti-contracture device for (1) one of 16 resident care plans reviewed. (Resident #6) Findings include: Review of the facility policy titled, Care Plans, with an update of 2/20/20 revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care . Record review of a care plan for Resident #6 revealed, Focus: (Resident proper name) requires assistance with anti-contracture device to left hand, revised 12/11/24, with Goal .will have application of anti-contracture .Interventions .assist with applying for scheduled wearing time . An observation of Resident #6 on 2/18/25 at 10:00 AM revealed the resident's left hand was contracted with no contracture device in place. In an interview with the Director of Nursing (DON) on 2/19/25 at 10:50 AM, she confirmed after review of the contracture care plan for Resident #6 that staff did not implement the care plan when they failed to apply the device. She stated the purpose of the care plan is to direct staff of the resident specific care needed. Record review of the Admission Record revealed the facility admitted Resident # 6 on 8/06/2009 with medical diagnosis that included Polyosteoarthritis Unspecified. Record review of Resident #6's Section GG: 0115 of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 was coded impairment on both sides of the upper and lower extremities.

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to implement infection control practices to prevent the possibility of the spread of infection for 2 (two) of sixteen sampled residents. Resident #6 and Resident #7. Findings Include: Review of the facility policy titled, Infection Prevention and Control Program, revised March 23, 2023, revealed, .Equipment Protocol: .b.) Single-use items must be discarded after use . Review of the facility policy titled, Enteral Tube Medication Administration Procedures, revised July 14, 2015, revealed, .Procedure: .10.) Clean feeding syringe . Review of the facility policy, Nebulizer Policy dated 02/06/15 revealed that .12. When not in use the nebulizer and the tubing should be stored in a zip lock bag . Resident #6 An observation and interview during medication administration for Resident # 6 on 2/19/25 at 8:35 AM, revealed Licensed Practical Nurse (LPN) #1 administer medications via percutaneous endoscopic gastrostomy (PEG) tube , the PEG became clogged, and LPN #1 removed a de-clogging device from an open package laying on the bedside table and used it to unclog the PEG. He then put the de-clogging device back into the open package it was removed from. He finished his medication administration and placed the PEG syringe plunger that was used to flush the PEG back into the storage bag without cleaning. LPN #1 confirmed the de-clogger device was in an opened package before using it, and he did not know if it had been used prior. He stated with the package being opened; it was most likely used and confirmed that it was for single use only and should be disposed of after use. LPN #1 then confirmed he should not have used the de-clogger that was in the open package but should have gotten a new one to ensure it was sanitary. Furthermore, he confirmed he failed to clean the PEG syringe plunger before placing it back in the clean storage bag. He stated that using a dirty de-clogger device and failing to clean the PEG syringe plunger could lead to an infection. Review of the manufacturer guidelines for the enteral feeding tube de-clogging devices revealed Designed for single use only .: In an interview with the Director of Nursing (DON) on 2/19/25 at 10:50 AM, she confirmed that the de-clogging devices are for single use only and should be disposed of after each use. She stated the nurse should not have used the de-clogger in the opened package. She also stated that the PEG syringe plunger should have been cleaned before placing it in the clean storage bag, and both practices could lead to an increased risk of the spread of infection. Record review of the Admission Record revealed the facility admitted Resident # 6 on 8/06/2009 with diagnoses that included Encounter for Attention to Gastrostomy. Record review of Resident #6's Section K Item 0520B of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 was coded feeding tube .PEG; while a resident. Surveyor: [NAME], [NAME] Resident #7 An observation on 02/18/25 at 11:45 AM revealed a nebulizer mask on the top of the nightstand next to Resident #7's bed and it was not in a protective storage bag. The mask and tubing were hooked to the nebulizer machine next to it. An observation and interview with Resident #7 on 02/19/25 at 10:15 AM, revealed a nebulizer mask with attached tubing on top of the nightstand next to her bed and it was not in a storage bag. Resident #7 revealed that she received scheduled breathing treatments about three times a day and that she had received one earlier that morning. An interview with Licensed Practical Nurse (LPN) #1 on 02/19/25 at 10:45 AM, revealed that Resident #7 had frequent shortness of breath and that she received scheduled and as needed nebulizer breathing treatments . In an interview and observation with LPN #1 on 02/19/25 at 10:55 AM in Resident #7's room, he confirmed that Resident #7's nebulizer mask with attached tubing was setting on top of the nightstand next to her bed without a covering. He revealed that nebulizer masks and tubing were supposed to be kept in a plastic bag when not in use to prevent the spread of germs which could lead to respiratory infections. LPN #1 revealed that it was the nurses' responsibility to ensure that nebulizer masks and tubing were placed in a protective bag when breathing treatments were completed. An interview with the Administrator on 02/19/25 at 11:00 AM, revealed that nebulizer masks and tubing were supposed to be kept in a plastic protective bag when not in use. She confirmed that failure to properly store nebulizer masks could cause infection. Record review of Resident #7's Medication Administration Record revealed that she received Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG (milligrams)/3ML (milliliters) three times a day related to Acute Respiratory Failure with Hypercapnia with a start date of 01/09/25. Record review of Resident #7's Admission Record revealed the facility admitted the resident on 01/09/25 with medical diagnoses that included Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia and Hypercapnia. Record review of Resident #7's MDS with an ARD of 1/15/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. 45598

Based on staff and resident interviews, record review, and facility policy review the facility failed to immediately notify administrative staff and the local police department to ensure the immediate safety of a cognitively intact resident who left the facility parking lot on foot when he returned after being out on pass with a friend for one (1) of three (3) residents reviewed. Resident #1. Findings included: Record review of the facility policy, Incidents and Accidents Investigating and Reporting with revised date of 05/25/24 revealed Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .Compliance Guidelines: 1 .It is the responsibility of the department supervisor to notify the Administrator or Director of Nursing Immediately . Record review of the facility policy, Missing Resident/Elopements updated 2/3/2023 revealed .Procedure: 1. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the Charge Nurse as soon as practical. 2. Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure .4. Should an employee discover that a resident is missing from the facility, he/she should: c. Notify the Administrator and the Director of Nursing Services; .Notify law enforcement officials; . Record review of the Incident Report from the Police Department revealed that on 05/25/24 at 0745, Officer (Proper Name) was dispatched to (Proper Name) Nursing Home in reference to a missing resident .At approximately 13:00 (1 PM), the officer was dispatched to an area in reference to a male laying down on the ground. Once he arrived on scene, he made contact with the male that was sitting on the ground. The officer introduced himself and asked him what his name was. Resident #1 gave the officer his proper name. The Officer then called the Administrator to report that Resident #1 had been located, and she and three nurses arrived on scene to check on Resident #1. On 06/03/24 at 9:40 AM, an interview with Administrator (ADM) revealed that on 05/25/24 at 7:32 AM, the Director of Nursing (DON) called her and reported that Nursing Supervisor had called her and reported that Resident #1 had left walking from the facility the night before when his friend brought him back just before midnight. The ADM revealed that during their investigation, they found out that the Charge Nurse called the Nursing Supervisor to see how they needed to handle the situation since Resident #1 was in his right mind and able to make his own decisions. The ADM revealed that Nursing Supervisor informed them to put a note in the computer since Resident #1 was still out on leave and to just let him go. The ADM revealed that the Nursing Supervisor was packing her stuff up the next morning because she knew she had messed up. The ADM revealed that the Nursing Supervisor should have reported this to the DON or Administrator and called 911 to ensure that Resident #1 was safe. The ADM revealed when she heard about this situation, she called 911 and the police were at the facility when she arrived on 05/25/24. She revealed that they split everyone up in pairs and sent them out in different directions to search roads, ditches, bridges, businesses, neighborhoods, wooded areas, and local restaurants for Resident #1. The ADM revealed that the police department called her and reported that they found him on 05/25/24 at 1:00 PM about a mile from the facility. The ADM revealed that she drove to the site and found Resident #1 sitting in the back of the police car. An ambulance arrived and they transported him to the local hospital to be checked out. The ADM revealed that during the investigation of the incident, they found out that Licensed Practical Nurse (LPN) #1 was working that night, 05/24/24, that he answered the doorbell and Resident #1's friend reported to him that he brought Resident #1 back to the facility, but the resident took off down the street. The ADM revealed that during the investigation, they found out that Resident #1's friend had checked him out of the facility earlier that day to go to the bank and that the resident had called the facility around 11:16 PM and said he wasn't coming back. She revealed that at 11:48 PM Resident's friend called the facility and said that he had talked Resident #1 into returning to the facility, returned him to the facility and that Resident #1 took off walking down the street when he got out of the vehicle. The ADM revealed that she reviewed camera footage when she came in on the morning of 05/25/24 and saw that Resident #1 exited the parking lot of the facility at 11:57 PM, crossed the street and last saw him in the parking lot of the eye clinic across the street from the facility. On 06/03/24 at 10:20 AM, an interview with Resident #1 revealed that he felt better since he had been at the facility and wanted to go home. He revealed that he had a friend who picked him up last week and took him to the bank and stated, I got out of here. Resident #1 revealed that his friend brought him back to the nursing home and he left walking. He revealed that he walked to the (Proper Name), got a cup of coffee and then went out back behind the bowling alley, sat all night and watched the sun come up. Resident #1 revealed that the next day a cop came by and let him sit in the backseat of his car and cool off. Resident #1 revealed that he went to the hospital for a couple of days, and they brought him back to the nursing home. He stated, I don't want to be here now, and if they give me half a chance, I'll leave again. I don't like being here. He revealed that this place was okay, and they took care of him, but he wanted to go home. On 06/03/24 at 11:48 AM, a phone interview with LPN #1, revealed that he was working on the night of 05/24/24 and that Resident #1 was checked out and not in their care. He revealed that around 12:00 AM, he answered the doorbell and Resident #1's friend told him that he had brought Resident #1 back to the facility and that Resident #1 had jumped out of the car and started running towards the road. LPN #1 revealed that he went to the nursing station, told Charge Nurse and she called the Nursing Supervisor to see how to handle the situation. LPN #1 revealed that it was five to ten minutes before the Nursing Supervisor got back with them and she instructed them to put a note in the computer about what the guy said at the door and let him go since Resident #1 was still out on leave. LPN #1 revealed that he went outside and looked around the parking lot and didn't see him. LPN #1 revealed that he did what they told him to do at that particular time. He stated, Didn't none of us know what to do. On 06/03/24 at 2:00 PM, an interview with Certified Nursing Assistant (CNA) Supervisor, revealed that she was working on 05/24/24 on the night shift. She revealed that she answered the phone around 11:00 PM from Resident #1 who told her that he was not coming back to the facility because he had a lot of work to do around his house and he would return in the morning. CNA Supervisor revealed that she reported this phone call to Charge Nurse who told her that Resident #1 was in his right mind and that was his right. CNA Supervisor revealed that she sent a text to DON, letting her know that Resident #1 wasn't returning to the facility that night. CNA Supervisor revealed that she heard the next day about Resident #1 being returned by his friend to the facility and that he walked away. The CNA Supervisor revealed that this should have been handled differently. She revealed that had she known, she would have gone outside, looked for him, called 911, and called the Administrator. The CNA Supervisor revealed that Resident#1 was out on the streets all night and everyone should have been out looking for him. She stated, He was on this property, they (facility staff) knew he belonged at the facility, and he was our responsibility. The CNA Supervisor revealed that she was so glad that he was safe, and nothing happened to him. On 06/03/24 at 2:10 PM, a phone interview with the Charge Nurse, revealed that she worked a double shift on 05/24/24. She revealed that Resident #1 had been out on leave and had called late that night saying he wasn't coming back because he had things to take care of. She revealed that about an hour later, Resident #1's friend called and said he was on his way back to the facility with Resident #1. The Charge Nurse revealed that they were really busy that night and that LPN #1 had come to the nurse's station just before midnight and reported that a man came to the door, was out in the parking lot, had brought Resident #1 back to the facility and that Resident #1 had left on foot. She revealed that she wasn't sure how to handle this situation, so she went through the proper chain of command and called the Nursing Supervisor. The Charge Nurse revealed that the Nursing Supervisor told them to put a note in the computer about what the resident's friend said since Resident #1 hadn't come back into the building. The Charge Nurse revealed that she clocked out at the end of her double shift and rode around for twenty minutes looking for Resident #1. She revealed that she went to the hospital, through parking lots, neighborhoods using fog lights and did not see him anywhere. The Charge Nurse revealed that if she had it to do over again, she would have called everyone on her list including the DON and Administrator and would have been out the door like lightning looking for him. She revealed that they should have called the DON or Administrator with this situation. The Charge Nurse revealed that Resident #1 could have been in a ditch, hit by a car, could have been hurt and that's why she went out and looked for him. On 06/03/24 at 2:50 PM, an interview with DON, revealed that she received a phone call about 7:30 AM on 05/25/24 from the Nursing Supervisor who reported that Resident #1 came back to the facility on the night of 05/24/24 just before midnight and that he walked away. The DON revealed that she informed the Nursing Supervisor that she should have notified the authorities and called administration when it happened so they could have looked for him and started the elopement process. The DON revealed the Nursing Supervisor told her that she thought about calling 911 at the time of the incident but did not since Resident #1 was out on therapeutic leave. The DON revealed that Resident #1 had been signed out on pass, but he was still their responsibility because he was there at the facility. The DON revealed they called the authorities, called in help, and dispersed staff in pairs out to look for the resident. She revealed that the police found Resident #1 sitting on the ground beside the bowling alley at 1:00 PM on 05/25/24 and he had no injuries. The DON confirmed that this should have been handled differently, that they should have notified the administration and should have called 911 when Resident #1 left the premises on foot. Record review of Resident #1's Facesheet revealed that he was admitted on [DATE] and had diagnoses that included Malignant Neoplasm of Rectum, Pain, and Severe Protein-Calorie Malnutrition. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date of 03/12/2024, Section C revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated that he had moderate cognitive impairment.

Based on interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented when a resident did not receive two (2) doses of a scheduled antiarrhythmic medication for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Findings Include: Record review of the facility policy titled Care Plans updated on 02/20/20 revealed that, Each resident will have a person centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care .Procedure: 6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the interventions. Record review of Resident #4's Care Plan with start date of 02/16/2024 revealed an intervention to receive Multaq 400 mg tablet - one tablet by mouth nightly. Record review of the facility Reportable Incident Form revealed that Resident #4 was admitted to the facility with orders for Multaq 400 milligram (mg) tablet to be administered nightly related to diagnosis of atrial fibrillation. The pharmacy was unable to provide Multaq 400 mg tablets on 02/16/24, due to backorder of the medication. Resident #4 did not receive Multaq on Saturday 02/17/24, or on Sunday 02/18/24. Multaq 400 mg tablets were delivered to the facility on [DATE] at 1:16 AM. On Monday, 02/19/24, Resident #4 displayed elevated heart rate, decreased blood pressure with dizziness and nausea while attending therapy and was sent out to the hospital for evaluation. While reviewing facility records, Administrator discovered that Licensed Practical Nurse (LPN) #2, documented Multaq 400 mg as administered on Saturday, 02/17/24. The medication was not available in the facility on this date to be administered. LPN #2, did not administer Multaq 400 mg nightly on 02/18/24 and did not attempt to obtain the medication from the pharmacy or notify administration of medication not being available. LPN #2 was terminated from facility related to incorrect documentation of medication administration and failure to administer prescribed medication. During an interview with the Administrator (ADM) on 02/26/24 at 9:45 AM, revealed that she did not realize that Resident #4 had missed two doses of Multaq until she began her investigation after the resident had reported it to the Director of Nursing (DON). ADM revealed that LPN #2 did not give it on two (2) days, 02/17/24 and 02/18/24. ADM also agreed that Resident #4's Care Plan was not followed when LPN #2 failed to administer the ordered medication During an interview with LPN #3 on 02/26/24 at 2:05 PM, revealed that the purpose of the care plan was to put things in place for each individual resident so the nurses could know what medications to give, what they were given for and to see if they were helping or not. LPN #3 agreed that when LPN #2 did not give Resident #4's medication, she failed to follow the care plan. During an interview with Assistant Director of Nursing (ADON) on 02/26/24 at 3:25 PM, confirmed that the order for Multaq 400 mg tablet-one tablet by mouth nightly was on Resident #4's Care Plan and was effective 02/16/2024. The ADON, also confirmed that LPN #2 did not follow the care plan when she failed to give the Multaq 400 mg on 02/17/24 and 02/18/24. Record review of Resident #4's eMAR (electronic Medication Administration Record) for the month of February of 2024 revealed that Multaq 400 mg tablet was marked administered on 02/17/24. On 02/18/24, the Multaq 400 mg was marked N for Not Administered by LPN #2. Record review of Resident #4's Physician Orders List revealed an order dated 02/16/24 for Multaq 400 mg tablet - one tablet by mouth nightly and an order dated 02/19/24 to transfer to ER related to tachycardia. Record review of Resident #4's Facesheet revealed an admitted [DATE] and that he had diagnoses which included Acute systolic (congestive) heart failure, Anemia, Ascites, Acute kidney failure, Unspecified Atrial Fibrillation, Chronic Kidney Disease and Localized Edema. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date of 02/22/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that he was cognitively intact. The State Agency (SA) validated through interview with the Administrator and record review that the facility reported incident related to a resident not receiving two doses of heart medication was immediately investigated by the facility Administrator on 02/20/24. The State Agency (SA) validated through interview with the Administrator and record review that in-services were conducted with all nursing staff on medication administration on 02/20/24. The SA validated through interview with the Administrator and record review that a Quality Assurance meeting was held on 02/23/24 concerning the medication signed off on the MAR and not administered according to physician orders or the care plan. The SA determined the facility was in compliance on 02/23/24 when LPN #2 was formerly terminated, and in-services completed and investigation concluded.

Based on interview, record review, and facility policy review the facility failed to ensure that a resident was free from a significant medication error as evidenced by not receiving two (2) doses of an antiarrhythmic medication which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross Reference F755 Findings Include: Record review of the facility policy Medication Errors updated on 02/03/2023 revealed, Medication/Treatment errors shall be documented on the Medication Error Report. An error shall be defined as any variation in administration of medication from the physician's orders and/or facility policy. The facility policy also revealed under Procedure: 1. Report all medication errors/drug reactions to the shift charge nurse/supervisor. 2. Notify the physician/alternate physician, resident and/or legal representative, Director of Nursing and consulting pharmacist of all occurrences . Record review of the facility Reportable Incident Form dated 2/23/24 and signed by the Administrator revealed that Resident #4 was admitted to the facility with orders for Multaq 400 milligram (mg) tablet to be administered nightly related to diagnosis of atrial fibrillation. The resident's medication orders were electronically sent to the pharmacy by the facility on 02/16/24. The pharmacy was unable to provide Multaq 400 mg tablets on 02/16/24, due to backorder of the medication. Resident #4 did not receive Multaq on Saturday 02/17/24, or on Sunday 02/18/24. Multaq 400 mg tablets were delivered to the facility on [DATE] at 1:16 AM. On Monday, 02/19/24, Resident #4 displayed elevated heart rate, decreased blood pressure with dizziness and nausea while attending therapy and was sent out to the hospital for evaluation. While reviewing facility records, Administrator discovered that Licensed Practical Nurse (LPN) #2, documented Multaq 400 mg as administered on Saturday, 02/17/24. The medication was not available in the facility on this date to be administered. LPN #2, did not administer Multaq 400 mg nightly on 02/18/24 and did not attempt to obtain the medication from the pharmacy or notify administration of medication not being available. LPN #2 was terminated from facility related to incorrect documentation of medication administration and failure to administer prescribed medication. An interview with Administrator (ADM) on 02/26/24 at 9:45 AM, revealed that she did not realize that Resident #4 had missed two doses of Multaq until she began her investigation after the resident had reported it to the Director of Nursing (DON). ADM revealed LPN #2 did not give it on two (2) days, 02/17/24 and 02/18/24. LPN #2 had signed out that she gave Multaq 400 mg on 02/17/24 and that this same medication was unavailable on 02/18/24. Resident #4 was sent out to the emergency room (ER) on 02/19/24, they treated him for Atrial Fibrillation (A-Fib) and he returned to the facility with an order to increase Multaq from once a day to twice a day to attempt to get his heart out of A-Fib. On 02/20/24, the DON went in to check on Resident #4 and he told her that he had not received his heart medication at the facility in several days prior to the emergency room visit. The DON reported this to her and they immediately started investigating. ADM revealed that she asked LPN #2 about the medication being signed off as given on the MAR on 02/17/24 and LPN #2 said that she accidentally clicked it off as administered. ADM stated, She didn't click as she went. LPN #2 told her that she didn't have the medication to give Resident #4 on 02/17/24 or 02/18/24. LPN #2 didn't tell anyone the medication wasn't available and stated, She could have killed him. ADM revealed that LPN #2 would not come into the facility when she called her, so she terminated her over the phone. ADM confirmed that LPN #2 failed to give two doses of Resident #4's ordered heart medication and this caused him to go into Atrial Fibrillation and resulted in him having to be sent to the hospital. The ADM stated, I hate it happened, but I'm glad it wasn't any worse. She revealed that they already had plans in place to correct the issue with medication storage and administration and were working diligently to make things better to prevent anything like this from happening again. An interview with Nurse Practitioner (NP), on 02/26/24 at 10:50 AM, revealed that she was not aware that Resident #4 had missed two doses of his medication on 02/17/24 and 02/18/24 until after it happened. She (NP) revealed that she was not in the facility those days and that LPN #2 had not contacted her about it. Nurse Practitioner revealed that Resident #4 should not have missed two doses of his heart medication, and that this could have been detrimental. She revealed that Multaq or any heart medication should not be skipped. An interview with DON on 02/26/24 at 11:20 AM, revealed that on 02/20/24, at around 8:30 AM, she went into Resident #4's room to check on him and he told her that he hadn't been given his Multaq. DON revealed that she reported this to the Administrator, and they immediately investigated the situation and found that resident had received the one dose of Multaq on 02/16/24 and had not received doses on 02/17/24 or 02/18/24. An interview with LPN #3 on 02/26/24 at 2:05 PM, revealed that they had a two-step process to complete in the computer when they administered medications. She revealed that when she pulled the medication out of the medication cart drawer, she checked it against the MAR, placed it in a medication cup and then marked it off as prepared on the computer screen. LPN #3 revealed that after all medications were pulled and prepared, she went into the resident's room and administered them. She revealed that after the resident took the medications, she went back to the medication cart and checked off each medication as administered on the computer. LPN #3 revealed that a nurse could not document that a medication was administered unless it had first been documented as prepared. LPN #3 confirmed that there was no way to accidentally click the administration of a medication. Record review of Disciplinary Report on LPN #2 revealed she was terminated on 02/21/24 with the following offenses: Carelessness, Dishonesty, Falsification of Records, Medication Errors, Poor Performance, Breaking Nursing Home Rules, and Non-Compliance of Policy and Procedures. Details of Offense: Employee falsified documentation of medication administration on 02/17/24 and failed to administer a physician ordered medication on 02/17/24 and 02/18/24. On 02/17/24 LPN #2 documented she administered Multaq 400 mg and the medication was not delivered by the pharmacy until 02/20/24 and not available. On 02/18/24 documented the same medication was not given because it was not available. She stated she did not mean to click that she gave the medication on 02/17/24. On 02/17/24 or 2/18/24 she did not contact the Registered Nurse (RN) SPV (supervisor), Assistant Director of Nursing (ADON), or Administrator, or MD to notify the medication was unavailable. She also failed to contact the pharmacy to check on this medication. When asked if LPN #2 contacted anyone to notify the medication was not available or the pharmacy to get an update on the medication, she stated she did not and did not know why. Employee refused to come to the facility . Record review of Resident #4's eMAR (electronic Medication Administration Record) for the month of February of 2024 revealed that Multaq 400 mg tablet was marked administered on 02/17/24. On 02/18/24, the Multaq 400 mg was marked N for Not Administered by (Proper Name) LPN #2. Record review of Resident #4's Physician Orders List revealed an order dated 02/16/24 for Multaq 400 mg tablet - one tablet by mouth nightly and an order dated 02/19/24 to transfer to ER related to tachycardia. Record review of Procedure Results revealed that Resident #4 had two 12 (twelve) lead EKGs (Electrocardiograms) completed during the time he was in the emergency department on 02/19/24 and was given Multaq 400 mg and Cardizem 30 mg by mouth. The results of both EKGs were abnormal, his heart rate was tachycardic and the clinical impression stated, Atrial Fibrillation with rapid ventricular response. The EKGs were completed at 3:12 PM and at 4:36 PM on 02/19/24. Record review of Resident #4's Facesheet revealed an admitted [DATE] and that he had diagnoses which included Acute systolic (congestive) heart failure, Anemia, Ascites, Acute kidney failure, Unspecified Atrial Fibrillation, Chronic Kidney Disease and Localized Edema. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date of 02/22/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that he was cognitively intact. The State Agency (SA) validated through interview with the Administrator and record review that the facility reported incident related to a resident not receiving two doses of heart medication was immediately investigated by the facility Administrator on 02/20/24. The SA validated through interview with the Administrator and record review that a Quality Assurance Meeting was held on 02/23/24 concerning the resident not receiving two doses of heart medications. The Plan to improve performance included 1. In-Services on medication deliveries 100% nursing, 2. Match backs will be performed on third shift each night. 100% on both carts. 3. Mandatory Meeting with pharmacist 100% nursing. 4. In-Service on pharmacy policy and procedures. 5. Mandatory meeting with nursing staff with Administrator/Director of Nursing and 6. Nurse Consultant (from pharmacy) will do a match back audit on March 4th and 5th for 100% match back on both carts. The SA validated through interview with Administrator and record review of the sign in sheets that inservices were conducted with all nursing staff on proper medication administration on 02/20/24. The SA determined that the facility was in compliance on 02/23/24 when LPN #2 was formerly terminated, inservices and investigation was concluded.

Based on interview, record review, and facility policy review the facility failed to ensure that an antiarrhythmic medication was available for a resident which resulted in the resident being transported to the hospital emergency department for one (1) of three (3) residents reviewed. Resident #4. Based on the facility's implementation of corrective actions completed on 2/23/24, the State Agency determined that the deficiency was Past Non-Compliance. Cross reference F760 Findings Include: Record review of the facility policy, Medication Shortages/Unavailable Medications with revision date of 01/01/13 revealed under Procedure: 3. If a medication shortage is discovered after normal Pharmacy hours: If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: Emergency delivery; or, Use of an emergency (back-up) Third Party Pharmacy . 4. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions . Record review of the facility Reportable Incident Form revealed that Resident #4 was admitted to the facility for skilled services on Friday, 02/16/24 following hospitalization for diagnosis of Congestive Heart Failure (CHF). Resident #4 was admitted with orders for Multaq 400 milligram (mg) tablet to be administered nightly related to diagnosis of atrial fibrillation. The local hospital provided the facility with one dose of Multaq 400 mg tablet to be administered on the night of 02/16/24. The resident's medication orders were electronically sent to the pharmacy by the facility on 02/16/24. The pharmacy was unable to provide Multaq 400 mg tablets on 02/16/24, due to backorder of the medication. Resident #4 did not receive Multaq on Saturday 02/17/24, or on Sunday 02/18/24. Multaq 400 mg tablets were delivered to the facility on [DATE] at 1:16 AM. On Monday, 02/19/24, Resident #4 displayed elevated heart rate, decreased blood pressure with dizziness and nausea while attending therapy and was sent out to the hospital for evaluation. Resident #4 was evaluated and returned to the facility on [DATE] with new orders to increase Multaq 400 mg to twice daily for one week and if tachycardia greater than 110 persist Wednesday morning to return to the emergency room . While reviewing facility records, the Administrator discovered that Licensed Practical Nurse (LPN) #2, documented Multaq 400 mg as administered on Saturday, 02/17/24. The medication was not available in the facility on this date to be administered. LPN #2 did not administer Multaq 400 mg nightly on 02/18/24 and did not attempt to obtain the medication from the pharmacy or notify administration of medication not being available. LPN #2 was terminated from facility related to incorrect documentation of medication administration and failure to administer prescribed medication. In-Services initiated with nursing staff on documentation of medication administration and pharmacy protocols. This reportable incident form was signed by the Administrator and dated 02/23/24. On 02/26/24 at 9:45 AM, an interview with Administrator (ADM), revealed that Resident #4 was sent out to the hospital on 02/19/24 with symptoms of nausea, tachycardia, dizziness, and hypotension. ADM stated that she did not realize that Resident #4 had missed two doses of medication until she began her investigation after the resident had reported it to the Director of Nursing (DON). ADM revealed that she contacted the pharmacy who told her that they had sent a slip to the facility with the delivered medications on 02/16/24 with documentation that Resident #4's Multaq was on backorder. ADM stated that LPN #2 did not give it on two (2) days, 02/17/24 and 02/18/24. The ADM revealed that LPN #2 had signed out that she gave it on 02/17/24. The ADM revealed that LPN #2 did not notify anyone of the medication being on back order, and stated, She did nothing. ADM revealed that Resident #4 was sent out to the emergency room (ER) on 02/19/24, they treated him for Atrial Fibrillation (A-Fib) and he returned to the facility with an order to increase Multaq from once a day to twice a day to attempt to get his heart out of A-Fib. ADM stated that on 02/20/24, the Director of Nursing (DON) went in to check on Resident #4 and he told her that he had not received his heart medication for several days prior to the ER visit. The ADM revealed the DON reported this to her and they immediately started investigating. ADM stated she called LPN #2 by phone and she told the ADM that she did not call or report that Resident #4's medication was not in the medication cart to anyone. ADM revealed that she asked LPN #2 about the medications being signed off as given on the MAR on 02/17/24 and LPN #2 said that she accidentally clicked it off as administered. LPN #2 told her that she didn't have the medication to give Resident #4 on 02/17/24 or 02/18/24. ADM revealed that LPN #2 should have called the pharmacy and had the medication sent to another local pharmacy, or she could have called the doctor to see what to do next. ADM stated, That's common sense and she didn't do it. ADM revealed that LPN #2 didn't tell anyone the medication wasn't available and stated, She could have killed him. ADM revealed that LPN #2 would not come into the facility when she called her, so she terminated her over the phone. ADM agreed that Resident #4's medication needs were not met and revealed that he went into A-fib as a result of missing the two doses of Multaq. ADM stated, I hate it happened, but I'm glad it wasn't any worse. She revealed that they already had plans in place to correct the issue with medication storage and administration and were working diligently to make things better to prevent anything like this from happening again. On 02/26/24 at 10:50 AM, an interview with Nurse Practitioner (NP), revealed that she was not aware that Resident #4 had missed two doses of his medication on 02/17/24 and 02/18/24 until after it happened. She (NP) revealed that she was not in the facility those days and that LPN #2 had not contacted her about it. Nurse Practitioner revealed that Resident #4 should not have missed two doses of his heart medication, and that this could have been detrimental. She revealed that Multaq or any heart medication should not be skipped. On 02/26/24 at 11:20 AM, an interview with DON, revealed that on 02/19/24, Resident #4 went out to the ER for tachycardia and hypotension, and he was given medication to try to get his heart back into rhythm. She revealed that the hospital sent an order to the facility with Resident #4 to hold the Multaq on 02/19/24 because he had received it in the hospital. DON revealed that on 02/20/24, at around 8:30 AM, she went into Resident #4's room to check on him and he told her that he hadn't been given his Multaq since he had been here. DON revealed that she reported this to the Administrator, and they immediately investigated the situation and found that resident had received the one dose of Multaq on 02/16/24. The DON revealed that on 02/17/24, the Multaq had been signed out on the Medication Administration Record (MAR) as given by LPN #2 and on 02/18/24, it was documented that the Multaq wasn't there by the same LPN. DON revealed that they investigated the situation and found that Resident #4 had received the one dose of Multaq that was sent with him from the hospital on 02/16/24 and that he had missed the doses on 02/17/24 and 02/18/24. DON revealed that when LPN #2 found that the Multaq was missing, she should have contacted the pharmacy to find out about the medication and called the doctor to see what to do from there. DON agreed that Resident #4's medication needs were not met and resulted in him having to go to the ER. Record review of Pharmacy Delivery Receipt revealed that on 02/16/24, Resident #4's Multaq 400 mg tablet had the following documented status: Backorder-remaining to follow Record review of Monthly Schedule February 2024 and Timecards revealed that LPN #2 was working on the 7P-7A shift on 02/17/24 and 02/18/24. Record review of Disciplinary Report on LPN #2 revealed she was terminated on 02/21/24 with the following offenses: Carelessness, Dishonesty, Falsification of Records, Medication Errors, Poor Performance, Breaking Nursing Home Rules, and Non-Compliance of Policy and Procedures. Details of Offense: Employee falsified documentation of medication administration on 02/17/24 and failed to administer a physician ordered medication on 02/17/24 and 02/18/24. On 02/17/24 LPN #2 documented she administered Multaq 400 mg and the medication was not delivered by the pharmacy until 02/20/24 and not available. On 02/18/24 LPN #2 documented the same medication was not given because it was not available. She stated she did not mean to click that she gave the medication on 02/17/24. On 02/17/24 or 2/18/24 she did not contact the Registered Nurse (RN) SPV (supervisor), Assistant Director of Nursing (ADON), or Administrator, or MD to notify the medication was unavailable. She also failed to contact the pharmacy to check on this medication. When asked if she contacted anyone to notify the medication was not available or the pharmacy to get an update on the medication, she stated she did not and did not know why. Employee refused to come to the facility . Record review of Resident #4's eMAR (electronic Medication Administration Record) for the month of February of 2024 revealed that Multaq 400 mg tablet was administered on 02/17/24. On 02/18/24, the Multaq 400 mg was marked N for Not Administered by (Proper Name) LPN #2. Record review of Resident #4's ED (Emergency Department) Provider Notes revealed that he was seen in the emergency roiagnom on [DATE] for tachycardia, dizziness, fatigue, and shortness of breath. Under History was documented, [AGE] year old male presents to the ED with the complaint of tachycardia x (times) 2 (two) days ago. The patient suffers from Afib (Atrial Fibrillation) that he normally treats with Multaq and Midodrine. He did have an unsuccessful ablation and has been using the medications instead. He has been out of Multaq since leaving the hospital Friday. He reports that he began having an underlying attack and began having labored breathing Record review of Procedure Results revealed that Resident #4 had two, 12 (twelve) lead EKGs (Electrocardiograms) completed during the time he was in the emergency department on 02/19/24 and was given Multaq 400 mg and Cardizem 30 mg by mouth. The results of both EKGs were abnormal, his heart rate was tachycardic and the clinical impression stated, Atrial Fibrillation with rapid ventricular response. The EKGs were completed at 3:12 PM and at 4:36 PM on 02/19/24. Record review of Resident #4's Facesheet revealed an admitted [DATE] and that he had diagnoses which included Acute systolic (congestive) heart failure, Anemia, Ascites, Acute kidney failure, Unspecified Atrial Fibrillation, Chronic Kidney Disease and Localized Edema. Record review of Resident #4's Minimum Data Set (MDS) with Assessment Reference Date of 02/22/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that he was cognitively intact. Record review of Resident #4's Physician Orders List revealed an order dated 02/16/24 for Multaq 400 mg tablet - one tablet by mouth nightly and an order dated 02/19/24 to transfer to ER related to tachycardia. The State Agency (SA) validated through interview with the Administrator and record review that the facility reported incident related to a resident not receiving two doses of heart medication was immediately investigated by the facility Administrator on 02/20/24. The SA validated through interview with the Administrator and record review that a Quality Assurance Meeting was held on 02/23/24 concerning the resident not receiving two doses of heart medications. The Plan to improve performance included 1. In-Services on medication deliveries 100% nursing, 2. Match backs will be performed on third shift each night. 100% on both carts. 3. Mandatory Meeting with pharmacist 100% nursing. 4. In-Service on pharmacy policy and procedures. 5. Mandatory meeting with nursing staff with Administrator/Director of Nursing and 6. Nurse Consultant from pharmacy will do a match back audit on March 4th and 5th for 100% match back on both carts. The SA validated through interview with Administrator and record review of the sign in sheets that inservices were conducted with all nursing staff on proper medication administration on 02/20/24. The SA determined that the facility was in compliance on 02/23/24 when LPN #2 was formerly terminated, inservices and investigation was concluded.

Based on staff interview, record review, and facility policy review the facility failed to ensure that a bottle of medication was locked securely inside a medication cart to prevent resident access by one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the undated facility policy titled, Medication Storage revealed, .All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . On 02/14/24 at 9:05 AM, an interview with the Administrator (ADM), revealed that she had reported the incident where Resident #1 took the bottle of Vitamin D3 off the med cart. They watched the surveillance camera videos and saw that on 12/09/23 at 10:13 AM, the bottle of Vitamin D3 was given to Licensed Practical Nurse (LPN) #1 by Registered Nurse (RN) Supervisor, and she placed it on top of the medication cart. The ADM revealed that camera footage showed that Resident #1 walked down the hall, stopped at the medication cart and obtained the bottle of Vitamin D3 and then walked to the dining room. At 11:36 AM resident poured the pills in his hand and took them. She revealed that at 11:36 AM, video camera showed that Activities Assistant looked at the pill bottle and noticed that resident was chewing, saw the pills in his mouth and called Certified Nursing Assistant (CNA) #1 who was there in the dining room. ADM revealed that CNA #1 got resident to spit the pills out at 11:37 AM and then she notified LPN #1. ADM revealed that LPN #1 should have put the bottle of Vitamin D3 into her med cart and locked it up as soon as she received it to prevent Resident #1 or any other resident from getting it. Administrator also revealed that they were thankful for no negative outcomes; but it could have been worse. On 02/14/24 at 10:20 AM, an interview with CNA #1, revealed that she was working the day that Resident #1 took the medication. She revealed that Resident #1 had walked into the dining room and the Activities Assistant told her that Resident #1 had a medicine bottle and had something in his mouth he was chewing on. CNA #1 revealed that she put on a glove and asked the resident to give them to her and he spit them out in her hand about ten pills. CNA #1 revealed that she took the bottle from him and gave it to LPN #1, and told her what happened. She revealed that LPN #1 told her to throw the pills away and she disposed of them in the trash on the medication cart. CNA #1 revealed that Resident #1 was quick and they all knew to try and keep up with him. On 02/14/24 at 10:40 AM, a phone interview with Registered Nurse (RN) Supervisor, revealed that she was working on the day of 12/09/24. She revealed that a nurse had informed her that there was not any Vitamin D3 on the medication cart. RN Supervisor revealed that she went into the medication room, found a bottle of Vitamin D3, brought it back and handed it to LPN #1. RN Supervisor revealed that a few hours later, she was told that Resident #1 had taken some medication, RN Supervisor was shown the pills and LPN #1 revealed that it was the same bottle that she had brought to her earlier, the Vitamin D3. RN Supervisor revealed that Resident #1 was seen in the dining room with the pill bottle and was seen with something in his mouth, so it was immediate action on CNA #1's part who got him to spit them out. She stated, After watching the camera footage, we're pretty certain that they got all of the pills and feel like this was an isolated incident. RN Supervisor, revealed that they did call the Nurse Practitioner and consulted with the Pharmacist, had a Vitamin D level drawn, and monitored the resident closely. She revealed that they did initiate education and In-Services on 100% of the nurses regarding medication carts. RN Supervisor revealed that LPN #1 should have placed the bottle of Vitamin D3 in the medication cart drawer and locked it up immediately when she received it and this would have prevented Resident #1 from picking it up off the medication cart and taking it. She stated, Thankfully, he didn't suffer. On 02/14/24 at 11:35 AM, an interview with Activities Assistant, revealed that she was working on the day of 12/09/24 and was in the dining room putting up her balloons after an activity when she noticed Resident #1 entering the dining room with something in his mouth. She revealed that his cheeks were big and he was chewing on something. Activities Assistant revealed that she went and asked him to open up his mouth and she saw that he had several pills in his mouth. She revealed that about that time, CNA #1 entered the dining room and she reported it to her. Activities Assistant revealed that CNA #1 put some gloves on and asked Resident #1 to spit the pills out and he did. On 02/14/24 at 2:05 PM an interview with Assistant Director of Nursing (ADON), revealed that the Nurse Practitioner was notified, and the Pharmacist was consulted on what to watch for. She revealed that they did a thorough full investigation on the incident and LPN #1 was terminated on 12/12/23. On 02/14/24 at 2:30 PM, an interview with the ADM, revealed that the incident with Resident #1 happened on Saturday, 12/09/23. She revealed that RN Supervisor, told her that Resident #1 had picked up a Vitamin D3 bottle off the medication cart and had put several in his mouth, this was noticed immediately, and he had spit them out in a CNA's hand. ADM revealed that after a full investigation was completed and they found out that LPN #1 had left the medication out on the medication cart unattended, she was terminated. In-services were initiated about keeping the medication carts locked and keeping all medications inside the medication cart. She also revealed that LPN #1 had been trained and had been evaluated for medication administration competency not long ago and she knew better than to leave a bottle of medication out like that. ADM revealed that LPN #1 should have locked the bottle of Vitamin D3 up in the medication cart as soon as the Registered Nursing Supervisor handed it to her and not left it on top of her cart unattended. Record review of the Reportable Incident Form completed on 12/12/23 by Administrator, revealed the following: Incident Date: 12/9/23. Incident Location: Medication Cart on South Hall and Dining Room. Brief Summary of Incident: On December 9, 2023, at approximately 10:13 AM, (Proper Name), LPN (#1) was preparing medications for her medication pass and a bottle of Vitamin D3 was placed on top of the medication cart. At 11:31 AM, (Proper Name) LPN (#1) leaves her medication cart and goes into a resident's room on South Hall. (Proper Name) (Resident #1)enters the hallway from his room at approximately 11:32 AM and obtains the bottle of Vitamin D3 from the top of the medication cart. (Proper Name) (Resident #1) continues down the hallway with his rolling walker holding the medication and takes it with him to the dining room. At 11:36:29 AM, (Proper Name) (Resident #1) pours the medication into his hand and puts his hand to his mouth putting the medication into his mouth. At 11:36:40, (Proper Name) activity assistant, notices (Proper Name) (Resident #1) has a bottle of medication with medication in his mouth and notified (Proper Name) CNA (#1). At 11:37:12, (Proper Name)CNA (#1), immediately put on a glove and had the resident spit out the medication into her glove. (Proper Name) CNA (#1), notifies (Proper Name) LPN (#1) at 11:40 AM and shows her the medication in her glove. (Proper Name) LPN, (#1) notified (Proper Name), RN Supervisor . Record review of Resident #1's Facesheet revealed admitted [DATE] and had the following diagnoses that included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, Generalized Anxiety disorder, Restlessness and Agitation. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/12/24 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 12 which indicated that he had moderate cognitive deficits The SA validated through interviews, record review, inservices and observations that the facility had corrected the deficient practice on 12/12/23 prior to the SA entrance into the facility on [DATE].

Based on observation, staff and resident interviews, record review, and facility policy the facility neglected to provide prescribed pain medication to a resident who experienced severe/uncontrolled physical pain and caused mental anguish or emotional distress as evidenced by the resident's verbalization of Just need to die for one (1) of five (5) residents reviewed for pain management. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. The facility neglected to ensure nursing staff had sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room resulting in Resident #25 going without essential pain medication for days. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff neglected to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The neglect by the facility to ensure needed pain medication was available for Resident #25 caused this resident harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and SQC and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation - F600 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Abuse, Neglect, and Exploitation dated 10/24/22, revealed, It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect . Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, students in the facility's nurse aide training program, and students from affiliated academic institutions, including therapy, social and activity programs. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . During an observation on 10/10/23 at 10:15 AM, revealed Resident #25 sitting in his wheelchair in the front hallway area speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but resident was observed to be very distraught and stated, Just need to die. During an observation and interview with Resident #25 on 10/10/23 at 10:45 AM, revealed resident was in his room sitting in his electric wheelchair. His posture was slumped to the side and resident did not sit upright and straight in his chair. He stated he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated that he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain. He stated he had to ration out his pain medicine to be comfortable. He revealed he had an order for one (1) to two (2) pain tablets every six (6) hours as needed for pain and after taking one this morning, he verified he had three tablets remaining. If he took the two for therapy, he would have only one to last him until midnight. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not gotten his medication before he ran out and this should not happen. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. Interview with Registered Nurse #1 on 10/11/23 at 11:00 AM. She stated the automated medication distribution system can be used to obtain medications for the resident if an active prescription is available in the pharmacy. She confirmed there were times when the resident did not have pain medication available and she had tried at times to notify the NP to have a refill sent to pharmacy, but it was not sent timely, and the resident was without pain medication for a longer period of time. Interview with the Director of Nursing (DON) on 10/11/23 at 4:00 PM, confirmed that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain on multiple days. The DON confirmed Resident #25 was sent to the hospital for chest pain when he was out of pain medications on 09/02/23. He received a prescription for pain medications from theER on [DATE] that was sent to the pharmacy, but it was after hours, and the facility staff did not know the procedure to contact the pharmacy to notify the on-call staff that the prescription was sent, and a code was needed. The resident, therefore, had to endure pain for a long holiday weekend as well as multiple other days. She confirmed that the resident did not receive the pain medication until 5:30 AM on 09/06/23 An interview with Nurse Supervisor/Registered Nurse (RN) #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was still unavailable. She stated she contacted the NP who stated she would come to the facility to evaluate the resident, but before she arrived, the resident called 911 from his personal cell phone and was sent to the emergency room for evaluation. She confirmed the resident was out of his pain medications and he was complaining of severe/uncontrolled pain. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with others also. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the Nurse Practitioner or the Medical Doctor but was not called back. She stated when the provided did not return her call, a prescription was not obtained to receive the medications. On 10/11/23 at 4:15 PM, during an interview ,the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She stated the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a written prescription for the narcotic timely. Therefore, the resident suffered with severe, unrelieved pain for multiple days. An interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23. She stated she relied on the Nurse Practitioner (NP) to follow through with sending the orders to pharmacy as needed. She stated she is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him. A phone interview on 10/12/23 at 10:05 AM, with the Nurse Practitioner revealed she was notified by the facility staff on 9/2/23 that the resident had no pain medication and was in pain and was sent to the emergency room for evaluation of chest pain and she was unaware the resident was requiring as many pain pills as he had needed. She did confirm that she occasionally had a missed call from the facility and when she called the facility, no one knew who needed to speak to her and she did not pursue trying to talk to the administrative staff members to determine who had a concern. She confirmed this could have been some of the times when this resident needed medications. On 10/16/23 at 1:45 PM, an interview with the Administrator revealed the facility staff attempted to notify the Nurse Practitioner multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage pain with as needed (PRN) medications. She confirmed the facility neglected to manage this resident's pain appropriately by the Nurse Practitioner and the Medical Director not responding to the facility's request for a needed resident's care and service which led to severe and uncontrolled pain for a resident. During a phone interview on 10/16/23 at 2:20 PM, with the Medical Director revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he did order short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not a successful option for pain management. He stated he would occasionally order this for a hospice resident, but otherwise he would order PRN pain medicine and not scheduled pain medication. He stated last week, when the facility notified him of the concerns for this resident's pain management, he did order a scheduled every 12 hour long-acting pain medication and a short acting PRN medication. He stated that generally he was only notified when the Nurse Practitioner was unavailable. During a phone interview on 10/17/23 at 11:20 AM, the Medical Director revealed, I am not reluctant about writing for short-acting pain medications, I just do not generally schedule it. He stated he is aware the nurse practitioner wrote prescriptions, but she was not required to notify him each time she wrote a prescription, and she had the right to do this without notifying him each time. He stated, I do not recall being notified that the resident was in extreme pain for days and did not have pain medications available over Labor Day weekend and was sent to the emergency room with chest pain. He stated I do not recall the staff attempting to contact him on 9/10/23 concerning the resident's level of pain and no medication available and the staff being unable to reach the Nurse Practitioner and the resident having to wait until 9/12/23 to receive his medication from pharmacy. He stated he wrote pain medication for short term therapy residents, so they were able to participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medications. He stated he did not recall being notified by the facility of the resident's comment concerning he would be better off dead related to his pain and lack of medication. He stated he does not recall being notified of this, but the staff would only notify him if they could not reach the NP. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated on the pharmacy recommendation dated 8/29/23, it was recommended for a stop date for resident's pain medication, and this was declined with reason of chronic pain syndrome. He stated this was declined since the resident needed the PRN pain medication. The Director of Nursing wrote on the form that the resident frequently complained of pain discomfort. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He confirmed that as of last week, he was aware of the resident's pain and medication availability concerns and put the resident on a long-acting scheduled pain medication and the short acting as needed medication to be used for breakthrough pain. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medication available from the pharmacy was received on 9/6/23 for 14 tablets (10 on one card/form and 4 on another card/form). The prescription was sent on 9/2/23 at 3:40 PM. The first dose of these was administered on 9/6/23 at 5:30 AM. The next prescription for 60 tablets was ordered by the NP on 9/11/23 and was received in pharmacy on 9/11/23 at 10:59 AM. These were delivered to the facility on [DATE]. The first dose was administered on 9/12/23 at 3:30 AM and the last dose was administered on 9/25/23 at 10:15 PM. The next prescription for 60 tablets was ordered by the NP on 9/26/23 and received in the pharmacy on 9/26/23 at 5:26 PM. These were received in the facility on 9/27/23. The first dose was administered to the resident on 9/27/23 at 6:30 AM. Record review of prescription from the emergency room to the pharmacy dated 9/2/23 for Norco 7.5-325 mg (milligram) tablets with quantity of 14 tablets. Record review of the Controlled Substance Proof of Use form revealed the 14 tablets ordered in the emergency roiagnom on [DATE] arrived in the facility on 9/6/23, and the first tablet of these was administered to the resident on 9/6/23 at 5:30 AM. The last dose of these 14 tablets was documented as signed out as given on 9/9/23 at 8:01 PM. Record review of text message sent to NP from RN #2 dated 9/10/23 at 10:39 AM, revealed, Hey just double checking you sent those hard copies in yesterday? Pharmacy is saying they don't see them in their fax list. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x (times) 3, message left, MD called x 2, awaiting call back. Record review of the next prescription dated 9/11/23 and was noted as received to the pharmacy on 9/11/23 at 10:59 AM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/11/23 and received in the pharmacy on 9/11/23 at 10:59 AM were delivered to the facility on [DATE] (with their routine delivery around midnight). The first of these doses given to the resident was on 9/12/23 at 3:30 AM and the last dose was given on 9/25/23 at 10:15 PM. Record review of progress note dated 9/26/23 at 11:59 AM by Registered Nurse #1 revealed, Resident is upset that his PRN (as needed) pain medication is not in currently however we are awaiting a hard copy from providers so therefore we can not give the specific pain med that he wants at this time. This was explained to resident however he is still upset. Resident is cussing at staff and yelling inappropriately. Resident informed that he can have a different PRN such as Tylenol but he is still upset about being out of his Norco. Again, tried to educate resident on what's going on however resident began to cuss at this writer. Record review of prescription dated 9/26/23 and was noted as received into pharmacy on 9/26/23 at 5:26 PM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of Progress Note dated 9/27/23 by Nurse Practitioner revealed, Charge nurse called to report patient needs refill of hydrocodone acetaminophen. She reports patient is requesting 2 tablets every 6 hours. Order clarified for 2 tablets before therapy for severe pain otherwise one tablet every 6 hours as needed for pain. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/26/23 was noted to have arrived to facility on 9/27/23. The first dose administered of these tablets was 9/27/23 at 6:30 AM and this was the medications being used by resident when the State Agency arrived in facility on 10/10/23 and the resident had 3 tablets left and no other medication prescription waiting. Record review of History and Physical by Medical Director dated 9/6/23. No documentation concerning pain noted. Record review of Progress Note by Nurse Practitioner dated 9/7/23, revealed, History of present illness: 9/2/23 patient was sent to the ER for complaint of chest pain. He returned to facility with discharge diagnoses of Gastroesophageal Reflux Disease (GERD), Osteoarthritis involving multiple joints, Infantile Cerebral Palsy, and Chronic Pain Disorder. No documentation of pain medication not being in facility noted. Record review of Consultation Report dated 8/29/23, revealed the pharmacy recommendation was declined due to the resident's diagnosis of Chronic Pain Syndrome. Record review of Consultation Report dated 10/9/23 revealed the resident's pain medication regimen was not addressed. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE]. His diagnoses included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis and Cerebral Palsy. Record review of Resident #25's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/3/23 revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview th [TRUNCATED]

Based on staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for administering pain medications as ordered (Resident #25), applying an anti-contracture device as ordered (Resident #32), and serving a correct therapeutic diet as ordered (Resident #26) for three (3) of 19 residents reviewed. The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to follow the care plan to administer needed pain medication for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR S483.21(b)(1)(i) Comprehensive Care Plans - F656 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Care Plans, dated 2/20/20, revealed, Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Interdisciplinary - all disciplines work together to develop approaches to help residents meet needs or resolve problems. Care Plan - contains resident problems/needs/strengths, resident goals, and interdisciplinary approaches. PROCEDURE: .6. Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . Resident #25 Record review of the Care Plan with a start date of 8/29/23 revealed a Care Plan Description listed as, Sometimes I have pain, stiffness, and weakness of joints because of my Arthritis . Care Plan Goal Make me comfortable when my Arthritis bothers me .Intervention .Administer pain medication as needed. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medications available from the pharmacy was received on 9/6/23 for 14 tablets (10 on one card/form and 4 on another card/form). The prescription was sent on 9/2/23 at 3:40 PM. The first dose of these was administered on 9/6/23 at 5:30 AM. The next prescription for 60 tablets was ordered by the NP on 9/11/23 and was received in pharmacy on 9/11/23 at 10:59 AM. These were delivered to the facility on [DATE]. The first dose was administered on 9/12/23 at 3:30 AM and the last dose was administered on 9/25/23 at 10:15 PM. The next prescription for 60 tablets was ordered by the NP on 9/26/23 and received in the pharmacy on 9/26/23 at 5:26 PM. These were received in the facility on 9/27/23. The first dose was administered to the resident on 9/27/23 at 6:30 AM. Resident #25 revealed in an interview on 10/10/23 at 10:45 AM, he had pain and was ordered pain medication, but the facility did not have this available several times since he was admitted on [DATE]. He stated he is not receiving his pain medication as needed and ordered and having frequent pain due to this. During an interview on 10/11/23 at 3:25 PM, the Minimum Data Set (MDS) Coordinator revealed the resident had a care plan for pain management which included administering ordered pain medications as needed. She confirmed the care plan provides a guide for a resident's care and Resident #25's care plan related to pain management was not followed. An interview with the Director of Nursing (DON) on 10/11/23 at 4:00 PM, revealed a care plan is a guide for the resident's needs and care. She confirmed the facility did not provide the resident's pain medication as ordered and needed and therefore, the care plan for the resident's pain management was not followed. Record review of the MDS with Assessment Reference Date (ARD) of 09/03/23 revealed under Section J Pain that the assessment indicated presence of pain and a pain intensity of seven (7). Section C revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis, and Cerebral Palsy. Resident #26 Record review of the Nutrition Care Plan for Resident # 26 revealed, Provide therapeutic diet as ordered. Record review of Resident # 26's Physician Orders List revealed an order dated 3/15/22, Regular Dental/Mechanical Soft Diet, Ground Meat . On 10/10/23 at 11:50 AM, during an observation of the dining room lunch meal, Resident # 26 was observed sitting at a table feeding himself. The resident was provided a whole thin boneless chicken breast (Tuscan Chicken) that had been cut into small pieces, a mix of peas and carrots, rice, and a roll. It was observed that the resident lacked teeth and had only eaten a small portion (approximately 1/3) of the cut-up chicken. The residents lunch meal ticket read, Dental/Mechanical Soft, Ground Meat. During an observation and interview with the Dietary Manager (DM) on 10/10/23 at 11:58 AM, she confirmed that Resident # 26 was served a whole boneless chicken breast that had been cut into small pieces. She revealed that this was an oversight by the dietary server and the resident should have gotten ground chicken. An interview and record review with the MDS Nurse on 10/12/23 at 10:10 AM, confirmed that Resident #26's nutrition care plan was not followed. An interview with the Administrator (ADM) on 10/12/23 at 10:22 AM, confirmed that Resident #26's nutrition care plan was not followed. Record review of Resident # 26's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Rhabdomyolysis, Anxiety Disorder, Depression, Pericardial Effusion (noninflammatory) and Gastro-esophageal Reflux Disease without Esophagitis. Record review of the MDS with an Assessment Reference Date (ARD) of 7/19/23 revealed, under Section K, Resident # 26 received a mechanically altered diet. Also revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 4, which indicated the resident is severely cognitively impaired. Resident #32 Record review of Resident #32's Care Plan with a start date of 6/20/22 revealed, Care Plan Description Sometimes I have pain, stiffness, and weakness of joints because of my Spinocerebellar degeneration, I have an increased risk for development of contractures related to my disease process Category: Pain .Intervention .Remove anticontracture device from left hand at least for 5 minutes every (Q) shift and observe the skin for any impaired integrity . During an observation on 10/10/23 at 10:20 AM, 10:45 AM, 2:20 PM, and 4:10 PM revealed Resident #32 with his left hand contracted closed with his fingertips touching the palm of his hand. No anticontracture device was observed in his left hand. An observation and interview on 10/11/23 at 10:45 AM, with Certified Nurse Aide (CNA) #2, Resident #32 lying in bed, his left hand was contracted, and no anti-contracture device was observed. CNA #2 revealed he used to have a hand roll when he first came here, and it was used to help his hand not contract. CNA #2 looked in the residents' bedside dresser drawers and stated, I don't see it in here now, I'll have to let therapy know. CNA #2 confirmed it had been quite a while since she had seen it in his hand. On 10/11/23 at 11:55 AM, interview with Licensed Practical Nurse (LPN) #1 revealed Resident #32 is supposed to have a hand roll in his left hand. She revealed the nurses are supposed to check it each shift. She confirmed that yesterday and today she had not put a hand roll in his left hand and revealed he is supposed to have something in his hand to prevent further contractures and she should have made sure it was being done. An interview on 10/11/23 at 11:25, the Minimum Data Set (MDS) nurse revealed she is responsible for developing the comprehensive care plans, she revealed the care plans are developed individually for each resident so that each department will know exactly how to take care of the resident. She confirmed Resident #32 had it in his care plan that he was to have an anti-contracture device in his left hand and if it was not being used then the plan of care was not being followed. Record review of the Face Sheet for Resident #32 revealed he was admitted to the facility on [DATE] with diagnoses which included Contracture left wrist, Hereditary ataxia, Epilepsy, Multiple sclerosis, and Chronic pain syndrome. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. The SA validated by record review and interview with ADON the inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. The SA validated by record review and interviews with Medical Director and Pharmacy Consultant one on one education was provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. The pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. The SA validated by record review and interviews with Medical [TRUNCATED]

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident received adequate pain management as evidenced by a resident experiencing excruciating unrelieved pain for one (1) of five (5) residents assessed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/2/23, when the facility failed to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure needed pain medication was available for Resident #25 caused this resident serious harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and SQC and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR S483.25(k) Pain Management F697 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled, Pain Assessment and Management, dated 1/16/14, revealed, The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being .Recognition: . 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: a. Loss of function; b. Resisting care, striking out; c. Bracing, guarding or rubbing; f. Fidgeting, increased or recurring restlessness; g. Facial expressions: grimacing, frowning, fear, grinding of teeth; h. Change in behavior: depressed mood, decreased participation in usual activities of daily living .Documentation: .c. Notify physician of new pain or pain not relieved by medication or treatment . Record review of facility policy titled, Medication Administration General Guidelines, undated, revealed, POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so . An observation on 10/10/23 at 10:15 AM, revealed Resident #25 sitting in his wheelchair in the front hallway area of facility speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but the resident was observed to be very distraught and stated, I just need to die. An interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine. He stated the staff told him things like Trying to get the Nurse Practitioner (NP) to send a copy to the pharmacy, or They will have to call the doctor or NP to get a new prescription, or We are still waiting for it to come from the pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do, and he felt as if they were not concerned that he was suffering in pain. The resident stated that he did not want to go to therapy today because he would not have enough pain medications left if he took his pain medication prior to therapy and he didn't know when he would be able to get anymore. Resident stated, I feel like I would be better off dead. An interview with Licensed Practical Nurse (LPN) #1 on 10/10/23 at 11:00 AM, revealed Resident #25 requested one tablet at times and requested two tablets at other times for pain, especially on his therapy days, so his supply was used quicker than if only one was taken each time. She stated he had run out of his pain medication before and took an analgesic powder which was one of his ordered as needed (PRN) medications, but it was not as effective as his pain pill. She stated the resident told her he was not going to therapy today since he was concerned with not having enough pain medication since he only has three (3) tablets available for use in the medication cart at this time. She stated he was given a pain pill at 6:43 AM and she could give him two tablets when due so he could have therapy, and he would have another tablet available to use at bedtime, but after that, he did not have another prescription and would not have any more pain pills available to take. She informed him that more medication should be delivered at midnight, but he did not want to risk not having any for his pain. She stated the facility had an automated medication dispensing system that was available if the resident needed additional pain medications if an active prescription was available. LPN #1 revealed she had not called the NP for this resident's pain medications, but she had called for other concerns in the facility, and it was difficult to get in touch with her and would often require calling her several times before she called back. During an interview on 10/10/23 at 1:30 PM, the Physical Therapy Assistant (PTA) revealed the resident was very upset that he did not have pain medication available and did not receive his pain medications as he was ordered to receive, therefore, he would not attend therapy today since he was concerned about being in pain. He stated it was out of character for Resident #25 to get that upset and he had never heard him say anything like He might as well die. He stated that he had reported that statement to the clinical staff for follow up. He stated that they saw the resident in therapy today with the focus on pain control with heat therapy, and he was not able to complete his scheduled therapy session that was normally scheduled. An interview with the facility's Pharmacy Consultant on 10/10/23 at 2:00 PM revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication to be dispensed from the system, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner or the Medical Doctor to have one sent to the pharmacy for staff to receive a code for the medication. She stated Resident #25's ordered pain medication was one of the medications available in the dispensing system and could have been obtained by the staff for this resident on 09/02/23 after his visit to the emergency room (ER). She stated that the staff should know how to retrieve it from the system. During an interview on 10/11/23 at 8:10 AM, Resident #25 revealed he was sent to the ER yesterday and he received a shot of Morphine and that held him over until he received his pain medication at the facility this morning. The resident stated that he had called 911 from his cell phone in his room because he was in so much pain that he was experiencing chest pain. He stated he had received Tylenol, Ibuprofen, and Analgesic Powder when his pain medications were not available and stated, It makes it easier to bear the pain, but it doesn't go away. He also stated he did not understand why his medications continued to be unavailable. An interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1, revealed if a resident had a current prescription in the pharmacy system, a code could be obtained from the pharmacy and the automated medication dispensing system could be used to obtain the medication. When an active prescription was not available, the facility nurse would notify the NP or the Medical Director (MD) for a hard copy to be sent to the pharmacy and it would be filled and delivered to the facility around midnight. She stated Resident #25 took one to two pain pills when needed, so his pill supply did not last long. She revealed the NP, or the MD are notified when the resident had five tablets remaining on his narcotic card and confirmed that this process was not sufficient for this resident since five tablets would only last him a few hours if the maximum was taken. She confirmed she had notified the NP at times for the resident needing refills on medications, but she did not respond timely, or she wouldn't call back at all, which led to the resident being in pain and without medications. She also confirmed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) had been notified of the concerns that the resident did not receive his pain medication as ordered and needed. During an interview on 10/11/23 at 4:00 PM, the DON confirmed that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain on multiple days. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets. The DON confirmed this resident was sent to the hospital for chest pain when he was out of pain medications on 09/02/23. He received a prescription for pain medications from theER on [DATE] that was sent to the pharmacy, but it was after hours, and the facility staff did not know the procedure to contact the pharmacy to notify the on-call staff that the prescription was sent, and a code was needed. The resident, therefore, had to endure pain for a long holiday weekend as well as multiple other days. She confirmed that the resident did not receive the pain medication until 5:30 AM on 09/06/23 and she was aware of the situation of the resident being sent to the hospital, yet no procedures were changed to prevent the reoccurrence, and the resident was without pain medication several other times after this incident which was unacceptable. She confirmed the staff were not in-service on the procedure of obtaining medications to prevent this from occurring, and therefore it occurred several additional times. She confirmed the facility failed to notify the NP, MD, and pharmacy timely to provide pain medications for the resident and due to this, the resident suffered severe pain multiple days and led to the resident taking less medication than what he needed due to trying to conserve the amount available. She confirmed it was the facility's responsibility to notify the provider and the pharmacy timely when additional medications were needed, and this was not done for this resident. An interview with Nurse Supervisor/Registered Nurse (RN) #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was unavailable. She stated she contacted the NP who stated she would come to the facility to evaluate the resident, but before she arrived, the resident called 911 from his personal cell phone because he was having chest pain. She confirmed the resident was out of his pain medication and was complaining of severe/unrelieved pain and chest pain and was sent to the ER by ambulance for an evaluation. He received pain medication in the ER and a prescription was sent from the ER to the pharmacy and when he returned, he was not in pain. RN #2 stated that she had spoken with the ER doctor because she knew him and told him to give the resident a prescription for his pain medication because he was out of medication at the facility. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the NP or the MD but was not called back. She stated without being able to contact the provider, a prescription could not be obtained, medication could not be given, and the resident suffered with severe and unrelieved pain. RN#2 confirmed that she worked that Saturday 09/02/23 and Sunday 09/03/23 and she assumed that the staff knew how to use and obtain the medication from the automated drug delivery system. During an interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She felt that the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a written prescription of the medication timely. She also confirmed the facility staff failed to be proactive in a timely manner to ensure the NP or MD were notified that a prescription was needed and to give the NP/MD an adequate amount of time to send to pharmacy and pharmacy an adequate amount of time to fill and provide to the facility. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications through the automated system when needed and not available on the medication cart. She confirmed that this drug delivery system was their emergency drug kit (EDK). She confirmed the staff were not adequately trained on the automated medication dispensing system procedure to receive needed medications for the residents for a one-time dose order sent to pharmacy or even when a prescription was in the pharmacy over the long Labor Day weekend, the staff were unaware of what to do and the medication was not obtained. She confirmed the facility neglected the resident's pain management needs and therefore the resident suffered with severe and unrelieved pain for multiple days. She confirmed there were times when pain medication was not available and Tylenol was given and documented that it was ineffective, yet nothing else was done, and there were also times when the resident rated his pain scale level as a 10 and no narcotic pain medication was available to ease this resident's pain and no other interventions were documented. She confirmed the facility staff failed to notify the pharmacy, MD, or the NP when concerns of pain and lack of medications occurred. An interview with LPN #2 on 10/11/23 at 4:20 PM revealed she had worked with Resident #25 several times and on 9/4/23, he was out of his pain pills, and she offered him a Tylenol and he refused since the pain medicine was his preference to ease his pain. She stated she did not notify the provider or the pharmacy since she notified the charge nurse of the resident being out of his pain medications and was told the medication was on its way from the pharmacy. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication on a weekend, holiday, or at night. She stated she failed to meet the resident's pain management needs by not providing the needed service of pain medication for his pain management. An interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23, but she did confirm that the staff had told her that they were unable to reach the NP or the MD over the weekend of 09/02/23-09/04/23. She stated she relied on the NP to follow through with sending the orders to pharmacy as needed and this was not always done timely. She stated she is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him. A phone interview on 10/12/23 at 10:05 AM, with the NP revealed she was notified by the facility staff on 9/2/23 that the resident had no pain medication and was in pain and was sent to the emergency room for evaluation of chest pain. She stated she was unaware the resident was requiring as many pain pills as he had needed. She denied that she did not send in prescriptions when requested by the facility or that she was unavailable when the staff needed to speak to her. She did confirm that at times the facility would call her and when she called the facility back, no one knew who needed to speak to her and she did not pursue trying to talk to the Administrator, DON or the supervisor to see who had a concern. She stated this could have been some of the times when this resident needed medications, but stated there was no way to know for sure. She confirmed the facility failed to meet the pain needs for this resident, but she denied it was her responsibility since she did what she was required to do and was unsure where the breakdown for this resident occurred. During an interview on 10/12/23 at 2:30 PM, the Administrator confirmed the facility failed to provide Resident #25 with adequate pain relief for his well-being. She stated the facility was responsible for meeting these needs and when the NP did not respond timely, the facility failed to initiate contact with the Medical Director for pain management which caused Resident #25 to go without pain medications for multiple days causing him further pain and mental anguish. She confirmed the prescription that was sent to the pharmacy from the emergency roiagnom on [DATE] was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday 09/05/23 and was delivered to the facility after midnight. She stated that is why the resident did not get a dose until 09/06/23 at 5:30 AM. She confirmed the facility failed to follow up with other options to ensure this resident received the necessary care. She confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication, therefore, the resident suffered unrelieved pain. She also confirmed there were also other days that the facility failed to obtain Resident #25's medication timely and was in pain without medication to ease his pain. During an interview on 10/12/23 at 3:20 PM, the DON confirmed the facility failed to have the resident's pain meds available as ordered and needed, which led to this resident having pain for several days. She confirmed the facility failed to notify the Medical Director or Nurse Practitioner to try to find a pain management solution for this resident. She also confirmed the nursing staff were not adequately trained to know the proper steps to take to obtain residents' pain medications to prevent unrelieved pain. An interview with the Administrator on 10/16/23 at 1:45 PM, revealed the facility staff attempted to notify the NP multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage with as needed (PRN) medications. She stated when the resident went to the emergency roiagnom on [DATE], he had a prescription for pain meds and this was sent to the pharmacy, but no staff member contacted the pharmacy to get a code for the system to be able to give the resident the medication for pain. She confirmed the facility failed to educate the staff of the steps to obtain pain medications from the automated medication system and because they were not properly trained, this resident suffered days of severe and unrelieved pain. An interview with Nurse Supervisor/RN#2 on 10/16/23 at 2:00 PM, revealed that on 9/2/23, the resident complained of pain and had no pain medication available in the medication cart. She stated the resident called 911 to be taken to the emergency room for evaluation of chest pain and she informed the ER doctor of the situation with the resident not having pain meds available and he sent a prescription for 14 Norco pills to the pharmacy. She stated he received pain medication in the ER so when he returned to the facility, he was not in pain. She revealed the resident had the prescription in the pharmacy, but the staff did not know the procedure for using the medication dispensing system. She stated she assumed the staff knew how to get the meds out of the system when a prescription was available, and she did not inform the other nurses of what to do to get the ordered medication if needed. She confirmed the DON was aware of the resident's pain medication being unavailable and staff not knowing how to obtain it. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with others also. A phone interview on 10/16/23 at 2:20 PM, with the Medical Director (MD) revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he ordered short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not always beneficial for pain management. He stated he would occasionally order this for a hospice resident, but otherwise it was not what he did. He stated last week, he did order this resident a scheduled every 12 hour long-acting pain medication and a short acting PRN medication for breakthrough pain. He stated the facility would notify the NP first and would usually only contact him if the NP was unavailable. He stated that he was called on 10/10/23 to order something different for pain management for the resident and he had not ever been contacted about this resident having pain issues prior to this. He stated, My goal is to manage their pain so they can receive therapy and go home. The MD was informed of the dates that the resident had unrelieved severe pain and was not able to receive therapy and he confirmed that he was not aware of any of this information. During an interview on 10/17/23 at 9:30 AM, the ADON revealed she and the DON were aware the resident did not have his needed pain medication several different occasions. She stated she called the NP and the MD several times and she finally heard back from the NP and informed her the resident needed a prescription for his pain medication. She stated she could not remember the date and time of the conversation with the NP and did not document this in the resident's record. She stated the NP told her that Resident #25 should have enough since he was just getting one every 6 hours except for therapy times, and the ADON informed her that he took two tablets often and the order had been for 1-2 tablets every 6 hours as needed. She stated the NP said she would send a prescription to the pharmacy, but she confirmed that it was not done timely, and they had to call her back again. She confirmed the communication between the providers and staff was part of the problem and that contacting the providers was often difficult. She stated The DON and everyone else were aware the resident had been out of pain medication. She stated the resident became verbally aggressive and was cursing and she felt like this was due to him being in pain. She stated she did not work Labor Day weekend, but she did hear that a prescription was available and had been sent to the pharmacy, but the staff were unaware of the procedure to obtain the ordered medication. She confirmed she felt that many of the facility's nurses were unaware of how the automated medication system worked and how it was available for the staff to obtain residents' medications day and night. She confirmed the facility failed to call the on-call pharmacy to get the resident's ordered medication which led to the resident experiencing unrelieved pain over Labor Day weekend, and failed to get new prescriptions sent to the pharmacy timely. An interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on a weekend, night, or holiday. She stated the pharmacy sent messages when they were off, so she was unsure what to do during these times. An interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system held routine medications, but he was not aware that pain medication was also available. He stated he was unaware of the procedure to obtain pain medication for a resident if none were available in the medication cart and he would have to ask someone if the situation happened. During an interview with the Rehab Director on 10/17/23 at 10:50 AM, it was revealed that Resident #25 had been cooperative and participated in therapy each time except for two times. She stated on 9/26/23 and on 10/10/23, the resident complained of pain and was expressing frustration that his pain medication was not available as needed and he could not understand why his pain medicine was unavailable so often. She stated the nursing staff were notified of the resident's pain and pain medicine concern. She stated on 9/26/23, therapy saw the resident in his room since he was in severe pain and could not get out of bed. Stated on that day, heat wave therapy was used to help relieve his pain and it helped a minimum amount, and the resident was still in pain. She stated on 10/10/23, the resident was upset that he did not have enough pain medicine to be able to participate in therapy without hurting. On that day, he also informed the PTA that he might as well be dead since his pain was uncontrolled. She stated that on that day, therapy placed hot pack to his back and neck, but he did not have relief from his pain. She also stated that on the days he received his pain medicine, he was cooperative and participated in therapy, was a very pleasant man and would also enjoy conversations with the therapy staff. She stated his goal was to get stronger and return to his apartment, so he was very motivated to participate in his therapy. On 10/17/23 at 10:55 AM, a phone interview with the Pharmacy Consultant revealed she did random checks of the medications where she verified the narcotic count, narcotic log, and electronic medication record, but this was not done with each resident on each visit. She stated Resident #25 was a new resident and the initial pharmacy review was completed on 8/29/23 with a recommendation for a stop date for the PRN pain medication which was declined by the MD due to diagnosis of Chronic Pain Syndrome. She stated on 10/9/23, a full pharmacy review was done and no recommendation for his pain medicine was made since he was a new admission with a diagnosis of Chronic Pain Syndrome and was in the facility for therapy. The Pharmacy Consultant confirmed that she was unaware that the resident had taken almost 60 tablets of the PRN pain medication and stated with Chronic Pain, his pain medication should have been scheduled daily instead of a PRN medication if he was taking it that much. She confirmed the DON had been in-serviced on the automated medication system and the directions are also located in the med room in a notebook that is attached to the machine. She stated she did not in-service all the nursing staff, but the DON and nursing management should have in-serviced the staff on the procedure for use. On 10/17/23 at 11:20 AM, during a phone interview, the MD revealed I'm not reluctant about writing for short acting pain medications, I said I wasn't going to, I just don't schedule it, because it is not shown to be affective. The MD confirmed that he was unaware that his NP was writing prescriptions for short acting pain medications and stated, They (NP) don't have to notify me with each prescription that is written. He stated that I do not recall that over Labor Day weekend and several other dates that he was notified of the resident being in extreme pain and pain medications were not available. He stated I do not recall the staff attempting to contact him on 9/10/23 concerning the resident's level of pain and no medication available. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He stated the 8/29/23 pharmacy recommendation was for a stop date, and this was declined with reason of Chronic Pain Syndrome. He stated it was declined because the resident needed the PRN pain medication. The DON wrote on the form that the resident frequently complained of pain discomfort. He stated that he was now aware of the resident's pain and had put the resident on a long-acting scheduled pain medication and the short acting as needed medication used for breakthrough pain and confirmed that he did this on 10/10/23 after the Administrator had contacted him. He stated for short term therapy residents, he wrote for pain medication for the residents to be able to receive and participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medication. He stated he does not recall a call on [DATE] about the need of pain medicine for this resident or for the staff being unable to get in touch with NP. He stated he does not recall being notified by the facility of the resident's comment concerning he would be better off dead. He stated he does not recall being notified of this, but unless the staff could not get in touch with the NP, they would not call him. Record review of the September 2023 Electronic Medication Administration Record (EMAR) revealed other PRN meds administered when Norco was unavailable from 9/2/23 (date of ER visit) until 9/5/23 (when Norco was obtained), the resident requested PRN pain medications including Ibuprofen 200 mg (milligrams) (3 tabs) times 4 doses with a verbalized pain scale of 7-10 and Tylenol 325 mg 1 tablet for pain on a scale of 1 - 3 on 2 days along with the Ibuprofen and Resident #25 had verbalized a pain scale of 10. On 9/10/23 the resident requested Ibuprofen 200 mg 3 tabs along with Tylenol 325 mg 2 tabs for pain scales of 9-10 times 2 doses and BC Arthritis 1000-65 mg 1 packet. On 9/11/23, the resident requested BC Arthritis times 2 doses and Tylenol 325 mg 2 tablets 1 dose and Ibuprofen 200 mg 3 tablets 1 dose for verbalized pain of 7-10. On 9/20/23 he received Tylenol 325 mg 2 tablets for verbalized pain of 10 and Ibuprofen 200 mg 3 tablets for verbalized pain of 5. On 9/26/23 he requested 2 doses of BC Arthritis for verbalized pain of 8. On 9/27/23 he received one dose of BC Arthritis for a pain scale of 6. Record review of Controlled Substances Proof of Use forms and prescriptions revealed 12 Norco tablets were received on 8/29/23 and the last dose of these 12 tablets was given on 9/1/23 at 9:25 PM. The next medications available from the pharmacy was received on 9/6/23 for 14 tablets (10 on one card/form and 4 on another card/form). The prescription was sent on 9/2/23 at 3:40 PM. The first dose of these was admini [TRUNCATED]

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff were competent in medication administration, pain assessment and treatment, notification of providers and pharmacy when medications were needed, and in the procedure for using the automated medication dispensing system for obtaining needed medications for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure nursing staff possessed the knowledge to obtain needed pain medication for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR S483.35(a)(3)(4) Nursing Services - F726 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Competency Evaluation dated 10/17/23, revealed, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents .Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . An observation and interview with Resident #25 on 10/10/23 at 10:45 AM, revealed resident was in his room sitting in his electric wheelchair. His posture was slumped to the side and resident did not sit upright and straight in his chair. He stated he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain and he had to ration out his pain medicine to be comfortable. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not received his medication before he ran out and this should not happen. The facility's Pharmacy Consultant revealed in an interview on 10/10/23 at 2:00 PM, the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated the ordered pain medication for Resident #25 was one of the medications available in the dispensing system and could have been obtained by the staff for this resident if the procedure was followed. An interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1 confirmed there had been times that Resident #25 had to go without his pain medication due to the medication not being available in the facility. The Director of Nursing (DON) confirmed during an interview on 10/11/23 at 4:00 PM, that the resident's pain medication was not available in a timely manner which led to the resident being in severe pain for multiple days. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets. The DON confirmed this resident was sent to the hospital and received a prescription for pain medications from the emergency room that was sent to the pharmacy, but it was after hours, and the facility staff did not know to call the pharmacy to receive a code to obtain the medication from the automated system. She confirmed she was aware of the situation of the resident being sent to the hospital, yet no procedures were changed and no in-services on who to notify and procedure to follow for obtaining medication were given to prevent reoccurrence, and the resident continued to be without pain medication several other times. She confirmed the facility failed to educate the staff on the procedures necessary to obtain needed medications 24 hours a day seven days a week and this led to the resident having severe, unrelieved pain. The Administrator confirmed during an interview on 10/11/23 at 4:15 PM, the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to effectively manage his pain, and due to this failure, the resident suffered multiple days of severe pain. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications when needed but not available on the medication cart, obtaining a prescription, obtaining a one-time dose, obtaining a dose when a prescription was available, or verifying with pharmacy what was needed. She confirmed the staff were not adequately trained on the automated medication dispensing system procedure to receive needed medications for the residents and that this was available 24 hours a day seven days a week. She confirmed the facility staff failed to follow through with notification of the pharmacy, MD, or the NP with concerns of pain and lack of medications available. Interview with LPN #2 on 10/11/23 at 4:20 PM, revealed she did not notify the provider or the pharmacy on 9/4/23 since she notified the charge nurse of the Resident #25 being out of his pain medications and was told the medication was on its way from the pharmacy. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication on a weekend, holiday, or night. An interview on 10/12/23 at 2:30 PM, with the Administrator confirmed the prescription that was sent to the pharmacy from the emergency roiagnom on [DATE] was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday. She confirmed there were other dates as well that the facility failed to obtain Resident #25's medication timely and he was in pain with no pain medication available. She confirmed the facility's contracted pharmacy had 24 hour a day seven day a week coverage, yet the facility staff were unaware of this and how to proceed to obtain the needed medication, therefore, the resident repeatedly suffered severe and unrelieved pain. In an interview on 10/12/23 at 3:20 PM, the DON confirmed the facility failed to have the resident's pain meds available as ordered and needed, due to the nursing staff not being adequately trained to know the proper steps to take to obtain residents' pain medications to prevent and treat his pain. Interview with the Administrator on 10/16/23 at 1:45 PM, revealed when the resident went to the emergency roiagnom on [DATE], he had a prescription for pain meds and this was sent to the pharmacy, but no staff member contacted the pharmacy to get a code for the system to be able to give the resident the medication for pain. She confirmed the medication administration skills checklist did not include the procedure for use of the automated medication system. She confirmed the facility failed to educate the staff of the steps to take to obtain pain medications from the automated medication system and because they were not properly trained, this resident suffered days of severe and unrelieved pain. Interview with Nurse Supervisor/Registered Nurse #2 on 10/16/23 at 2:00 PM, revealed on 9/2/23, the resident complained of pain and had no pain medication available in the medication cart. She stated Resident #25 called 911 to be taken to the emergency room for evaluation of chest pain and she informed the emergency room (ER) doctor of the situation with the resident not having pain meds available and he sent a prescription for 14 Norco pills to the pharmacy. She revealed the resident had an active prescription in the pharmacy, but the staff did not know the procedure for using the medication dispensing system. She stated she assumed the staff knew how to get the meds out of the system when a prescription was available, and she did not inform the other nurses of what to do to get the ordered medication after the resident had returned from the ER. An interview on 10/17/23 at 9:30 AM, the Assistant Director of Nursing revealed she was aware that the resident had been out of his pain medication on several occasions. She stated Labor Day weekend she did hear that a prescription was available in the pharmacy, but the staff were unaware of the procedure to obtain the ordered medication. She confirmed the facility failed to call the on-call pharmacy to obtain the resident's ordered medication which led to the resident experiencing unrelieved pain. In an interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on weekends, nights, or holidays. She stated the pharmacy sends messages when they are off, so she was unsure what to do during these times. During an interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system stored routine medications, but he was not aware that pain medication was also available. He stated he was unaware of the procedure to obtain pain medication for a resident if none were available in the medication cart and he would have to ask someone if the situation happened. On 10/17/23 at 10:55 AM, a phone interview with the Pharmacy Consultant revealed the DON had been in-serviced on the automated medication delivery system. She confirmed she did not in-service the nursing staff but felt that the DON and nursing management should have in-serviced the staff on the procedure for use. Record review of Medication Administration Skills Checklist for LPN #1, LPN #2, and LPN #3 revealed there was no instruction on the automated medication dispensing system in the facility documented on the checklist. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication admini [TRUNCATED]

Based on staff and resident interviews, record review, and facility policy review, the facility failed to acquire and administer the resident's pain medication in a timely manner causing Resident #25 to experience severe/uncontrolled pain multiple times for one (1) of five (5) residents reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure needed pain medication was available for Resident #25 caused this resident harm and placed other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates. The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR S483.45(a)(b)(2) - F755 Pharmacy Services was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Consultant Pharmacist Services, undated, revealed, The consultant pharmacist will ensure that the following services are performed: . 9. Advises facility on policies and procedures for safe and effective delivery, organization, destruction, and use of medications/services in the facility. 11. Conducts in-service education for nursing staff on drug and pharmacy services topics including changes in regulations . Record review of facility policy titled, 1.0 Providing Pharmacy Products and Services dated 1/1/13, revealed, 1. Pharmacy will provide facility with the Facility-Specific Information Sheet . which details how Facility staff can contact Pharmacy twenty-four hours a day, seven (7) day a week (24/7). 3. After the normal business hours set forth in the Facility-Specific Information Sheet, Facility staff should contact Pharmacy by dialing the telephone number provided in the Facility-Specific Information Sheet to page the on-call pharmacist. Resident #25 reported during an interview on 10/10/23 at 10:45 AM, that he was admitted to the facility for therapy on 8/28/23 and he had back and neck pain from a previous injury. He stated he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine to be comfortable. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. On 10/10/23 at 2:00 PM, in an interview with the facility's Pharmacy Consultant, revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner (NP) or the Medical Doctor (MD) to have one sent to the pharmacy for staff to receive code. She confirmed that this system is the facilities Emergency Drug Kit (EDK), that the machine houses things that would be needed in an emergency. She stated the pain medication that Resident #25 received was one of the medications available in the dispensing system and could have been obtained by the staff for this resident. The Administrator confirmed during an interview on 10/11/23 at 4:15 PM, the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She confirmed the facility failed to educate the staff on the procedure to follow to obtain residents' pain medications when needed and not available on the medication cart. She confirmed the facility staff were not adequately trained on the automated medication dispensing system procedure or how to obtain pain medication from the system to administer to this resident with an active prescription available in the pharmacy or how to obtain a prescription for a one-time dose order sent to the pharmacy. She confirmed the facility staff failed to notify the pharmacy, MD, or the NP when concerns of pain and lack of medications occurred. Licensed Practical Nurse (LPN) #2 revealed in an interview on 10/11/23 at 4:20 PM, that she had worked with Resident #25 several times and on 9/4/23, he was out of his pain medicine, and she offered him a Tylenol and he refused since the pain medicine was his preference to ease his pain. She stated she had knowledge of the automated medication dispensing system but had not been in-serviced that narcotics were in the system and did not know the procedure for obtaining pain medication of a weekend, holiday, or night when the pharmacy was closed. The Nurse Practitioner stated during a phone interview on 10/12/23 at 10:05 AM, she was notified by the facility staff on 9/2/23 that the resident had no pain medication available and was in pain and was sent to the emergency room for evaluation of chest pain. She denied that she did not send in prescriptions when requested by the facility or that she was unavailable when the staff needed to speak to her. She did confirm that at times the facility would call her and not leave a message and when she called the facility back, no one knew who needed to speak to her and she did not pursue trying to talk to administrative staff to see who had a concern. She stated this could have been some of the times when this resident needed medications. On 10/12/23 at 2:30 PM, during an interview, the Administrator confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication. Therefore, the resident suffered unrelieved pain for multiple days because staff did not realize that they could access the narcotic written prescription and obtain medications from the dispensing machine. The DON confirmed during an interview on 10/12/23 at 3:20 PM, the facility failed to have the resident's pain meds available as ordered and needed, which led to this resident having pain for several days. She also confirmed the nursing staff were not adequately trained to know the proper steps to take to obtain residents' pain medications to prevent unrelieved pain. At 1:45 PM on 10/16/23 , in an interview with the Administrator, revealed the resident was evaluated in the emergency roiagnom on [DATE] and a prescription for pain medication was sent to the pharmacy, but the facility staff did not contact the pharmacy to get a code for the automated medication system to provide the resident the medication needed for pain relief. She confirmed the facility failed to educate the staff of the steps to take to obtain pain medications from the automated medication system and since they were not properly trained, this resident suffered days of severe and unrelieved pain. The Nurse Supervisor/Registered Nurse #2 reported on 10/16/23 at 2:00 PM, on 9/2/23, the resident complained of pain but had no pain medication available in the medication cart. The resident called 911 to be taken to the emergency room . She stated she informed the emergency room physician that the resident did not have any pain medication available at the facility, so he sent a prescription for 14 Norco pills to the pharmacy. She revealed the resident had the prescription in the pharmacy system, but the staff did not know the procedure for using the automated medication dispensing system to retrieve the medications and stated, I assumed they knew how to get it, and confirmed that she did not provide instruction for the weekend nurses as how to obtain the medication, or that they could get it from the dispensing machine. Interview on 10/17/23 at 9:30 AM, the Assistant Director of Nursing revealed she was aware the resident did not have his needed pain medication several different times and he became verbally aggressive and was cursing and she felt this was due to his pain with no medication for relief. She confirmed that not all the nurses were aware of how to use the automated medication system and how it was available for the staff to obtain residents' medications. She confirmed that after the emergency room visit when a prescription was available in the pharmacy, the facility failed to call the on-call pharmacy to get the resident's ordered medication which led to the resident experiencing unrelieved pain. An interview with Licensed Practical Nurse (LPN) #1 on 10/17/23 at 10:25 AM, revealed she was familiar with the automated medication system, but she was uncertain what to do on weekends, nights, or holidays. She stated the pharmacy sends messages when they are off, so she was unsure what to do during these times. An interview with LPN #3 on 10/17/23 at 10:30 AM, revealed he was aware that the automated medication system held routine medications, but he was not aware that pain medications were also available. He stated he was unaware of the procedure to obtain pain medication for a resident if unavailable in the medication cart. During a phone interview on 10/17/23 at 10:55 AM, the Pharmacy Consultant confirmed the DON had been in-serviced on the automated medication dispensing system. She confirmed she did not in-service the nursing staff but that the DON and nursing management should in-service the staff on the procedure for using this system. Record review of prescription from the emergency room to the pharmacy dated 9/2/23 for Norco 7.5-325 mg (milligram) tablets with quantity of 14 tablets. Record review of the Controlled Substance Proof of Use form revealed the 14 tablets ordered in the emergency roiagnom on [DATE] arrived in the facility on 9/6/23, and the first tablet of these was administered to the resident on 9/6/23 at 5:30 AM. The last dose of these 14 tablets was documented as signed out on 9/9/23 at 8:01 PM. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x 3, message left, MD called x 2, awaiting call back. Record review of the next prescription dated 9/11/23 and was noted as received to the pharmacy on 9/11/23 at 10:59 AM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/11/23 and received in the pharmacy at 10:59 AM were delivered to the facility on [DATE] (with their routine delivery around midnight). The first of these doses to be given to the resident was on 9/12/23 at 3:30 AM and the last dose was given on 9/25/23 at 10:15 PM. Record review of prescription dated 9/26/23 and was noted as received into pharmacy on 9/26/23 at 5:26 PM for Hydrocodone 7.5 mg - Acetaminophen 325 mg tablet - take one tablet by mouth every six hours. May take one or two tablets by mouth every six hours as needed for severe pain. Quantity of 60 tablets. Record review of the Controlled Substance Proof of Use form revealed the medications for the prescription dated 9/26/23 was noted to have arrived to facility on 9/27/23. The first dose administered of these tablets was 9/27/23 at 6:30 AM. Record review of Resident #25's Face Sheet revealed the resident was admitted to the facility on [DATE]. His diagnoses included Chronic Pain Syndrome, Cervical Disc Degeneration, Polyneuropathy, Polyosteoarthritis, and Cerebral Palsy. Record review of Resident #25's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/3/23 revealed the Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 2 PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 2 PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that Resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to Resident #25. On 9/2/23, Resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that Resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for Resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, Resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that Resident #25 was very upset he was he was running low on his pain medication and Resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28 PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data S [TRUNCATED]

Based on staff and resident interviews, record review, and job description review the facility Administrator failed to ensure care was coordinated between the facility, Nurse Practitioner (NP) and the Medical Director (MD) for pain management for a resident who experienced severe/uncontrolled pain that resulted in the resident being transferred to the emergency room (ER) for pain control for one (1) of 19 sampled residents. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's Administration failed to ensure needed pain medication was available for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR S483.70 Administration was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of facility policy titled, Job Title: Administrator, signed by the Administrator on 10/18/23, revealed, Duties and Responsibilities - Responsible for planning, organizing, staffing, directing, and coordinating of the facility to ensure quality care for residents; be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The policy also revealed, Functions: 1. Select personnel to supervise activities of major departments and consult with them regarding problems, .7. Supervise department heads, including office staff; meet with department heads and make rounds . 12. Work with department heads and supervisors to provide staff . in-service training . 13. Maintain personal contact with residents and their families, or guardians . 18. Operate, manage, and maintain facility in accordance with established policies and procedures of the governing body. 19. Act as liaison with the governing body and professional and supervisory staff through meetings and reports . Record review of facility policy titled, Job Title: Director of Nursing, signed by the Director of Nursing on 6/2/23, revealed, Qualifications: . Job Knowledge: Working knowledge of nursing services . administration, supervision, resident care, etc.; .18. Evaluate, plan and organize nursing care according to established policies.20. Supervise nursing activities and promote improvement in nursing care . 32. Be accountable for nursing compliance, excellence, and delivery of resident-care services in adherence with federal, state, and local regulations . In an interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was admitted to the facility for therapy on 8/28/23. He had back and neck pain from a previous injury. He verbalized he was angry that the facility did not ensure he had enough pain medications available for his use and continued to run out which left him in severe, unrelieved pain. He stated there had been multiple times the facility had not received his pain medication before he ran out and that should not happen. He stated he had to ration out his pain medicine to be comfortable. The staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that the medicine was not available so there was nothing they could do and were not concerned that he was suffering in pain. In an interview with the facility's Pharmacy Consultant on 10/10/23 at 2:00 PM, revealed the facility had an automated medication dispensing system available and this service, as well as a pharmacist, were available 24 hours a day seven days each week. She stated an active prescription was required for the pharmacy to give a code for the medication, and if there was not an active prescription, the facility staff would notify the Nurse Practitioner or the Medical Doctor to have one sent to the pharmacy for staff to receive a code. She stated the pain medication that Resident #25 received was one of the medications available in the dispensing system and could have been obtained by the staff for this resident. In interview on 10/11/23 at 11:00 AM, with Registered Nurse (RN) #1 confirmed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) had been notified of the concerns that the resident did not receive his pain medication as ordered and needed. She confirmed there had been times that this resident had to go without his pain medication due to the medication not being available in the facility. In an interview on 10/11/23 at 4:00 PM, the Director of Nursing (DON) confirmed that she was aware that at times, the resident had run out of his pain medicine, and it was not available in a timely manner which led to the resident being in severe pain for multiple days. She confirmed in-services should have been initiated, but the staff were not in-serviced on who to notify and what to do to prevent this from occurring, and therefore it occurred several additional times. She stated the facility's system of initiating an order for more medications when this resident had five to eight tablets remaining was not appropriate for this resident since he required a larger quantity of pain tablets yet no new plan to prevent this from occurring was initiated. She confirmed the need to address changes in their normal process for this resident was not discussed with administrative staff, therefore no change occurred, and the resident was in pain without appropriate pain management interventions. In an interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications to ensure his pain was properly managed and due to this failure, the resident suffered multiple days of severe pain. She revealed she had not been aware that the resident was without his pain medication on multiple occasions, but as Administrator of the facility, she should have known. She confirmed the administration staff and department heads failed to communicate concern with a resident's pain and no solution was initiated and it continued to occur. In an interview on 10/12/23 at 2:30 PM, the Administrator confirmed the facility failed to provide Resident #25 with adequate pain relief for his well-being. She stated the facility was responsible for meeting these needs and when the NP did not respond timely, the facility failed to initiate contact with the Medical Director for pain management which caused Resident #25 to go without pain medications for multiple days causing him further pain and mental anguish. She confirmed the prescription that was sent to the pharmacy from the emergency roiagnom on [DATE] was over Labor Day weekend and was not filled until the pharmacy reopened on Tuesday 09/05/23 and was delivered to the facility after midnight. She stated that is why the resident did not get a dose until 09/06/23 at 5:30 AM. She confirmed the facility failed to follow up with other options to ensure this resident received the necessary care. She confirmed the facility's contracted pharmacy had 24/7 coverage, yet the facility staff were unaware of this or how to proceed to obtain the needed medication, therefore, the resident suffered unrelieved pain. She also confirmed there were also other days that the facility failed to obtain Resident #25's medication timely and was in pain without medication to ease his pain. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that Resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to Resident #25. On 9/2/23, Resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that Resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for Resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, Resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that Resident #25 was very upset he was he was running low on his pain medication and Resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that Resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. The SA validated by record review and interviews with ADON, LPN #1, LPN #2, and LPN #3 the inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been inserviced on adequate documentation will be in serviced prior to start of shift. 19. The SA validated by interview with the Pharmacy Consultant and record review that on 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. The SA validated by record review and interview with ADON the inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. The SA validated by record review and interviews with Medical Director and Pharmacy Consultant one on one education was provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. The pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. The SA validated by record review and interviews with Medical Records Nurse and MDS Nurse that on 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. The SA validated by record review and interview with Pharmacy Consultant that on 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. The SA validated by record review and interview with the Medical Director that on 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implem [TRUNCATED]

Based on observation, resident and staff interviews, record review, and Medical Director Agreement review, the facility's Medical Director (MD) failed to coordinate medical care and ensure that he or his Nurse Practitioner (NP) responded to the facility for pain control when a resident experienced severe/uncontrolled pain for one (1) of five (5) resident reviewed for pain. Resident #25 The SA identified an Immediate Jeopardy (IJ) that began on 9/2/23, when the facility neglected to ensure medications for pain management were available for Resident #25 who experienced severe pain requiring emergency room visits and verbalized suicidal ideation's related to the pain. Nursing staff lacked sufficient knowledge of how to obtain emergency medication from the automated medication distribution system located in the facility medication room. It was also determined the providers at the facility did not provide the pharmacy with an active prescription for pain medication timely, which led to a delay in receiving medications. Administrative staff failed to recognize the reoccurring concern with Resident #25 receiving his pain medications and failed to initiate a plan to ensure pain medications were readily available. The facility's failure to ensure the Medical Director managed and coordinated pain control for Resident #25 placed this resident and other residents who require pain medication in a situation that was likely to cause serious injury, harm, impairment, or death. On 10/17/23 at 2:00 PM, the SA notified the facility's Administrator of the IJ and provided the facility with the IJ templates . The facility submitted an acceptable Removal Plan on 10/18/23, in which the facility alleged all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. The SA validated the Removal Plan on 10/20/23, and determined the IJ was removed on 10/19/23, prior to exit. Therefore, the scope and severity (S/S) for 42 CFR 483.70(h)(2)(i)(II) Medical Director - F841 was lowered from a S/S of J to a S/S of D, while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the Medical Director Agreement signed by the Medical Director on 1/1/13, revealed, .3. Services: . ii. Collaborating with the Facility's management staff to help develop, implement, and evaluate resident care policies and procedures that reflect current standards of practice; iii. Working with Facility's leadership in identifying, evaluating, and resolving medical and clinical concerns and issues that affect resident care, medical care, or quality of life or that relate to the provisions of services by physicians and other licensed health care professionals . Record review of the Medical Director Agreement, signed by the Medical Director on 4/28/10, revealed, .The Medical Director is responsible for technical assistance with the implementation of resident care policies and the coordination of medical care in the facility. In order to monitor implementation and provide oversight of medical services, the Medical Director will be present for monthly staff meetings to discuss issues related to resident care and safety. The Medical Director will be accessible by phone, fax, e-mail, or person for resident care issues that arise. The Medical Director will be accessible by person as the needs of the residents dictate, but no less than two visits per month. On 10/10/23 at 10:15 AM, an observation revealed Resident #25 sitting in his wheelchair in the front hallway area speaking to a staff member. The State Agency was unable to hear all the conversation or the context of the conversation, but resident was observed to be very distraught and stated, Just need to die. Interview with Resident #25 on 10/10/23 at 10:45 AM, revealed he was angry that he did not receive his pain medications as needed and ordered and the facility continued to run out which left him in severe, unrelieved pain and he had to ration out his pain medicine to be comfortable. He stated the nurses told him that his medication would probably come in tonight but he had heard that before and was in pain for days before it arrived, and he did not want to have severe pain for no telling how long 'til it comes back in. He stated there had been multiple times and multiple days that the staff had not received his medication before he ran out and this should not happen. He stated the staff told him things like trying to get the Nurse Practitioner (NP) to send a copy to pharmacy, or have to call the doctor or NP to get a new prescription, or still waiting for it to come from pharmacy. He was told by the staff that when the medicine was not available there was nothing they could do, and he felt they were not concerned that he was suffering in pain. Interview with Registered Nurse (RN) #1 on 10/11/23 at 11:00 AM, stated the automated medication distribution system can be used to obtain medications for the resident if an active prescription is available in the pharmacy. She confirmed there were times when the resident did not have pain medication available and she had tried at times to notify the NP to have a refill sent to pharmacy, but it was not sent timely, or she would not return the phone call and the resident was without pain medication for a longer period of time. Interview with Nurse Supervisor/Registered Nurse #2 on 10/11/23 at 4:14 PM, revealed on 9/2/23, the resident was very agitated and angry and was yelling that he needed his pain medication, and it was still unavailable. The resident called 911 from his personal cell phone and was sent to the emergency room (ER) for evaluation. She confirmed the resident was out of his pain medications and he was complaining of severe/uncontrolled pain. She stated she can generally get in touch with the physician, but the NP is difficult to get in touch with, not only with this resident but with other residents also. She confirmed there were other times the resident was out of his pain medication, and she attempted to notify the Nurse Practitioner or the Medical Director but was not called back by either of them. She stated when the provider did not return her call, a prescription was not obtained to receive the medications. Interview on 10/11/23 at 4:15 PM, the Administrator confirmed the facility failed on multiple occasions to ensure the resident had an adequate supply of pain medications. She stated the delay in obtaining the medications timely was often due to the NP or MD not responding quickly and providing the pharmacy with a hard copy timely. Therefore, the resident suffered with severe, unrelieved pain for multiple days. The Administrator confirmed that she Finally got the Medical Director to order something scheduled for pain for the resident last night. Interview with the Administrator on 10/12/23 at 8:20 AM, confirmed the facility failed to involve the Medical Director with the concerns of this resident for his pain management to ensure the resident received the necessary care for his well-being until the evening of 10/11/23. She stated she relied on the Nurse Practitioner (NP) to follow through with sending the orders to pharmacy as needed. She is unsure if the NP is just hesitant to write for too many narcotics or what, but if a resident is in pain, the meds are needed. She confirmed the Medical Director is contracted with the facility and the NP works under him and she confirmed that the NP is very difficult to get in touch with at times. Phone interview on 10/12/23 at 10:05 AM, with the Nurse Practitioner confirmed that she occasionally had a missed call from the facility and when she called the facility, no one knew who needed to speak to her and she did not pursue trying to talk to the administrative staff members to determine who had a concern. Interview with the Administrator on 10/16/23 at 1:45 PM, revealed the facility staff attempted to notify the Nurse Practitioner multiple times without a response for this resident as well as for other residents and this was an ongoing issue. She stated the Medical Director did not order scheduled pain medication often and he preferred to manage pain with as needed (PRN) medications. But this resident had chronic pain and was taking this medication daily prior to his admission to the facility and he still needed the medication on a scheduled basis, but the Medical Director refused to order it as scheduled until she talked to him last night. Phone interview on 10/16/23 at 2:20 PM, with the Medical Director revealed he is Board Certified in Palliative Care and has worked with pain management. He stated he did order short acting as needed (PRN) medications but he did not order short acting scheduled pain medications since he has found that this was not a successful option for pain management. He stated he would occasionally order this for a hospice resident, but otherwise he would order PRN pain medicine and not scheduled pain medication. He stated last week, when the facility notified him of the concerns for Resident #25's pain management, he did order a scheduled every 12 hour long-acting pain medication and a short acting PRN medication. He stated that generally he was only notified when the Nurse Practitioner was unavailable. A phone interview on 10/17/23 at 11:20 AM, the Medical Director revealed, I am not reluctant about writing for short-acting pain medications, I said I wasn't going to write it. I just do not generally schedule it. He stated he is aware the NP wrote prescriptions, but she was not required to notify him each time she wrote a prescription, and she had the right to do this without notifying him each time. He stated, I do not recall being notified that the resident was in extreme pain for days and did not have pain medications available over Labor Day weekend and was sent to the emergency room with chest pain. He stated I do not recall the staff attempting to contact me on 9/10/23 concerning the resident's level of pain and no medication available and the staff being unable to reach the Nurse Practitioner or the resident having to wait until 9/12/23 to receive his medication from pharmacy. He stated he wrote pain medication for short term therapy residents, so they were able to participate in therapy and he was not aware of this resident's refusal of therapy because of pain and lack of medications. He stated he did not recall being notified by the facility of the resident's comment concerning he would be better off dead related to his pain and lack of medication. He stated he does not recall being notified of this, but the staff would only notify him if they could not reach the NP. He stated he received a tremendous amount of calls every day and cannot recall all of them. He stated he had an on-site visit with Resident #25 on 9/6/23 and when asked if resident mentioned his severe pain and his lack of medications, he stated, I'm sure he did vocalize his pain management concerns. He confirmed that as of last week, he was aware of the resident's pain and medication availability concerns and put the resident on a long-acting scheduled pain medication and the short acting as needed medication to be used for breakthrough pain. Record review of Nurses Progress Note by RN #2 dated 9/10/23 at 6:13 PM, revealed, Resident complained of pain and wanting his Norco pain medication. Resident informed of need to call to get medication refilled. NP called yesterday, 9/9/23 and verbalized understanding of need for refill. Medication was awaiting verification still, NP called x (times) 3, message left, MD called x 2, awaiting call back. Record review of text message sent to NP from RN #2 dated 9/10/23 at 10:39 AM, revealed, Hey just double checking you sent those hard copies in yesterday? Pharmacy is saying they don't see them in their fax list. Record review of progress note dated 9/26/23 at 11:59 AM by Registered Nurse #1 revealed, Resident is upset that his PRN (as needed) pain medication is not in currently however we are awaiting a hard copy from providers so therefore we can not give the specific pain med that he wants at this time . Record review of Resident #25's History and Physical by Medical Director dated 9/6/23. No documentation concerning pain noted. REMOVAL PLAN Credible Removal Plan to Remove Immediacy of an Immediate Jeopardy that was called on 10/17/2023 at 28PM by the State Agency. Immediate Jeopardy templates were provided to the Administrator on 10/17/2023 at 28PM. Brief Summary On 10/11/2023, the Administrator was notified by the State Agency that resident #25 did not receive effective pain management by the nursing staff or medical provider due to not obtaining prescribed pain medication or prescription for pain medication on 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/10/23, 9/11/23, and 9/26/23. The facility failed to provide services necessary to avoid physical harm, pain, anguish, or emotional distress to resident #25. On 9/2/23, resident #25 returned from the emergency room with a prescription for pain medication. The prescription was then faxed to the contracted pharmacy by licensed nursing personnel after hours. The licensed nursing personnel did not contact the after hours on call pharmacist to receive a code to obtain medication from the electronic emergency drug supply system on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The licensed nursing personnel failed to notify the Medical Director or the Administrator that resident #25 did not receive pain medication and was not receiving effective pain management on 9/2/23, 9/3/23, 9/4/23, or 9/5/23. The pain medication prescription was delivered to the facility on [DATE] at 1:01 AM. The licensed nursing personnel neglected to provide effective pain management and follow the plan of care for pain management. The licensed nursing personnel failed to demonstrate competency of pharmacy procedures on 9/2/23, 9/3/23, 9/4/23, and 9/5/23. On 9/9/23, the Nurse Practitioner verbalized understanding of the need for a refill on pain medication for resident #25. The Nurse Practitioner was attempted to be reached via telephone three times and the Medical Director via telephone two times on 9/10/23 by the Registered Nurse Supervisor without success. The prescription was not received by the contracted pharmacy until 9/11/23 at 11:58 AM resulting in the resident not receiving effective pain management on 9/10/23 and 9/11/23 and experiencing pain. The facility received the pain medication from contracted pharmacy on 9/11/23 at 11:03 PM. On 9/26/23, resident #25 did not receive effective pain management by the medical provider due to delay in pharmacy receiving hard copy prescription for the controlled pain medication from the Medical Director or Nurse Practitioner. The facility licensed nursing personnel-initiated request for the refill from the Medical Director on 9/23/23 via fax. The pain medication prescription was received by the pharmacy on 9/26/23 at 5:26 PM and delivered to the facility on [DATE] at 1:07 AM. On 10/10/23, The Registered Nurse Supervisor was informed by the therapy supervisor that resident #25 was very upset he was he was running low on his pain medication and resident #25 stated to the therapy supervisor that he might as well die than be in severe pain again and was not wanting to attend therapy. Resident #25 stated to surveyor he was rationing out his medication so he would not run out and he was worried that if he took two of the three remaining pain pills for therapy, he would not get anymore in at midnight and he would be in severe pain again. Immediate actions taken. 1. On 10/10/23 at 3:30 PM, resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. On 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. On 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. On 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. Inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. Inservice initiated on 10/11/23 at 4:20 PM for 100% licensed nursing personnel related to pain management by Assistant Director of Nursing. The in-service included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. Inservice initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The Medical Director was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. On 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. On 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. On 10/11/23 at 6:37 PM Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. On 10/12/23 at 09:00 AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from contracted pharmacy. 14. On 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. On 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. On 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. On 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeeping Supervisor, Therapy Manager, Wound Treatment Nurse, Certified Nursing Assistant Supervisor, and Registered Nurse Supervisor via telephone to discuss facility policies on neglect, pain management, contracted pharmacy policies, and communication between facility and providers as well as facility performance improvement plan regarding pain management. 18. Inservice initiated on 10/17/23 at 2:45 PM by Assistant Director of Nursing educating 100% of licensed nursing personnel on adequate documentation of narcotic medication on the electronic medical record and the narcotic medication log. Any licensed nursing staff who have not been in serviced on adequate documentation will be in serviced prior to start of shift. 19. On 10/17/23 at 04:45 PM, the Pharmacy Nursing Consultant contacted and confirmed to in-service documentation of narcotic medication, pain management and medication administration. Pharmacy Nursing Consultant confirmed to observe medication administration. 20. Inservice initiated on 10/17/23 at 5:16 PM by Assistant Director of Nursing with 100% of licensed nursing personnel regarding communication with providers, usage of communication form, and contacting facility administrator when unable to reach medical provider. Any licensed nursing staff who have not been in serviced on the usage of provider communication forms and inability to reach medical provider will be in serviced by the Assistant Director of Nursing prior to the start of their shift. 21. One on one education provided on 10/17/23 at 5:39 PM by Pharmacy Consultant with Medical Director regarding pain management regulations and F697. Pharmacy Consultant discussed nursing communication regarding pain medications, pharmacy processes for receiving and dispensing controlled medications, and protocols for afterhours prescriptions. Pharmacy Consultant also reviewed opioid pain guidelines and short acting versus long-acting opioids. 22. On 10/17/23 at 6:00 PM, Medical Records Nurse and Minimum Data Set Coordinator audited 100% pain management care plans on all residents receiving as needed and scheduled pain medication to validate accuracy and completion of care plan. All plans of care were updated to reflect current pain management medications. 23. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Pharmacy Consultant agreement to identify responsibilities related to pain management in developing and implementing safeguard and systems to control, account for, and reconcile controlled medications. The Pharmacy Consultant agreement is valid and requires no revision. 24. On 10/17/23 at 8:00 PM, the Director of Operations reviewed the Medical Director's agreement to identify responsibilities as assistance with implementation of resident care policies, coordination of medical care of facility, and monitoring and providing oversight of medical services. 25. On 10/18/23 at 02:00 PM, Facility Administrator reviewed F841 Medical Director responsibilities and facility Medical Director Policy with the Medical Director. Administrator reviewed and discussed the Medical Director responsibilities related to coordinating medical care and oversight of resident pain management regimens. Medical Director will participate in monthly quality assurance meetings with facility administrator to ensure ongoing implementation and compliance in effective pain management. 26. On 10/18/23 at 02:15 PM, Pharmacy General Manager provided hands on education and training with licensed nursing personnel on emergency drug dispensing system including verification of logins, passwords, and demonstrating choosing residents and orders. 27. On 10/18/23 at 03:00 PM, Facility Administrator was in serviced by Corporate Nurse on Administrator job duties and responsibilities. Administrator was in serviced on attending daily clinical meetings and reviewing nurses' notes, electronic medication administration records, narcotic logs, and physician orders daily. The facility alleges all corrective actions were completed on 10/18/2023 and the immediate jeopardy removed on 10/19/2023. VALIDATION The State Agency validated on 10/20/23 through record review and interviews that all corrective actions to remove the IJ were completed and the IJ was removed on 10/19/23. 1. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was assessed by Registered Nurse Supervisor regarding suicidal ideation and Resident #25 denied any thoughts of suicidal ideation. 2. The SA validated by record review and Administrator interview that on 10/10/23 at 3:30 PM, Resident #25 was immediately placed on one-on-one observation. The Psychiatric Nurse Practitioner was contacted on 10/10/23 at 3:30 PM and the Registered Nurse Supervisor received an order to send Resident #25 to emergency room for psychiatric evaluation. 3. The SA validated by record review and Administrator interview that on 10/10/23 at 4:00 PM, Resident #25 was transferred to the local emergency room for evaluation and was determined to not be suicidal and was transferred back to the facility. 4. The SA validated through record review and Administrator interview that on 10/10/23 at 8:15 PM, Resident #25 returned to the facility with a diagnosis of acute cystitis and an order for antibiotic therapy. Resident was then placed on every fifteen minutes checks until 10/11/23 at 2:00 PM 5. The SA validated on through record review and ADON interview the inservice initiated by Assistant Director of Nursing on 10/11/23 at 4:20 PM for 100% of staff regarding facility policy on abuse and neglect related to providing services necessary to prevent pain related to effective pain management and control. Facility staff that have not been in serviced on neglect related to pain management will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 6. The SA validated by record review and interview with ADON that inservice was initiated on 10/11/23 at 4:20 PM for 100% of licensed nursing personnel related to pain management by Assistant Director of Nursing. The inservice included direct care nursing staff education on effective pain control, assessment of pain, documentation of administered pain medications, non-pharmacological interventions, and notification of provider if pain interventions are not effective. Any licensed nursing staff who have not been in serviced on pain management will be in serviced prior to the start of the shift by Assistant Director of Nursing. 7. The SA validated by record review and interview with the ADON that inservice was initiated on 10/11/23 at 4:20 PM by Assistant Director of Nursing for 100% of licensed nursing personnel regarding contracted pharmacy policy and procedures. Nursing staff educated on usage of electronic emergency medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers. Any licensed nursing staff who have not been in serviced on pharmacy policy and procedures and usage of electronic medication kit, obtaining medication after contracted pharmacy business hours, requesting order refills, and requesting controlled prescriptions from medical providers will be in serviced prior to the start of the shift by the Assistant Director of Nursing. 8. The SA validated by record review and interview with Medical Director that he was notified by the Administrator on 10/11/23 4:45 PM that resident #25 did not receive effective pain management by the nursing staff. The Medical Director reviewed Resident #25's current pain regimen on 10/11/23 and initiated a new pain regimen to include a scheduled pain medication in addition to the as needed pain medication scheduled to begin on 10/12/23. 9. The SA validated by record review and interview with the Administrator that on 10/11/23 5:00 PM a 100% audit of narcotic documentation on the electronic medical record versus the narcotic sign out log was completed by the Administrator, Corporate Nurse, Registered Nurse Supervisor, and Medical Records Nurse. 10. The SA validated by record review and interview with the Administrator that on 10/11/23 at 6:33 PM, an audit was performed by the Director of Nursing to ensure all current direct care nurses have logins to the electronic emergency medication kit. Audit of electronic emergency medication kit users revealed all current direct care nurses have logins to electronic emergency medication kit. 11. The SA validated by record review and interview with Nursing Supervisor that on 10/11/23 at 6:37 PM, the Registered Nurse Supervisor audited all as needed pain medication to ensure availability of medication for the resident. The audit revealed that four residents needed hard copy prescriptions sent to the pharmacy for refills and three residents received updated orders. All corrections were made on 10/11/23. 12. The SA validated through record review and Administrator interview that Resident #25 was assessed by Director of Nursing on 10/11/23 07:28PM to ensure resident was not in pain and pain regimen was effective at this time. Resident #25 denied pain or discomfort at the time of assessment by Director of Nursing on 10/11/23 and no negative outcomes noted. 13. The SA validated by record review and interview with ADON that on 10/12/23 at 09:00AM, the Assistant Director of Nursing confirmed expedited delivery of the resident's new pain medication from the contracted pharmacy. 14. The SA validated by record review and interview with the MDS Coordinator that on 10/12/23 at 10:34 AM, the Minimum Data Set Coordinator completed 100% audit of section J0200 to identify residents that triggered for having pain on pain interview. Minimum Data Set Coordinator confirmed residents that reported pain have pain management regimens in place as well as a plan of care for pain management. 15. The SA validated by record review and interview with Resident #25 that on 10/13/23 at 3:00PM, the Director of Nursing interviewed all interviewable residents to assess the effectiveness of their current pain regimen. The audit of the effectiveness of the current pain regimens reveals all interviewable residents are satisfied with their current pain regimens. 16. The SA validated by record review and interview with ADON that on 10/16/23 at 10:00 AM, the Assistant Director of Nursing verified availability of all scheduled pain medications and all pain medications were available for all residents. 17. The SA validated by record review, interview with Administrator, ADON/QA Nurse, MDS Nurse that on 10/16/23 11:17 AM, a Quality Assurance meeting was held with the Medical Director, Administrator, Assistant Director of Nursing, Dietary Director, Social Services Director, Activities Director, Maintenance Supervisor, Minimum Data Set Coordinator, Medical Records Nurse/Infection Preventionist, Clinical Liaison, Housekeep [TRUNCATED]

Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from involuntary seclusion for one (1) of five (5) residents reviewed for involuntary seclusion. Resident #1 On 6/7/21, at approximately 4:00 PM, the Administrator was notified by Employee #1 that a dirty linen cart and a Hoyer lift was in front of the door of Resident #1's room. The cart and lift were blocking the door preventing Resident #1's exit from the room. Employee #2 removed the objects from the doorway. The Administrator viewed camera footage and noted at 3:45 PM Registered Nurse (RN) #5 assisted Resident #1 to his room due to him being naked in the hallway. RN #5 immediately exited Resident #1's room and talked with Certified Nursing Assistant (CNA) #4. RN #5 then returned to her medication cart. CNA #4 pushed a linen/laundry cart into the doorway of Resident #1. Resident #1 pushed the cart away from the door and CNA # 4 put the cart back in front of Resident #1's door and pushed a total lift in front of the laundry cart to hold it in place. Employee #1 and Employee #2 exited the therapy department, which is next door to Resident #1's door and saw the door blocked. Employee #2 removed the cart and lift to allow Resident #1 to exit the room. RN #5 then helped Resident #1 back to his room to get dressed. The Administrator did not suspend RN #5 pending investigation. RN #5 was allowed to complete her scheduled shift on 6/7/21. RN #5 also worked in the facility on 6/8/21, 6/9/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21. The facility's failure to protect Resident #1 from involuntary seclusion and allow a staff member to work in the facility following an incident of witnessed involuntary seclusion placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care which began on 6/7/21 when the involuntary seclusion occurred. The facility's Administrator was notified of the IJ and SQC on 6/18/21 at 5:30 PM and provided with the IJ templates. A credible Removal Plan was provided by the facility on 6/19/21, in which the facility alleged all corrective actions were completed as of 6/18/21, and the IJ was removed on 6/19/21. The State Agency (SA) validated the Removal Plan on 6/21/21 and determined the IJ was removed on 6/19/21. Therefore, the scope and severity for 42 CFR(s): 483.12 (a)(1) Free from Involuntary Seclusion, (F603) lowered from a J to a D while the facility develops and implements a plan of correction and monitors for the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Abuse Program, revised May 23, 2017, revealed,It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, exploitation, misappropriation of resident property, and involuntary seclusion. The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, sponsors, visitors, surrogates, friends, and other caregivers who provide care and services on behalf of the facility . Involuntary Seclusion is defined as separation of a resident from other residents or from her/his room or confinement to his/her room (with or without roommates) against the residents will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs. Record review of a self-reported complaint allegation submitted to the SA on 6/10/21 and documented 6/7/21, revealed CNA #4 placed a laundry cart and a lift in the doorway of Resident #1's room to prevent his exit from his room. A telephone interview, on 6/17/21 at 5:46 PM, with Certified Nursing Assistant (CNA) #4, revealed on the day of the incident, 6/7/21, she was getting vital signs when Registered Nurse (RN) #5 told her to get one of the residents and change him because his family was waiting for him. CNA #4 stated that while she was in the room changing that resident, RN #5 came in the room and told her that Resident #1 was in the hallway naked and was hitting her and said she needed some help. CNA #4 stated that she left the resident and went into the hallway to help. Resident #1 was in his room naked, and RN #5 told her to put the laundry cart in front of his door. CNA #4 stated she put the laundry cart in Resident #1's doorway and was going back to finish the other resident when Resident #1 moved the laundry cart. She stated she put the linen cart back in front of his door and got the lift and put it in front of the linen cart. CNA #4 confirmed she locked the wheels on the linen cart and the lift. She stated that when she came out of the other resident's room the cart and lift had been moved. CNA #4 stated that RN #5 told her that she had already taken care of Resident #1.CNA #4 stated that about a week before, RN #5 had told her she could put the cart in Resident #1's door. She confirmed she had done this one time before to keep Resident #1 from going into his room. When asked why she did not report this, she stated it was because the RN #5 was on the hall and she (CNA #4) asked RN #5 if this was okay, and she was told by RN #5 that it was fine to do it. CNA #4 stated she thought it was okay to put the cart in the doorway because the nurse said it was. On 6/17/21 at 6:14 PM, attempted to interview RN #5 by phone again. No answer. Same recorded message that voice mail was full. On 6/18/21 at 1:45 PM, an interview with the Director of Nursing (DON) revealed that in a telephone conversation, RN #5 revealed she would not be available due to illness. Record review of the written statement by RN #5 concerning the incident revealed a resident was out in the hallway with no clothes on and visitors as well as other residents were in the building. I asked CNA #4 to pull the laundry cart in front of the resident's room, to leave the resident's door open so we (staff) could keep an eye on him and perhaps keep him in his room until we could get clothes on the resident. Another resident was waiting to be changed and he had family members waiting outside on him. An interview, on 6/18/21 at 10:00 AM, with Employee #2 revealed that she was walking to the therapy department and noticed a laundry cart in front of the door of Resident #1 with a lift wedged under the laundry cart and blocking the doorway of the room. She stated that she went into therapy and reported it to her supervisor, Employee #1. Employee #2 stated that she saw the Director of Nurses at the medication cart in the hallway talking to the nurses. Employee #2 stated that she unlocked the cart and the lift and moved them. She stated Resident #1 was sitting close to the laundry cart in his room. He appeared to be in no distress. She stated that she did not remember seeing Resident #1 push on the cart. She stated that she moved the equipment across the hall and thinks that she went back to therapy at that time because other people had come to the room. She remembered seeing the Director of Nursing and she saw CNA #4 come out of another room. She stated that she had had not seen seclusion before. An interview, on 6/18/21 at 10:11 AM, with Employee #1 revealed that Resident #1's room is next door to therapy. Employee #1 stated that Employee #2 showed us the linen cart and the total lift against the door with legs under the cart. Employee #1 stated that Resident #1 was sitting still inside the door when Employee #2 moved the cart and the lift away. Employee #1 stated she went into the therapy room and called the Administrator to report what had been seen. An interview on 6/18/21 at 10:25 AM, with Employee #7 revealed Employee #2 came into therapy room and told them to come look at this. Employee #7 stated she saw a laundry cart against the door and a lift against the laundry cart in front of Resident #1's room. She stated that Resident #1 was sitting calmly behind the cart looking out the door around the side of the cart. An observation and interview, on 6/18/21 at 11:10 AM, with the Administrator (ADM) confirmed the cart that was placed in front of Resident #1's door was a three (3) compartment cart that held dirty linen in one section, trash in another section and dirty briefs in the other section. She confirmed that he could be injured trying to push the cart out of the way and possible danger due to the dirty items in the bins. The cart was approximately two (2) feet wide by five (5) feet long. An interview, on 6/18/21 at 4:10 PM, with Certified Nursing Assistant (CNA) #1 revealed that she had seen the dirty laundry cart in front of Resident #1's door. She stated that she works the East hall and about two weeks ago she saw it when she was helping a CNA with another resident in Resident #1's room. CNA #1 stated that she had no idea the cart was to keep Resident #1 from getting back in the room. She stated that she really just did not think about it, she just helped the other CNA and then left. CNA #1 stated that she realizes she should have reported it. She stated that after this happened, they had an in service on abuse and seclusion. An interview, on 6/18/21 at 4:20 PM with Certified Nursing Assistant (CNA) #2, revealed that Resident #1 takes his clothes off and is stubborn. She stated that there was not enough help when he is in one of his moods. She stated that she had seen the cart in front of his door, and she assumed they were trying to keep him out of the room. She stated that she saw the cart there while putting out trays. She stated that she did not move it because the nurses were there in the hallway, one of the nurses was RN #5. She stated that she had seen the cart in front of his door twice within the past two to three weeks. She stated she thought Administration would have seen it on the cameras. An interview, on 6/18/21 at 4:30 PM, with CNA #3, revealed that she had seen Resident #1 outside the room with a laundry cart halfway blocking the door. She said he may have pushed it out of the way to get out of the room. She stated that she had seen this twice. CNA #3 stated she could not remember when she saw it. CNA #3 stated that Resident #1 does have behaviors and he hits at the nurses, but the cart should not have been in the doorway. She stated that she should have moved it. An interview, on 6/18/21 at 4:45 PM, with Licensed Practical Nurse (LPN) #1, revealed that she had seen the dirty linen cart in front of Resident #1's door twice. LPN #1 could not recall any dates or times but did not think about it being intentional and had never seen the cart locked. She stated Resident #1 is in and out of his room a lot and comes out into the hallway naked. LPN #1 confirmed that she had never seen the cart in front of any other resident's doorway. She also stated that staffing was not adequate to care for all the residents and take care of Resident #1 when he is having behaviors. She stated they usually just have one CNA per hall on her shift. An interview, on 6/18/21 at 11:09 AM, with the Administrator (ADM), revealed that she called in the seclusion incident to the State Agency within two hours. She confirmed that the therapy staff notified her of the incident. She stated that RN #5 should have been making sure all the residents were taken care of and that the staff was doing what they should have been doing. The ADM confirmed that telling the CNA to put the linen cart in front of a Resident's door was not a prudent practice for any nurse. She stated that she should have sent both of them home, but she thought at the time that it was OK for RN #5 to stay and finish her shift because she was in the building until 10:30 or 11:00 PM. She stated that she had staff that could have covered if she had sent RN #5 home. She stated at the time she did not feel like Resident #1 was in any harm, although, she did agree that the incident should not have happened. The ADM stated that during her interview with RN #5 and CNA #4, they both understood the severity of the situation and RN #5 and CNA #4 knew where they went wrong. No one had reported any other similar incident until this incident on 6/7/21. The Administrator stated, at the time, she felt like she did what she should, but in hindsight she stated she should have sent them both home. An interview, on 6/19/21 at 1:10 PM with Resident #2, revealed that he had seen the staff put the cart in front of Resident #1's door at least one time, but he could not remember exactly when this was. Record review of other employee personnel files revealed CNA #4 was hired on 4/28/18 and had one prior discipline in her employee file, dated 4/5/2020. RN #5 was hired by the facility on 2/19/21 and had no prior disciplines or corrective actions in her employee file. Review of the timecard for RN #5 revealed she continued to work in the facility on 6/7/21, 6/8/21, 6/9/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21 after the incident of involuntary seclusion occurred. Record review of an in-service attendance record dated 4/18/21, with the topic of abuse and neglect revealed RN #5 was in attendance. Record review of the Face Sheet revealed the facility admitted Resident #1 on 3/6/19. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/28/21 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. The facility submitted an acceptable Removal Plan on 6/19/21, for the IJ. Review of the facilities Removal Plan revealed the facility took the following corrective actions to remove the IJ: 1. On 06/07/2021 at 4:00 pm, the Administrator was notified by Employee # 1 that Employee # 2 had observed a dirty linen cart and a Hoyer lift in front of room [ROOM NUMBER] where Resident #1 resides. Employee #1 removed the dirty linen cart and Hoyer lift from in front of Resident #1's doorway which was blocking his exit out of his room and Employee #1 notified the Administrator immediately. 2. Administrator began an investigation on 06/07/2021 at 4:30 pm by reviewing camera footage to see persons involved. Administrator determined Employee # 4 had placed dirty linen cart and Hoyer lift in front of resident # 1 doorway. Administrator called Employee # 4 to Administrator office for statement. Employee #4 stated she was told by Employee #5 to place the dirty linen cart in front of the Resident #1's door until she could get to dress him. Employee # 4 was then placed on investigative leave. Employee # 5 was called to Administrator office for statement. Employee # 5 was in-serviced one on one on resident's rights, abuse, neglect, and involuntary seclusion of vulnerable adult by the Administrator and Employee # 5 was allowed to finish her shift until 11:00 PM under the supervision of the Administrator and was told not to return to work until the investigation was finished. Employee # 5 continued to work her scheduled shifts on 6/8/2021, 6/9/2021, 6/10/2021, 6/13/2021, 6/14/2021, and 6/15/2021. 3. Employee # 3 assessed Resident #1 for any physical or mental anguish or potential body injury, and none was noted 06/07/2021 at 4:45PM. 4. Administrator in-serviced all available staff on 3-11 shift on 06/07/2021 beginning at 5:00 pm. Resident # 1 was put on frequent well-being checks by nursing staff each two hours. 5. On 06/07/2021 through 06/10/2021, all staff on each shift were in-serviced on resident's rights, abuse, neglect, and involuntary seclusion of vulnerable adults. 6. CNA # 4 who was involved was put on investigative leave on 06/07/2021 at 5:45 PM and terminated on 06/08/2021 by telephone after investigation was complete. 7. On 06/10/2021, cognitive residents that were cared for by CNA # 4 and RN # 5 were interviewed by Employee # 6 with no adverse outcomes. 8. On 6/11/2021, Psychiatric Nurse Practitioner came to facility to assess Resident # 1 for a routine visit. Psychiatric Nurse Practitioner noted there were no new concerns noted from the recent incident on 06/07/2021. The following steps were taken to remove the immediacy: A. Staffing was immediately reviewed by Administrator and Director of Nursing to ensure adequate staff were in place for the following shifts. There were no adjustments needed to the staff scheduled. B. On 6/18/2021, at 5:45 PM, the Staff Development Coordinator immediately began in-servicing all available staff on resident rights, abuse, neglect, and involuntary seclusion of vulnerable adults, and the reporting of such. C. All staff are to be in-serviced on resident's rights, abuse, neglect, and involuntary seclusion prior to returning to work. No staff will be allowed to return to work until in-service education has been completed. D. Resident #1 was observed during the wellness checks 06/07/2021 through 06/18/2021 for any negative outcomes, mental anguish, or changing behaviors and none were noted. E. RN Employee # 5 was terminated on 6/18/2021 at 7:12 PM and was reported to the Board of Nursing on 6/18/2021 at 9:13 PM by the Director of Nursing. F. On 6/18/2021 at 6:00 pm the Quality Assurance Meeting was conducted with the Medical Director via phone, Human Resource Director, Maintenance Supervisor, Wound Care Registered Nurse (RN), Staff Development Coordinator/Infection Control Nurse, Dietary Manager, Business Office Manager, Social Service Director, Housekeeping Supervisor, RN MDS Coordinator, Medical Records Licensed Practical Nurse (LPN), Activities Director, Director of Nursing, and the Nursing Home Administrator. The Quality Assurance Committee discussed increasing Resident # 1's daily activities, purchasing a cd player/radio for entertainment, reaching out to specialty services to get ideas to assist with resident behaviors, increase staff if behaviors are noted, in-service staff on how to react to resident behavior(s), and view camera more frequently. The policy on Abuse Prohibition was reviewed during the Quality Assurance Meeting and there were no changes needed. Corrective actions to remove the Immediate Jeopardy was completed on 6/18/21. The facility alleges the IJ was removed on 6/19/21. On 6/21/21, the State Agency (SA) validated the facility's Removal Plan through observation, staff interviews, review of in-service sign in sheets and record reviews of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: The State Agency validated that Resident #1 was free from involuntary seclusion that occurred on 6/7/21 when RN #5 instructed CNA #4 to put a laundry cart in front of Resident #1's doorway to prevent him from leaving his room and CNA #4 also putting a body lift in front of the laundry cart to prevent the resident from leaving his room. The Administrator knew of the incident on 6/7/21 and failed to protect the resident by not suspending RN #5. A. The SA validated through interview and record review that adequate staffing was in place. B. The SA validated through staff interviews and record review that in-service education had been initiated on 6/18/21 concerning resident rights, abuse, neglect, involuntary seclusion of vulnerable adults, and the reporting of such. C. The SA validated through record review and staff interviews that no staff would be allowed to return to work until in service education had been completed. D. The SA validated by observation, staff interview, and record review that Resident #1 had been observed during the Wellness checks for any negative outcomes. None were noted. E. The SA validated through interview and record review that RN Employee #5 was terminated on 6/18/21 at 7:12 PM and was reported to the Board of Nursing on 6/18/21 at 9:13 PM by the Director of Nursing. F. The SA validated through record review and interviews the Quality Assurance Performance Improvement (QAPI) meeting was held on 6/18/21. The SA validated that all corrective actions were completed as of 6/18/21 and the IJ was removed on 6/19/21.

Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of involuntary seclusion to State Board of Nursing and allowed staff to continue caring for residents following the allegation for one (1) of five (5) residents reviewed. Resident #1. On 6/7/21, at approximately 4 PM, the Administrator was notified by Employee #1 that a dirty linen cart and a Hoyer lift was in front of Resident #1's doorway blocking the door where he could not exit the room. Employee #2 removed the objects from the doorway. The Administrator viewed camera footage and noted at 3:45 PM Registered Nurse (RN) #5 assisted Resident #1 to his room due to him being naked in the hallway. RN #5 immediately exited Resident #1's room and talked with Certified Nursing Assistant (CNA) #4. RN #5 then returned to her medication cart. CNA #4 pushed a linen/laundry cart into the doorway of Resident #1. Resident #1 pushed the cart away from the door and CNA # 4 put the cart back in front of Resident #1's door and pushed a total lift in front of the laundry cart to hold it in place. Employee #1 and Employee #2 exited the therapy department, which is next door to Resident #1's door and saw the door blocked by a laundry cart and a lift. Employee #2 removed the cart and lift to allow Resident #1 to exit the room. RN #5 then helped Resident #1 back to his room to get dressed. The Administrator did not suspend RN #5 pending investigation. RN #5 was allowed to complete her scheduled shift on 6/7/21. RN #5 also worked in the facility on 6/8/21, 6/9/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21. The facility's failure to protect Resident #1 from involuntary seclusion and allow a staff member to work in the facility following an incident of witnessed involuntary seclusion placed Resident #1 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care which began on 6/7 21 when the involuntary seclusion occurred. The facility's Administrator was notified of the IJ and SQC on 6/18/21 at 5:30 PM and provided with the IJ templates. An acceptable credible Removal Plan was provided by the facility on 6/19/21, in which the facility alleged all corrective actions were completed as of 6/18/21, and the IJ was removed on 6/19/21. The State Agency (SA) validated the Removal Plan on 6/21/21 and determined the IJ was removed on 6/19/21. Therefore, the scope and severity for 42 CFR (s): 483.12 (c)(2)-(4) Investigate, Prevent, Correct Alleged Violation (F610) was lowered from a J to a D while the facility develops and implements a plan of correction and monitors for the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse, Neglect, Exploitation, with a review date of 4/30/18, revealed, It is the policy of this facility to report all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames . #4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: .b. Abuse: The willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .v. Involuntary seclusion refers to the separation of a resident from other residents or from his/ her room, or confinement to his/ her room against the residents will or the will of the resident's legal representative. Emergency or short term monitored separation will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention as long as the least restrictive approach is used for the minimum amount of time . #7 Protection: The facility will protect residents from harm during an investigation. #8 Reporting/ Response: The facility will report all alleged violations an all-substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences .Procedure for Response and Reporting Allegations of Abuse /Neglect/ Exploitation .When suspicion of abuse, neglect, exploitation, or reports of abuse, neglect, exploitation occur, the following procedure will be initiated: .2. The Director of Nursing Services, Administrator, or designee will: .c. Suspend the accused employee pending completion of the investigation .e. Report to the state nurse aide registry or nursing board any knowledge of any actions which would indicate an employee is unfit for service. Record review of the incident report dated 6/7/21, at approximately 4 PM, the Administrator was notified by Employee #1 that a dirty linen cart and a Hoyer lift was in front of Resident #1's entrance door, blocking the door so he could not exit the room. Employee #2 removed the objects from the doorway. The Administrator viewed camera footage and noted at 3:45 PM Registered Nurse (RN) #5 assisted Resident #1 to his room due to him being naked in the hallway. RN #5 immediately exited Resident #1's room and talked with Certified Nursing Assistant (CNA) #4. RN #5 then returned to her medication cart. CNA #4 pushed a linen/laundry cart into the doorway of Resident #1. Resident #1 pushed the cart away from the door and CNA # 4 put the cart back in front of Resident #1's door and pushed a total lift in front of the laundry cart to hold it in place. Employee #1 and Employee #2 exited the therapy department, which is next door to Resident #1's door and saw the door blocked. Employee #2 removed the cart and lift to allow Resident #1 to exit the room. RN #5 then helped Resident #1 back to his room to get dressed. The Administrator did not suspend RN #5 pending investigation. RN #5 was allowed to complete her scheduled shift on 6/7/21. RN #5 also worked in the facility on 6/8/21, 6/9/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21. An interview, on 6/18/21 at 11:09 AM, with the Administrator (ADM), revealed that she called in the seclusion incident to the state within two hours. She confirmed that the therapy staff notified her of the incident. She stated that RN #5 should have been making sure all the residents were taken care of and that the staff was doing what they should have been doing. The ADM confirmed that telling the CNA to put the linen cart in front of a residence door was not a prudent practice for any nurse. She stated that she should have sent both of them home, but she thought at the time that it was OK for RN #5 to stay and finish her shift because she was in the building until 10:30 or 11:00 PM. She stated that she had staff that could have covered if she had sent RN #5 home. She stated at the time she did not feel like Resident #1 was in any harm, although, she does agree that the incident should not have happened. The ADM stated that during her interview RN #5 and CNA #4, they both understood the severity of the situation and RN #5 and CNA #4 knew where they went wrong. No one had reported any other similar incident until this incident on 6/7/21. The Administrator stated, at the time, she felt like she did what she should, but in hindsight she stated she should have sent them both (CNA #4 and RN #5) home. Review of the timecard for RN #5 revealed she continued to work in the facility on 6/7/21, 6/8/21, 6/9/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21 after the incident of involuntary seclusion occurred. The facility submitted an acceptable Removal Plan on 6/19/21, for the IJ. Review of the facilities Removal Plan revealed the facility took the following corrective actions to remove the IJ. 1. On 06/07/2021 at 4:00 pm, the Administrator was notified by Employee # 1 that Employee # 2 had observed a dirty linen cart and a Hoyer lift in front of room [ROOM NUMBER] where Resident # 1 resides. Employee #1 removed the dirty linen cart and Hoyer lift from in front of Resident #1's doorway which was blocking his way of exit out of his room and Employee #1 notified the Administrator immediately. 2. Administrator began an investigation on 06/07/2021 at 4:30 pm by reviewing camera footage to see persons involved. Administrator determined Employee # 4 had placed dirty linen cart and Hoyer lift in front of resident # 1 doorway. Administrator called CNA # 4 to Administrator office for statement. CNA #4 stated she was told by RN #5 to place the dirty linen cart in front of the Resident #1's door until she could get to dress him. CNA # 4 was then placed on investigative leave. RN #5 was called to the Administrator office for a statement. RN #5 was in-serviced one-on-one concerning resident rights, abuse, neglect, and involuntary seclusion of a vulnerable adult by the Administrator. RN #5 was allowed to finish her shift until 11:00PM under the supervision of the Administrator and told not to return to work until the investigation was finished. RN #5 continued to work her scheduled shifts on 6/8/21, 6/8/21, 6/10/21, 6/13/21, 6/14/21, and 6/15/21. 3. Employee # 3 assessed Resident #1 for any physical or mental anguish or potential body injury, and none was noted 06/07/2021 at 4:45pm. 4. Administrator in-serviced all available staff on 3-11 shift on 06/07/2021 beginning at 5:00 pm. Resident # 1 was put on frequent well-being checks by nursing staff each two hours. 5. On 06/07/2021 through 06/10/2021, all staff on each shift were in-serviced on resident's rights, abuse, neglect, and involuntary seclusion of vulnerable adults. 6. Employee # 4 who was involved was put on investigative leave on 06/07/2021 at 5:45 pm and terminated on 06/08/2021 by telephone after investigation was complete. 7. On 06/10/2021, cognitive residents that were cared for by Employee # 4 and Employee # 5 were interviewed by Employee # 6 with no adverse outcomes. 8. On 6/11/2021, Psychiatric Nurse Practitioner came to facility to assess Resident # 1 for a routine visit. Psychiatric Nurse Practitioner noted there were no new concerns noted from the recent incident on 06/07/2021. The following steps were taken to remove the immediacy: A. Staffing was immediately reviewed by Administrator and Director of Nursing to ensure adequate staff were in place for the following shifts. There were no adjustments needed to the staff scheduled. B. On 6/18/2021, at 5:45 pm, the Staff Development Coordinator immediately began in-servicing all available staff on resident rights, abuse, neglect, and involuntary seclusion of vulnerable adults, and the reporting of such. C. All staff are to be in-serviced on resident's rights, abuse, neglect, and involuntary seclusion prior to returning to work. No staff will be allowed to return to work until in-service education has been completed. D. Resident #1 was observed during the wellness checks 06/07/2021 through 06/18/2021 for any negative outcomes, mental anguish, or changing behaviors and none were noted. E. RN Employee # 5 was terminated on 6/18/2021 at 7:12 pm and was reported to the Board of Nursing on 6/18/2021 at 9:13 pm by the Director of Nursing. F. On 6/18/2021 at 6:00 pm the Quality Assurance Meeting was conducted with the Medical Director via phone, Human Resource Director, Maintenance Supervisor, Wound Care Registered Nurse (RN), Staff Development Coordinator/Infection Control Nurse, Dietary Manager, Business Office Manager, Social Service Director, Housekeeping Supervisor, RN MDS Coordinator, Medical Records Licensed Practical Nurse (LPN), Activities Director, Director of Nursing, and the Nursing Home Administrator. The Quality Assurance Committee discussed increasing Resident # 1's daily activities, purchasing a cd player/radio for entertainment, reaching out to specialty services to get ideas to assist with resident behaviors, increase staff if behaviors are noted, in-service staff on how to react to resident behavior(s), and view camera more frequently. The policy on Abuse Prohibition was reviewed during the Quality Assurance Meeting and there were not changes that needed. Corrective actions to remove the Immediate Jeopardy was completed on 6/18/21. The facility alleges the IJ was removed on 6/19/21. On 6/21/21, the State Agency (SA) validated the facility's Removal Plan through observation, staff interviews, review of in-service sign in sheets and record reviews of documents across all diciplines. The SA verified the facility had implemented the following measures to remove the IJ: The State Agency validated that Resident #1was free from involuntary seclusion that occurred on 6/7/21 when RN #5 instructed CNA #4 to put a laundry cart in front of Resident #1's door doorway to prevent him from leaving his room and CNA #4 also putting a body lift in front of the laundry cart to prevent the resident from leaving his room. The administrator knew of the incident on 6/7/21 and failed to protect the resident by not suspending RN #5. A. The SA validated through interview and record review that adequate staffing was in place. B. The SA validated through staff interviews and record review that in service education had taken place concerning resident rights, abuse, neglect, involuntary seclusion of vulnerable adults, and the reporting of such. C. The SA validated through record review and staff interviews that no staff would be allowed to return to work until in service education had been completed. D. The SA validated by observation, staff interview, and record review that Resident#1 had been observed during the Wellness checks for any negative outcomes. None were noted. E. The SA validated through interview and record review that RN Employee #5 was terminated on 6/18/21 at 7:12 PM and was reported to the Board of Nursing on 6/18/21 at 9:13 PM by the Director of Nursing. F. The SA validated through record review and interviews the Quality Assurance Performance Improvement (QAPI) meeting was held on 6/18/21. The SA validated that all corrective actions were completed as of 6/18/21 and the IJ was removed on 6/19/21.