Every finding on record at Baptist Village, Inc.

Based on record review, staff interviews, and the facility policy titled Pharmacy Services and Medication Regimen Review (MRR), the facility failed to ensure that one of nine residents (R) (R1) was free from an unnecessary medication related to an excessive dose of Methotrexate Sodium tablets. Specifically, the facility administers Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:27 pm. The noncompliance related to the IJ was identified as existing on [DATE].An Acceptable IJ Removal Plan was received on [DATE]. Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE] (Past Noncompliance).Findings included:A review of the electronic medical record (EMR) revealed that R1 was a readmission to the facility on [DATE] with diagnoses including, but not limited to, rheumatoid arthritis, dementia, spinal stenosis, syncope and collapse, and hypertension.A review of the hospital discharge notes for R1 dated [DATE] revealed that the hospital discharge medication list included Methotrexate sodium 2.5 milligram (mg) tablet 15 mg by mouth once a week.A review of the EMR revealed that upon R1's readmission on [DATE], a Licensed Practical Nurse (LPN) AA transcribed the medication order as Methotrexate sodium oral tablet 15 mg by mouth one time a day and sent a copy of the hospital discharge medication list to the pharmacy.A review of the Medication Administration Record (MAR) for R1 dated [DATE] through [DATE] revealed the Methotrexate sodium oral tablet 15 mg to give one tablet by mouth one time a day with a start date of [DATE] for RA (rheumatoid arthritis).A review of the MAR for R1 dated [DATE] revealed the Methotrexate sodium oral tablet 2.5 mg to give six tablets by mouth one time a day with a start date of [DATE] for RA.A review of the MAR for R1 dated [DATE] revealed the Methotrexate sodium oral tablet 2.5 mg to give six tablets by mouth one time a day with a start date of [DATE] for RA.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN CC administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN CC administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the MAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the (Named) pharmacy Admission/readmission or Change of Condition Drug Regimen Review (DRR) dated [DATE] revealed that Pharmacist VV completed the form and electronic signature with a date timestamp of [DATE] at 10:29 am. In the DRR Summary section, the hospital discharged orders and completed med rec form were checked to indicate that these documents were available to her. In the Nursing Recommendations - follow-up with the prescriber is NOT required: was noted, please update the administration time of tamsulosin to 6:00 pm, or approximately 30 min after supper. Please add 'do no crush' to finasteride and methotrexate orders. Update.There was no evidence that Pharmacist VV identified the discrepancy of Methotrexate frequency for once a week instead of daily.A review of the New RX electronically signed by Physician ZZZ dated [DATE] revealed Methotrexate Sodium oral tablet 15 mg, give one tablet by mouth one time a day for RA DO NOT CRUSH, and please update the order to 2.5 mg, take six tablets. There was no evidence that Physician ZZZ identified the discrepancy of Methotrexate frequency for once a week instead of daily.A review of the (Named) Pharmacy Current List of Residents Reviewed dated [DATE] and [DATE] revealed R1 was listed as having a medication regimen review. There was no evidence that indicated the discrepancy with the frequency of Methotrexate sodium tablets was identified.A review of the death certificate dated [DATE], which revealed R1's death was accidental secondary to Methotrexate toxicity.During an interview on [DATE] at 1:43 pm with Pharmacist TT (pharmacy consultant), who reported that she was not the pharmacist who did the original review of the medications for this resident upon admission to the facility, but she provides the monthly pharmacy review. There is no evidence that she identified the discrepancy with the Methotrexate frequency during her monthly review.During an interview on [DATE] at 9:50 am, Physician ZZZ revealed that she is familiar with R1 and had received the hospital discharge records. And what she recalled mostly was reviewing the discharge summary from the hospital and treatment orders. Physician ZZZ continued to state that after the resident was diagnosed with the flu, and was not getting better. We (staff) thought it was just taking him longer to get over it. She became aware of the medication error on [DATE]. R1 had lab work obtained, and he had critically low white blood cells and platelets. When she had asked the nurse when the last time R1 had the methotrexate drug, that is when she was told the medication had been given daily. She gave the order to send the resident out to the hospital.During an interview on [DATE] at 3:50 pm, Pharmacist YY revealed that she never saw the hospital discharge orders, and the conversion was made based on the order in the system. She was not aware of the medicator error until her immediate supervisor notified her.During an interview on [DATE] at 10:41 am, Pharmacist UU Senior Manager revealed that the Pharmacists involved received verbal and written counsel.During an interview on [DATE] at 8:05 pm, DON revealed the concern was noted through abnormal lab results, and the charge nurse notified the primary physician. After reviewing the orders, active and comparing them to discharge orders. The nurse was calling out the orders over the phone and comparing them to the hospital orders, and they (nurse and physician) realized the medication error. The methotrexate should have been given weekly instead of daily. The resident was sent to the hospital.During an interview on [DATE] at 6:56 pm, LPN SS revealed that she never saw the original order and was following the order in the electronic health system. And she was informed and educated after the medication error was discovered.Multiple attempts were made to interview LPN CC and LPN RR, but they were unavailable for an interview.A review of the policy titled Pharmacy Services with a last review date of [DATE] revealed that an admission Drug Regimen Review (DRR) is done for new admissions, readmissions, and patients with a change in condition related to medications or when otherwise requested by the center. The pharmacist should complete a DRR upon receipt of the request from the center (notification of the new admission/readmission/change in condition). This should be completed as close to the time of admission as possible. Any identified potential clinically significant medication issues in the DRR will be communicated to the physician with follow-up by midnight of the next calendar day. Contact the prescriber for additional orders and/or clarification, if needed. A follow-up with the prescriber should be completed by midnight of the following calendar day.A review of the facility's policy titled Medication Regimen Review (MRR) with a review date of [DATE] revealed that it is the intent of this policy to provide a review of the medication regimen of each patient at least monthly by the Consultant Pharmacist and report any irregularities. Guideline: The consultant pharmacist performs a comprehensive and systematic Medication Regimen review (MRR) for each patient monthly.Recommendations are provided to optimize medication safety, clinical appropriateness, and therapeutic efficiency. The pharmacist collaborates with the interdisciplinary care team and supports adherence to all applicable federal, state, and center-specific regulatory requirements.The facility implemented the following actions to remove the IJ:1. On [DATE], a medication error was identified on R1. The physician ordered R1 to be sent to an acute care hospital for evaluation, and R1 was admitted to the hospital on [DATE] and expired on [DATE].2. On [DATE], staff education was initiated by a combination of the Director of Nursing (DON), the Assistant Directors of Nursing (ADONs), the Director of Education, and continued, to include 14/14 (100%) RNs, 37/37 (100%) LPNs, 7/7 (100%) Certified Medication Technicians (CMAs), on the following: Medication Reconciliation process, Medication Administration Rights. The process included the admission Audit Tool, Charge Nurse Nightly Audit Tool, and High-Alert/Hazardous Medications.3. On [DATE], staff education was initiated by the DON and Director of Education, and continued, to include 13/14 (92.8%) charge nurses (1 on leave), on the following: New Admission/Readmission, Medication Reconciliation, the EMR Medication Alerts with the Physician and Nurse Practitioner (MD/NP) notification and documentation.4. On [DATE], a Quality Assurance Process Improvement (QAPI) meeting was conducted to discuss the medication error and the initial draft of the performance improvement plans. The team included the Administrator, DON, two ADONs, Director of Education, Chief Operating Officer (COO), and Medical Director (via phone).5. On [DATE], audits were initiated by the ADONs and continued: New/readmission Medication Reconciliation Documentation Audit. The audit included validating the 2-person check of admission/readmission orders and validating the DRR accuracy and timeliness. 84/84 (100%) residents were audited and 100% compliant.6. On [DATE], audits were initiated by the pharmacy: 1/1 resident on Methotrexate. Zero findings were noted.7. On [DATE], pharmacy-initiated implementation of internal process improvements, i.e., drug-specific pop-up alerts, visual aids on medication shelves, high-alert stickers, etc.8. All corrective actions were completed on [DATE]. The facility alleges that the immediate jeopardy was removed on [DATE].The State Survey Agency (SSA) validated the facility's IJ Removal Plan as Past Noncompliance, as follows:A review of the education records revealed education started on [DATE] for all licensed nurses and CMAs and included Medication Administration Rights.During multiple interviews, staff confirmed education with charge nurses started on [DATE] and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor. Re-education is done if noncompliance or issues arise.A review of the education records revealed that education started on [DATE] for all charge nurses, was conducted by the DON, ADON, and/or Education Nurse, and included new admission/readmission medication reconciliation, EMR medication alerts with MD/NP notification and documentation.During multiple interviews with staff, confirmed education and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor; alerts require a manual override and a 2-step process. This process was ongoing.During an interview on [DATE] at 5:30 pm, the DON confirmed that initial education, audits, and monitoring were initiated, and audits/monitoring were ongoing. A review of the QAPI meeting records confirmed that a QAPI meeting was held on [DATE], and the QAPI committee began discussions about the medication error and began developing a Process Improvement Plan (PIP) for the medication error. A review of the sign-in sheet confirmed that the Administrator, DON, 2 ADONs, Director of Education, COO, and Medical Director (via phone) were in attendance.During an interview on [DATE] at 5:30 pm, the DON confirmed that a QAPI meeting was held on [DATE].A review of completed audit tools confirmed that audits were initiated on [DATE] and checked for 2-person validation of all new admissions or readmissions and validated the DRR for accuracy and timeliness. Further review of the completed audit tools revealed 100% residents were audited and no concerns were identified.During an interview on [DATE] at 5:30 pm, the DON confirmed that audits were initiated and are ongoing. The nightly audit tool monitored for the DRR for accuracy, if it was completed correctly and timely, and checked for the 2-step person validating orders. No issues to date. If the ADON finds an issue, they will go immediately to the nurse and re-educate.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist UU revealed what the pharmacy had put in place and included: Labeled all high-risk meds/shelves, added computer warning for high-risk meds, for manual override, they did high alert med training for all staff, evaluated what the pharmacist had going on/workload and evaluated their environment to decrease their distractions so they could concentrate more on verifying orders. Any verbal write-ups they enter as part of our Quality Assurance (QA). A write-up is completed with all errors. They did a Root Cause analysis to determine what happened and why it happened. The pharmacy revealed and confirmed follow-up action items that were implemented.During an interview with the Senior Manager Pharmacist UU, Administrator, and hall staff confirmed the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.An interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist, UU revealed that the pharmacy completed a Root Cause Analysis to determine what happened and why the error occurred. The pharmacy revealed and confirmed follow-up action items that were implemented. During the interview with the Senior Manager Pharmacist UU, Administrator, and multiple hall staff, confirmed that the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.During an interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.It was determined and validated that all corrective actions were completed on [DATE], and the immediate jeopardy was removed on [DATE].

Based on record review, staff interviews, and the facility policy titled Pharmacy Services and Medication Regimen Review (MRR), the facility failed to ensure that one of nine residents (R) (R1) was free from a significant medication error related to facility staff administering Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:27 pm. The noncompliance related to the IJ was identified as existing on [DATE].An Acceptable IJ Removal Plan was received on [DATE]. Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE] (Past Noncompliance).Findings included:A review of the Electronic Medical Record (EMR) revealed R1 was readmitted from the hospital to the facility on [DATE]. R1 had diagnoses that included but were not limited to metabolic encephalopathy, dementia, rheumatoid arthritis, hyperlipidemia, and anxiety.A review of [Named] hospital records revealed an admission date of [DATE] with chief complaint of physical deconditioning, and a discharge date of [DATE] with primary discharge diagnosis of acute encephalopathy. Review of hematology results on [DATE] revealed a white blood count (WBC) of 6.30 and a platelet count of 201. Discharge instructions included discharge to a skilled nursing facility, reason for visit: gen (general) weakness, follow-up with PCP (primary care physician) (Physician ZZZ was listed), and medication (med) instructions included but not limited to Methotrexate sodium 2.5 mg tablet 15 mg PO (by mouth) AS DIRECTED Once a week. {sic}A review of the physician's orders in the EMR revealed an order dated [DATE] at 3:22 pm for Methotrexate sodium oral tablet 15 mg by mouth one tablet one time a day. The order instructions read to give one tablet by mouth one time a day for RA (rheumatoid arthritis). There were a Black Box Warning alert and a Dose Warning alert. A review of the physician's orders in the EHR revealed an order dated [DATE] at 5:38 pm for Methotrexate sodium oral tablet 2.5 mg by mouth, six tablets one time a day. The order instructed to give six tablets by mouth one time a day for RA. The review also revealed there was a Black Box Warning alert and a Dose Warning alert. A review of the physician's orders in the EMR revealed an order for Methotrexate sodium oral tablet 15 mg by mouth one tablet one time a day for RA. DO NOT CRUSH. {sic} There was a Black Box Warning alert, and a Dose Warning alert.A review of the 'Black Box Warning detail' for Methotrexate sodium warned of serious adverse reactions, including death, have been reported with methotrexate.Closely monitor.A review of order detail revealed that Methotrexate was to be given one time a day, every day between 6:45 am-9:45 am for RA, start date [DATE], end date indefinite.A review of the [DATE] electronic Medication Administration Record (eMAR) revealed that the Methotrexate sodium 15 mg was scheduled to be administered once a day, in the morning, with a start date of [DATE]. The Methotrexate sodium 2.5 mg was to be given one time a day, with a start date of [DATE]. There was no specific time noted, only morning. Further review of the eMAR revealed R1 received 15 doses of Methotrexate in [DATE].A review of the [DATE] eMAR revealed that the Methotrexate sodium 2.5 mg six tablets by mouth one time a day for RA had a start date of [DATE], and a D/C (discontinue) date of [DATE]. There was no specific time noted; the medication was ordered for morning. Further review of the eMAR revealed that R1 received nine doses of methotrexate in [DATE].A review of the eMAR revealed that on [DATE], Licensed Practical Nurse (LPN) RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN CC administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN CC administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN SS administered the medication to R1 as indicated by her initials.A review of the eMAR revealed that on [DATE], LPN RR administered the medication to R1 as indicated by her initials.A review of all physician orders, now discontinued, revealed R1 had five separate orders for Methotrexate sodium 15 mg, and two orders for Methotrexate sodium 2.5 mg. All orders are to be given every day for the diagnosis of RA.A review of the facility's investigation timeline documented that on Friday, [DATE], the ADON notified the DON that R1's WBC was critically low, and it had been identified that the wrong frequency of Methotrexate had been given. The Methotrexate was given daily instead of weekly as ordered.A review of the facility form titled Medication Discrepancy Report dated [DATE] for LPN AA revealed R1 received an unordered dose of medication, the dosage was greater than that which was ordered, the order was written correctly on the discharge orders, and the order was not transcribed onto the MAR properly. A written account by LPN AA described the incident and documented, Order was placed (incorrectly) on ([DATE]) and discontinued on ([DATE]).A review of a facility form titled Nursing Medication Discrepancy Report Follow-Up revealed a wrong dose/amount given and a transcription error. Report findings: Nurse transcribed Methotrexate 15 mg daily, and it should have been given weekly. (LPN AA) was the nurse making the error, and the report was signed by the DON and Administrator on [DATE].A review of the facility form titled Medication Discrepancy Report dated [DATE] for LPN CC revealed R1 received an unordered dose of medication, the dosage was greater than that which was ordered, the order was written correctly on the discharge orders, and the order was not transcribed/not entered in the EMR properly. A written account by LPN CC described the incident and documented, Order placed into (the EMR) for Methotrexate sodium 2.5 mg, give 15 mg (six tabs) daily, and the order was weekly. {sic}A review of a facility form titled Nursing Medication Discrepancy Report Follow-Up revealed wrong dose/amount given, the medication given resulted in adverse response., and a transcription error. Report findings: Nurse placed order in EMR for 15 mg of Methotrexate, and it should only be given once a week. (LPN CC) was the nurse making the error, and the report was signed by LPN CC, the DON, and Administrator on [DATE].A review of R1's EMR under Progress Notes revealed an Order Note dated [DATE] at 1:35 pm, which revealed, This order is outside of the recommended dose or frequency. Methotrexate Sodium Oral Tablet 15 mg (Methotrexate sodium), give six tablets by mouth one time a day for RA. The dosing regimen of six tablets daily exceeds the usual dosing regimen of 0.25 to 1.6667 tablets every seven days. The frequency of daily exceeds the usual frequency of every seven days. The single dose of six tablets exceeds the maximum single dose of 1.6667 tablets. The usual dosing regimen is 0.25 to 1.6667 tablets every seven days. {sic}A review of R1's EMR revealed an Order Note dated [DATE] at 1:34 pm: This order is outside of the recommended dose or frequency. Methotrexate sodium oral tablet 15 mg, give one tablet by mouth one time a day for RA. The dosing regimen of one tablet daily exceeds the usual dosing regimen of 0.25 to 1.6667 tablets every seven days. The frequency of daily exceeds the usual frequency of every seven days. {sic}A review of R1's EMR revealed an Order Note dated [DATE] at 1:12 pm: This order is outside of the recommended dose or frequency. Methotrexate sodium oral tablet 15 mg, give one tablet by mouth one time a day for RA. The dosing regimen of one tablet daily exceeds the usual dosing regimen of 0.25 to 1.6667 tablets every seven days. The frequency of daily exceeds the usual frequency of every seven days. {sic}A review of R1's EMR revealed an order note entered by the DON dated [DATE] at 9:02 pm revealed, Transfer to Hospital Summary Note Text, [R1] went to the hospital on [DATE] and has not returned as of this time.A review of R1's EMR revealed an order note entered by the DON dated [DATE] at 9:02 pm revealed, EMS left with (R1) via stretcher.A review of R1's EMR revealed an order note entered by the DON dated [DATE] at 8:57 pm, which revealed, EMS arrived at facility. The resident was alert and talking. Resident was transferred to stretcher . without incident.A review of R1's EMR under Progress Notes revealed an order note entered by the DON dated [DATE] at 8:48 pm, which revealed, 911 called.A review of R1's EMR under Progress Notes revealed an order note entered by the DON dated [DATE] at 8:22 pm, which revealed that [Named] Physician ZZZ called requesting the resident to be sent to the ER (emergency room).A review of R1's EMR under Progress Notes revealed an order note entered by the DON dated [DATE] at 7:37 pm revealed, Health Status Note-Note Text: [Named Physician ZZZ] called approx 15 mins ago discussing Resident's lab work of WBC 1.23 and Plate 42,000 with dayshift charge nurse. Physician ZZZ stated that with the lab values, Leukemia may be a concern. Physician ZZZ obtained the [family member] phone number and was going to call and speak with her and would call us back. Physician ZZZ called back and reviewed the resident's medications. Physician ZZZ wants a CBC to be done about 7:00 am- 8:00 am and sent to the lab. Discontinue all medications except Flomax, and the resident can have Tylenol 650 mg by mouth as needed every six hours. {sic}A review of a Health Status Note dated [DATE] at 5:20 am documented, Bleeding noted to the mouth and tongue, resident unable to voice what happened, MD notified. Physician ZZZ with no new orders just continues to monitor.Late entry Health Status Note dated [DATE] at 5:38 pm documented, Resident stated it hurts when he eats or drinks. Noted sores in the mouth. Contacted Physician ZZZ, gave new order for Nystatin suspension, four times a day for 10 days. Contacted family member [Named], explained the risks and benefits. Verbalized understanding.A review of a Health Status Note dated [DATE] at 12:33 pm documented, Writer assessed resident. Noted continued productive cough. Resident stated he has body aches. Lung sounds are wet, bilateral lower lobes. Contacted Physician ZZZ. Gave new order to repeat CXR stat, albuterol neb every six hours as needed for two weeks, z pack 500 mg one-time dose, and 250 mg daily for four days. Contacted family member-[Named]. Notified of new orders. Explained the risks and benefits. Verbalized understanding. Resident is currently still taking [NAME] flu 75 mg twice a day for five days.Note [DATE] at 2:08 pm documented, RP inquiring about resident going to [Named] doctor for Arthritis infusions. Attempted to contact the office. Left voicemail for infusion nurse to contact the facility back. {sic}A review of a Health Status Note dated [DATE] at 2:26 pm documented, Resident upright in wheelchair. The resident is awake and alert with some confusion. Skin is warm and dry to the touch. Resident noted to have some coughing but is taking Tamiflu and Robitussin as needed for coughing. Resident tolerating meals well. Resident encouraged to increase fluid intake. The resident agreed to the plan of care.A review of an Order Note dated [DATE] 5:39 pm documented, This order is outside of the recommended dose or frequency. Methotrexate sodium oral tablet 2.5 mg, give six tablets by mouth one time a day for RA. The dosing regimen of six tablets daily exceeds the usual dosing regimen of 1 to 10 tablets every seven days. The frequency of daily exceeds the usual frequency of every seven days. Created [DATE] at 5:39 pm by LPN CC/Lead. (terminated [DATE], same day discovered).A review of an Order Note dated [DATE] at 2:21 pm documented, This order is outside of the recommended dose or frequency. Methotrexate sodium oral Tablet 15 mg, give one tablet by mouth one time a day for RA. DO NOT CRUSH. The dosing regimen of one tablet daily exceeds the usual dosing regimen of 0.25 to 1.6667 tablets every seven days. The frequency of daily exceeds the usual frequency of every seven days. Created [DATE] at 2:21 pm by LPN BB. {sic} (terminated)A review of nurse (LPN CC) termination paperwork dated [DATE] revealed the Associate's (LPN CC) employment was terminated on [DATE] because she did Unsatisfactory work related to medication administration. What she should have done was Administer medications according to the 5 Rights. The form was signed by the DON and Administrator. The Associate (LPN CC) did not sign the form.A review of critical lab results dated [DATE] included: WBC (white blood cell count): 1.23 with a reference range of 4.50-11.00, and PLT (platelets): 42 with a reference range of 150-350.A review of a Police report documented that on [DATE], they spoke with the Medical Examiner from Jacksonville, Florida, about a death. The Medical Examiner advised that they had been notified of the death of a w/m (white/male) named [R1] who was brought to the [Named local] hospital. The report states that R1 was originally at [Named] nursing home. He was prescribed Methotrexate and was supposed to be given the dosage once a week; however, the home-health nurse who was treating him was giving the dose daily for 29 days leading up to his transport to [Named local] Hospital for overdose. [Named local hospital] was unable to treat [Named R1], and he was transported to [Named hospital out of state]. He was transported to an inpatient hospice that same day with a diagnosis of acute respiratory failure with hypoxia, encephalopathy, and poisoning by antineoplastic and immunosuppressive drugs. During admission, the decedent's health continued to deteriorate, and on [DATE], he was pronounced. {sic}The Medical Examiner also advised that the decedent arrived at the [out of state] hospital on [DATE] around and was admitted for Methotrexate toxicity. It is also advised in the report that the Medical Examiner spoke with [Named R1's family member], who advised the Medical Examiner that R1's internal organs were burned from his tongue to his anus.A review of the Death Certificate revealed that R1's the cause of death ([DATE]) was Methotrexate toxicity.During an interview on [DATE] at 3:25 pm, LPN AA confirmed she made the transcription error and incorrectly entered the Methotrexate order for once daily instead of once a week. The interview further revealed that the Black Box Warning and Dose Alert got signed off because the charge nurse overrode the alert. R1 was readmitted from the hospital on [DATE], with orders including Methotrexate sodium 15 mg (milligrams) once weekly, and the nurse entered the frequency incorrectly. LPN AA incorrectly entered the order in the EMR on [DATE] and entered the order for once daily instead of once weekly. The pharmacy called back and said to change the order from 15 mg to 2.5 mg, take six tablets. They sent it out, it arrived on [DATE], and R1 started receiving the Methotrexate daily on [DATE]. The pharmacy completed a DRR (Drug Regimen Review) that they sent for, do not crush for a prostate medication, but nothing was said about the once-daily dose of the Methotrexate. LPN CC confirmed she entered the order 2.5 mg and entered it qd (every day) in the electronic system. She revealed there was no structured process in place at that time. There was auditing where the night shift reviewed the 24-hour report, but everyone had a different perception of what 24-hour checks meant. There was nothing in place at that time to catch med errors.During a telephone interview on [DATE] at 9:20 am, Pharmacist VV with [Named] Pharmacy revealed she occasionally did DRR's for [Named] facility. She confirmed she received the hospital DC orders for review on R1, and they included medication orders. She also confirmed that she received medication orders from the facility for R1. She revealed she verified the orders from the facility and compared them to the hospital DC orders. She revealed that they had a two-person step, confirmed she checked R1's orders behind another pharmacist, but did not know the first pharmacist's name. She revealed she was in [Named city], and the first pharmacist to review orders was in (another) [Named] city. She revealed that no one else verified the orders because she was the second person, the final person in the process.During a telephone interview on [DATE] at 9:50 am, Physician ZZZ revealed she was familiar with R1, and she reviewed the Admissions orders from the hospital. What she recalled mainly from reviewing the DC summary from the hospital was treatment orders. She revealed that no one verified what was entered into the system at the facility. The interview revealed she was aware of the med error on Friday evening,[DATE], about 7:00 pm. R1 had the flu, and she was notified earlier in the day that he was not getting better. She stated, I thought it was just taking longer to get over the flu, but I gave an order for labs, and they were collected that afternoon. I was not expecting his WBC and platelets to be abnormal; they were critically low. I asked the nurse to review his meds and when he last received the Methotrexate. The nurse told me it was daily, and I had him sent out.During a telephone interview on [DATE] at 7:18 pm, RN (Registered Nurse) YYY (also the MDS Coordinator) confirmed R1 care planned for pain, with an intervention for meds as ordered. She felt the intervention for pain was followed because his pain was controlled. She confirmed there was no other focus on the care plan for rheumatoid arthritis or methotrexate, and looking back, R1 should have had a specific focus for rheumatoid arthritis or methotrexate/immunosuppressant medication instead of under the focus for pain. She revealed she should have been more specific but was grouping the pain and arthritis all together. She revealed she gets updates through looking at orders, diagnoses, the med list, and for new admissions, she looks at the hospital paperwork. She revealed she did not specifically remember seeing the order for the Methotrexate order on the hospital discharge paperwork.Cross Reference F656 The facility implemented the following actions to remove the IJ:1. On [DATE], a medication error was identified on R1. The physician ordered R1 to be sent to an acute care hospital for evaluation, and R1 was admitted to the hospital on [DATE] and expired on [DATE].2. On [DATE], staff education was initiated by a combination of the Director of Nursing (DON), the Assistant Directors of Nursing (ADONs), the Director of Education, and continued, to include 14/14 (100%) RNs, 37/37 (100%) LPNs, 7/7 (100%) Certified Medication Technicians (CMAs), on the following: Medication Reconciliation process, Medication Administration Rights. The process included the admission Audit Tool, Charge Nurse Nightly Audit Tool, and High-Alert/Hazardous Medications.3. On [DATE], staff education was initiated by the DON and Director of Education, and continued, to include 13/14 (92.8%) charge nurses (1 on leave), on the following: New Admission/Readmission, Medication Reconciliation, the EMR Medication Alerts with the Physician and Nurse Practitioner (MD/NP) notification and documentation.4. On [DATE], a Quality Assurance Process Improvement (QAPI) meeting was conducted to discuss the medication error and the initial draft of the performance improvement plans. The team included the Administrator, DON, two ADONs, Director of Education, Chief Operating Officer (COO), and Medical Director (via phone).5. On [DATE], audits were initiated by the ADONs and continued: New/readmission Medication Reconciliation Documentation Audit. The audit included validating the 2-person check of admission/readmission orders and validating the DRR accuracy and timeliness. 84/84 (100%) residents were audited and 100% compliant.6. On [DATE], audits were initiated by the pharmacy: 1/1 resident on Methotrexate. Zero findings were noted.7. On [DATE], pharmacy-initiated implementation of internal process improvements, i.e., drug-specific pop-up alerts, visual aids on medication shelves, high-alert stickers, etc.8. All corrective actions were completed on [DATE]. The facility alleges that the immediate jeopardy was removed on [DATE].The State Survey Agency (SSA) validated the facility's IJ Removal Plan as Past Noncompliance, as follows:A review of the education records revealed education started on [DATE] for all licensed nurses and CMAs and included Medication Administration Rights.During multiple interviews, staff confirmed education with charge nurses started on [DATE] and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor. Re-education is done if noncompliance or issues arise.A review of the education records revealed that education started on [DATE] for all charge nurses, was conducted by the DON, ADON, and/or Education Nurse, and included new admission/readmission medication reconciliation, EMR medication alerts with MD/NP notification and documentation.During multiple interviews with staff, confirmed education and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor; alerts require a manual override and a 2-step process. This process was ongoing.During an interview on [DATE] at 5:30 pm, the DON confirmed that initial education, audits, and monitoring were initiated, and audits/monitoring were ongoing. A review of the QAPI meeting records confirmed that a QAPI meeting was held on [DATE], and the QAPI committee began discussions about the medication error and began developing a Process Improvement Plan (PIP) for the medication error. A review of the sign-in sheet confirmed that the Administrator, DON, 2 ADONs, Director of Education, COO, and Medical Director (via phone) were in attendance.During an interview on [DATE] at 5:30 pm, the DON confirmed that a QAPI meeting was held on [DATE].A review of completed audit tools confirmed that audits were initiated on [DATE] and checked for 2-person validation of all new admissions or readmissions and validated the DRR for accuracy and timeliness. Further review of the completed audit tools revealed 100% residents were audited and no concerns were identified.During an interview on [DATE] at 5:30 pm, the DON confirmed that audits were initiated and are ongoing. The nightly audit tool monitored for the DRR for accuracy, if it was completed correctly and timely, and checked for the 2-step person validating orders. No issues to date. If the ADON finds an issue, they will go immediately to the nurse and re-educate.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist UU revealed what the pharmacy had put in place and included: Labeled all high-risk meds/shelves, added computer warning for high-risk meds, for manual override, they did high alert med training for all staff, evaluated what the pharmacist had going on/workload and evaluated their environment to decrease their distractions so they could concentrate more on verifying orders. Any verbal write-ups they enter as part of our Quality Assurance (QA). A write-up is completed with all errors. They did a Root Cause analysis to determine what happened and why it happened. The pharmacy revealed and confirmed follow-up action items that were implemented.During an interview with the Senior Manager Pharmacist UU, Administrator, and hall staff confirmed the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.An interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist, UU revealed that the pharmacy completed a Root Cause Analysis to determine what happened and why the error occurred. The pharmacy revealed and confirmed follow-up action items that were implemented. During the interview with the Senior Manager Pharmacist UU, Administrator, and multiple hall staff, confirmed that the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.During an interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.It was determined and validated that all corrective actions were completed on [DATE], and the immediate jeopardy was removed on [DATE].

Based on staff interviews, record review, review of the facility documentation, and review of the facility's policy titled MDS (Minimum Data Set) - Care Plan, the facility failed to implement a person-centered, comprehensive care plan related to the administration of medication as ordered for one of nine residents (R) (R1) reviewed for a medication administration. Specifically, the facility administers Methotrexate 2.5 mg (milligram) once a day instead of once weekly, as ordered. As a result, R1 experienced medical complications requiring a transfer to an acute care hospital and expired on [DATE] due to Methotrexate toxicity.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 4:27 pm. The noncompliance related to the IJ was identified as existing on [DATE].An Acceptable IJ Removal Plan was received on [DATE]. Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE] (Past Noncompliance).Findings included:A review of the clinical Electronic Medical Record (EMR) revealed that R1 was last readmitted to the facility on [DATE] with diagnoses including, but not limited to, metabolic encephalopathy, dementia, rheumatoid arthritis, hyperlipidemia, and anxiety.A review of [Named] hospital records revealed R1 had an admission date of [DATE] with chief complaint, physical deconditioning, and a discharge date of [DATE] with primary discharge diagnosis acute encephalopathy. Discharge instructions documented, Discharge to: Skilled Nursing Facility, reason for visit: gen (general) weakness, and medication instructions included but not limited to methotrexate sodium 2.5 mg, 15 mg PO (by mouth) as directed once a week.A review of the EMR revealed the facility entered a physician's order for R1 dated [DATE] at (5:38 pm) as follows: Methotrexate sodium oral tablet 2.5 mg PO given six tablets PO once daily for RA (rheumatoid arthritis).A review of the care plan revealed R1 had a focus area for pain r/t the history of spinal stenosis and rheumatoid arthritis, initiated [DATE] and target date [DATE]. Interventions included, but were not limited to, Medication as ordered and document results, date initiated [DATE]. There was no other focus r/t rheumatoid arthritis, immunosuppressant medication, and/or methotrexate.During an interview on [DATE] at 3:25 pm, Licensed Practical Nurse (LPN) AA confirmed she made the transcription error and incorrectly entered the Methotrexate order for once daily instead of once a week. The interview further revealed that the Black Box Warning and Dose Alert got signed off because the charge nurse overrode the alert. R1 was readmitted from the hospital on [DATE], with orders including Methotrexate sodium 15 mg once weekly, and the nurse entered the frequency incorrectly. LPN AA incorrectly entered the order in the EMR on [DATE], and for once daily instead of once weekly. The pharmacy called back and said to change the order from 15 mg to 2.5 mg, take six tablets. They sent it out, it arrived on [DATE], and R1 started receiving the Methotrexate daily on [DATE]. The pharmacy completed a DRR (Drug Regimen Review) that they sent for, do not crush for a prostate medication, but nothing was said about the once-daily dose of the methotrexate. LPN CC confirmed she entered the order 2.5 mg and entered it qd (every day) in the electronic system. She revealed there was no structured process in place at that time. There was auditing where the night shift reviewed the 24-hour report, but everyone had a different perception of what 24-hour checks meant. There was nothing in place at that time to catch med errors.During a telephone interview on [DATE] at 9:20 am, Pharmacist VV revealed she occasionally did DRR's for [Named] facility. She confirmed she received R1's hospital discharge orders for review, and they included medication orders. She also confirmed that she received medication orders from the facility for R1. She revealed she verified the orders from the facility and compared them to the hospital DC orders. She revealed that they had a two-person step, confirmed she checked R1's orders behind another pharmacist, but did not know the first pharmacist's name. She revealed she was in [Named city], and the first pharmacist to review orders was in (another) [Named] city. She revealed that no one else verified the orders because she was the second person, the final person in the process.During a telephone interview on [DATE] at 9:50 am, Physician ZZZ revealed she reviewed the admission orders for R1. She revealed that no one verified or compared the hospital orders, and the orders were entered into the system at the facility. The interview revealed she was aware of the med error on Friday evening, [DATE], about 7:00 pm. R1 had the flu, and she was notified earlier in the day that he was not getting better. Physician ZZZ revealed she thought it was just taking R1 longer to get over the flu, but she gave an order for labs, and they were collected that afternoon. Physician ZZZ revealed she was not expecting R1's WBC and platelets to be abnormal, but they were critically low. Physician ZZZ asked the nurse to review his meds. When R1 last received the methotrexate, and when the nurse revealed R1 was getting the methotrexate daily, she had R1 sent out to the hospital. Physician ZZZ revealed she saw him on [DATE], and he looked great at that time.During a telephone interview on [DATE] at 7:18 pm with Registered Nurse (RN) YYY (also the MDS Coordinator) confirmed that R1 was care planned with a focus on pain with an intervention, meds as ordered. RN YYY confirmed there was no other focus on the care plan for rheumatoid arthritis or methotrexate. RN YYY revealed that looking back, she should have been more specific and R1 should have had a specific focus for rheumatoid arthritis, administration of the Methotrexate or immunosuppressant medication, instead of lumping it under the focus for pain, but she grouped the pain and arthritis all together. She revealed she got resident updates by looking at orders, diagnoses, med list, and for new admissions, she looked at the hospital paperwork. She revealed she did not specifically remember seeing the Methotrexate order on the hospital discharge paperwork.A review of the facility's undated policy titled MDS - Care Plan revealed, Policy: 4. The care plan must address all identified needs and risks, including measurable goals and timetables, specify interventions, responsible staff and services, reflect the resident preferences, goals, and discharge planning. Required content includes medical diagnoses, treatments, functional status, ADLs (Activities of Daily Living), nutrition and dietary needs, psychosocial and mental status needs, equipment, services required, and plans for discharge or community return. 10. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities initially and when changes are made.Cross Reference F760The facility implemented the following actions to remove the IJ:1. On [DATE], a medication error was identified on R1. The physician ordered R1 to be sent to an acute care hospital for evaluation, and R1 was admitted to the hospital on [DATE] and expired on [DATE].2. On [DATE], staff education was initiated by a combination of the Director of Nursing (DON), the Assistant Directors of Nursing (ADONs), the Director of Education, and continued, to include 14/14 (100%) RNs (including the MDS Coordinator), 37/37 (100%) LPNs, 7/7 (100%) Certified Medication Technicians (CMAs), on the following: ensuring to follow the plan of care related to Medication Reconciliation process and Medication Administration Rights. The process included the admission Audit Tool, Charge Nurse Nightly Audit Tool, and High-Alert/Hazardous Medications.3. On [DATE], staff education was initiated by the DON and Director of Education, and continued, to include 13/14 (92.8%) charge nurses and the MDS Coordinator related to the plan of care for New Admission/Readmission, Medication Reconciliation, the EMR Medication Alerts with the Physician and Nurse Practitioner (MD/NP) notification and documentation.4. On [DATE], a Quality Assurance Process Improvement (QAPI) meeting was conducted to discuss the medication error and the initial draft of the performance improvement plans. The team included the Administrator, DON, two ADONs, Director of Education, Chief Operating Officer (COO), and Medical Director (via phone).5. On [DATE], audits were initiated by the ADONs and continued: New/readmission Medication Reconciliation Documentation Audit. The audit included validating the 2-person check of admission/readmission orders and validating the DRR accuracy and timeliness. 84/84 (100%) residents were audited and 100% compliant.6. On [DATE], audits were initiated by the pharmacy: 1/1 resident on Methotrexate. Zero findings were noted.7. On [DATE], pharmacy-initiated implementation of internal process improvements, i.e., drug-specific pop-up alerts, visual aids on medication shelves, high-alert stickers, etc.8. All corrective actions were completed on [DATE]. The facility alleges that the immediate jeopardy was removed on [DATE].The State Survey Agency (SSA) validated the facility's IJ Removal Plan as Past Noncompliance, as follows:A review of the education records revealed education started on [DATE] for all licensed nurses and CMAs and included Medication Administration Rights.During multiple interviews, staff confirmed education with charge nurses started on [DATE] and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor. Re-education is done if noncompliance or issues arise.A review of the education records revealed that education started on [DATE] for all charge nurses, was conducted by the DON, ADON, and/or Education Nurse, and included new admission/readmission medication reconciliation, EMR medication alerts with MD/NP notification and documentation.During multiple interviews with staff, confirmed education and included a revised nightly audit tool and nightly admission tool. Nursing staff were educated that if they see something in the record with no action, they must contact the doctor; alerts require a manual override and a 2-step process. This process was ongoing.During an interview on [DATE] at 5:30 pm, the DON confirmed that initial education, audits, and monitoring were initiated, and audits/monitoring were ongoing. A review of the QAPI meeting records confirmed that a QAPI meeting was held on [DATE], and the QAPI committee began discussions about the medication error and began developing a Process Improvement Plan (PIP) for the medication error. A review of the sign-in sheet confirmed that the Administrator, DON, 2 ADONs, Director of Education, COO, and Medical Director (via phone) were in attendance.During an interview on [DATE] at 5:30 pm, the DON confirmed that a QAPI meeting was held on [DATE].A review of completed audit tools confirmed that audits were initiated on [DATE] and checked for 2-person validation of all new admissions or readmissions and validated the DRR for accuracy and timeliness. Further review of the completed audit tools revealed 100% residents were audited and no concerns were identified.During an interview on [DATE] at 5:30 pm, the DON confirmed that audits were initiated and are ongoing. The nightly audit tool monitored for the DRR for accuracy, if it was completed correctly and timely, and checked for the 2-step person validating orders. No issues to date. If the ADON finds an issue, they will go immediately to the nurse and re-educate.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist UU revealed what the pharmacy had put in place and included: Labeled all high-risk meds/shelves, added computer warning for high-risk meds, for manual override, they did high alert med training for all staff, evaluated what the pharmacist had going on/workload and evaluated their environment to decrease their distractions so they could concentrate more on verifying orders. Any verbal write-ups they enter as part of our Quality Assurance (QA). A write-up is completed with all errors. They did a Root Cause analysis to determine what happened and why it happened. The pharmacy revealed and confirmed follow-up action items that were implemented.During an interview with the Senior Manager Pharmacist UU, Administrator, and hall staff confirmed the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.An interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.During a telephone interview on [DATE] at 10:45 am with the Senior Pharmacist, UU revealed that the pharmacy completed a Root Cause Analysis to determine what happened and why the error occurred. The pharmacy revealed and confirmed follow-up action items that were implemented. During the interview with the Senior Manager Pharmacist UU, Administrator, and multiple hall staff, confirmed that the pharmacy consultant came and did observations, education with staff, audits, and medication observations for all licensed nurses and CMAs.During an interview on [DATE] at 5:30 pm, the DON confirmed that the pharmacy implemented processes, including drug-specific pop-up alerts, visual aids on medication shelves, and high-alert stickers, which were put in place for their facility. The pharmacist did education with staff, performed cart and storage room audits, and observed med administration with staff, did education, did medication observations, and checked the med storage rooms. The pharmacy consultant comes monthly and does education and DRR. The nurse consultant from the pharmacy comes every other month, and she does the med observations, checks the storage room, and carts.It was determined and validated that all corrective actions were completed on [DATE], and the immediate jeopardy was removed on [DATE].

Based on observations, staff interviews, and record review, the facility failed to implement care plan interventions for two of 48 sampled residents (R) (R94 and R66). This failure had the potential for R94 and R66 to not receive treatment and/or care according to their needs. Findings include: 1. A review of R94's medical record revealed diagnoses included but was not limited to, pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented that R94 received oxygen while a resident. A review of the care plan revealed that R94 received oxygen therapy and had diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. Interventions included oxygen as ordered. A review of the Physician Orders revealed an order dated 9/9/2024 to check oxygen saturation and apply oxygen at 2 liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 92 percent. Observation on 9/17/2024 at 12:05 pm and 9/18/2024 at 8:52 am revealed R94 was receiving oxygen at 3 LPM. In an interview on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB verified R94's physician's order for oxygen at 2 LPM and verified the oxygen was set on the wrong flow rate. She confirmed that R94's care plan included administering oxygen as ordered by the physician and that if the oxygen was not administered as ordered, staff were not following the resident's care plan. 2. A review of R66's medical record revealed diagnoses included but was not limited to, hypertension. A review of the Quarterly MDS dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented that R66 received oxygen while a resident. A review of the care plan revealed the resident had hypertension. Interventions included administering oxygen as ordered. A review of R66's Physician's Orders revealed an order dated 3/25/2024 for oxygen at 2 LPM via NC as needed for shortness of breath. Observations on 9/17/2024 at 3:00 pm, 9/18/2024 at 10:41 am, and 9/19/2024 at 8:49 am revealed that R66 was receiving oxygen with the flow rate set above 3 LPM. In an interview on 9/19/2024 at 10:24 am, LPN CC verified R66's physician's order for oxygen at a rate of 2 LPM. She confirmed that R66's oxygen flow rate was above 3 LPM. She confirmed that R94's care plan included administering oxygen as ordered by the physician and that if the oxygen was not administered as ordered, staff were not following the resident's care plan. In an interview on 9/19/2024 at 3:40 pm, MDS Coordinator FF stated nursing staff was responsible for ensuring resident care plans were followed. Cross-Reference F695

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Therapy, the facility failed to ensure that two of 48 sampled residents (R) (R94 and R66) were administered oxygen therapy in accordance with the physician orders. This failure had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice. Findings include: A review of the facility policy titled Oxygen Therapy, dated 12/28/2023, revealed the Purpose section included 1. There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration and how long the oxygen is to be administered. 5. The Unit Nurse must instruct staff members that they must not . c. change the flow rate of the oxygen. 1. A review of R94's medical record revealed diagnoses included but was not limited to, pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments and Programs) documented that R94 received oxygen while a resident. A review of the Physician Orders revealed an order dated 9/9/2024 to check oxygen saturation and apply oxygen at 2 liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 92 percent. Observation on 9/17/2024 at 12:05 pm and 9/18/2024 at 8:52 am revealed R94 was receiving oxygen at 3 LPM. In an interview on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB verified R94's physician's order for oxygen at 2 LPM and verified the oxygen was set on the wrong flow rate. She stated the medication nurses were responsible for checking the oxygen flow rates daily to ensure the flow rate was correct. 2. A review of R66's medical record revealed diagnoses included but was not limited to, hypertension. A review of the Quarterly MDS dated [DATE] revealed Section O (Special Treatments and Programs) documented that R66 received oxygen while a resident. A review of R66's Physician's Orders revealed an order dated 3/25/2024 for oxygen at 2 LPM via NC as needed for shortness of breath. Observations on 9/17/2024 at 3:00 pm, 9/18/2024 at 10:41 am, and 9/19/2024 at 8:49 am revealed that R66 was receiving oxygen with the flow rate set above 3 LPM. During an interview and observation on 9/19/2024 at 10:24 am, LPN CC verified R66's physician's order for oxygen at a rate of 2 LPM. She confirmed that R66's oxygen flow rate was above 3 LPM and adjusted the rate to 2 LPM. She stated risks to the resident when receiving the wrong oxygen flow rate included breathing and heart rate problems. In an interview on 9/19/2024 at 10:30 am, Assistant Director of Nursing (ADON) AA revealed that she expected nursing staff to check oxygen rates frequently. She further stated she expected all oxygen flow meters to be set at the rate prescribed by the physician.

Based on observations, staff interviews, record review, and review of the facility policy titled Urinary Catheter Care, the facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of two of four sampled residents (R) (R71 and R94) with indwelling urinary catheters. This failure had the potential to diminish R71 and R94's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility's policy titled Urinary Catheter Care, revised 12/27/2023, revealed 2. Catheter tubing and bag: d. Use a catheter bag cover to protect the resident's dignity. 1. A review of R71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section H (Bladder and Bowel) documented the resident did not have an indwelling urinary catheter. A review of the Physician's Orders revealed an order dated 9/14/2024 for a urinary catheter and catheter care every shift. A review of the comprehensive care plan revealed a focus area for an indwelling urinary catheter with a diagnosis of neuromuscular dysfunction of the bladder. An observation on 9/17/2024 at 11:49 am revealed R71 lying in bed with a catheter drainage bag uncovered, exposing R71's urine to other residents and visitors During an interview and observation on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB confirmed that R71's urinary catheter drainage bag was not in a privacy bag. 2. A review of R94's Quarterly MDS dated [DATE] revealed section H (Bladder and Bowel) documented that R94 had an indwelling urinary catheter. A review of the Physician's Orders revealed an order dated 9/9/2024 to change the urinary catheter every month. A review of the comprehensive care plan revealed a focus area for an indwelling urinary catheter with diagnoses of benign prostatic hyperplasia and obstructive and reflux uropathy. Observations on 9/17/2024 at 11:21 am and 9/18/2024 at 8:52 am revealed R94 lying in bed with a urinary catheter drainage bag uncovered, exposing R94's urine to other residents and visitors. During an interview and observation on 9/19/2024 at 10:10 am, LPN BB confirmed that a privacy bag was not on R94's urinary catheter drainage bag on 9/17/2024 or 9/18/2024 and revealed she placed the privacy cover over the catheter drainage sometime on 9/18/2024. LPN BB stated urinary catheter drainage bags should be in a privacy bag. In an interview on 9/19/2024 at 10:30 am, the Assistant Director of Nursing (ADON) AA revealed that all residents with urinary catheters should have the drainage bag in a privacy bag.

Based on observation, staff interviews, and review of facility policy titled, Infection Preventionist the facility failed to designate at least one qualified Infection Preventionist (IP), who is responsible for the facility's Infection Prevention, Control & Immunizations (IPCP). Findings include: Review of facility policy titled, Infection Preventionist revised 9/16/2021 indicated Policy Statement: The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. An observation on 4/27/2023 at 11:00 a.m. revealed the facility does not have a designated Infection Preventionist (IP) nurse. An interview with Director of Nursing (DON) and Administrator on 4/27/2023 at 11:10 a.m. also confirmed the facility does not have a qualified IP nurse. Further interview with Administrator on 4/27/2023 at 11: 20 a.m. revealed the previously qualified IP nurse voluntarily resigned on 4/18/2023.

2. Record review for R#159 revealed resident was admitted to the facility with the diagnoses not all inclusive of Pulmonary fibrosis, Malignant neoplasm, dependence on supplemental oxygen, shortness of breath, and chronic obstructive pulmonary disease. Review of resident physicians' orders revealed continuous oxygen at 3 liters per minute via nasal cannula. Review of Quarterly MDS assessment dated [DATE] section C0500 revealed a BIMS score of 15 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. Observation on 4/25/2023 at 10:36 a.m. revealed R#159's oxygen tank filter dirty, nebulizer machine on floor uncovered, portable oxygen tank has an exposed nasal cannula. Observation on 4/26/2023 at 8:42 a.m. revealed oxygen tank filter dirty, nebulizer machine on floor uncovered, and portable oxygen tank with an exposed nasal cannula. Observation on 4/27/2023 at 9:15 a.m. revealed oxygen concentrator filter was dirty, nebulizer machine on floor uncovered, and portable oxygen tank with an exposed nasal cannula. Interview on 4/27/2023 at 1:00 p.m. with Licensed Practical Nurse (LPN) EE revealed she was responsible for maintenance and cleaning of equipment. She mentioned the resident always refuses her assistance, but she failed to document it. She further revealed care orders were changed to PRN since the resident does it herself now and the portable oxygen tank personally belongs to the resident, and it was brought to the facility by a family member. Interview on 4/27/2023 at 10:45 a.m. with the Administrator revealed there was not a policy for storing respiratory equipment when not in use, but Best practice is to store items in a plastic bag and hang at the head of the bed. Interview on 4/27/2023 at 1:20 p.m. with DON and Administrator confirmed the nurse assigned to that resident's hall is responsible for the maintenance and cleaning of the oxygen concentrator filter, ensuring the nebulizer machine is stored properly when not in use, and ensuring that the oxygen tubing is stored in a bag when not in use. 47948 Based on observations, record review, and staff interviews, the facility failed to ensure oxygen equipment was properly clean and stored when not in use for two (2) of 50 residents (R) (R#113, and R#159). The deficient practice had the potential to increase the probability of R#113, and R#159 of contracting respiratory infections. Findings include: Record review for R#113 revealed resident was admitted to the facility with the diagnoses not all inclusive of obesity, chronic obstructive pulmonary disease, Occlusion and stenosis of unspecified carotid artery, hypokalemia, and anemia. Review of the physicians' orders revealed oxygen at (2) liters per minute via nasal cannula as needed for shortness of breath, oxygen filter washed with soap and water. Wipe down the outside machine with sanitizer as needed every Sunday night shift 7P- 7A, if used on the past week. There was no indication on R#113 plan of care pertaining to oxygen use. Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 Brief interview for Mental Status (BIMS) score was 14 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. 1. Observation on 4/25/2023 at 11:38 a.m. revealed R#113 oxygen concentrator tubing was not being stored in bag while not in use. Observation on 4/26/2023 at 8:59 a.m. revealed R#113 oxygen concentrator not in use with nasal cannula tubing lying on the floor and not covered. Observation on 4/27/2023 at 8:45 a.m. revealed R#113 oxygen concentrator not in use with nasal cannula tubing lying on the floor and not covered. Interview on 4/27/2023 at 10:15 a.m. during walking rounds with an Assistant Director of Nursing (ADON) AA, confirmed that oxygen was lying on the floor and not properly stored. A further interview also revealed that if it falls on the floor, they need new tubing. During the interview it was disclosed that the facility currently does not have a policy for storing oxygen equipment.

Based on record review, staff interview, and review of the facility policy titled, MDS: OBRA Assessments the facility failed to develop a person-centered care plan related to oxygen use for one of three residents (R) (R#113). Specifically, the facility failed to ensure that a care plan was developed for R#113 pertaining to the prn use of oxygen therapy. Findings include: Review of facility policy titled, MDS: OBRA Assessments dated 10/3/2022 under procedures 7. The information gathered for the OBRA assessments will be used to develop, revise, and review each resident's individual plan care. Record review for R#113 revealed resident was admitted to the facility with the diagnoses not all inclusive of obesity, chronic obstructive pulmonary disease, Occlusion and stenosis of unspecified carotid artery, hypokalemia, and anemia. Review of the physicians' orders dated 3/6/2023 revealed oxygen at (2) liters per minute via nasal cannula as needed for shortness of breath, oxygen filter washed with soap and water. Wipe down the outside machine with sanitizer as needed every Sunday night shift 7P- 7A, if used on the past week. There was no indication on R#113 plan of care pertaining to oxygen use. Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 Brief interview for Mental Status (BIMS) score was 14 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. Review of residents' weights and vitals summary report for March 2023, April 2023, and May 2023 for R#113 revealed resident used oxygen on the following dates since order was obtained. 3/22/2023, 3/23/2023, 3/25/2023, 3/26/2023,3/27/2023, 4/13/2023, 4/19/2023, 4/22/2023, 4/23/2023. A follow-up interview on 5/5/2023 at 12:15 p.m. with Minimum Data Set (MDS) Coordinator revealed that R#113 has an order for oxygen at 2 liters per minute as needed and has been using it sometimes at night. The dates the resident used the oxygen therapy were 4/24/2023, 4/27/2023, 4/28/2023, 5/2/2023, 5/3/2023, and 5/5/2023. The continued interview also revealed that if the resident is not routinely using oxygen, then a care plan would not be initiated for that care area and that R#113 did not have a care plan for oxygen use.

Based on record review, staff interviews, and the review of the policy entitled, Safety Guidelines for Resident Safety, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by using appropriate techniques, to prevent accidents, for one of three residents (R#1) reviewed. Actual harm was identified on 6/29/2022, when a Certified Nursing Assistant (CNA), provided ADL care to R#1, who rolled resident away from her while providing ADL care. Subsequently, R#1 fell from the bed resulting in a cervical fracture. Findings include: A review of the facility policy, Safety Guidelines for Resident Safety under General Instructions, bullet number eight (8) states, Support the residents' body well during all positioning, transferring and ambulation. Record review revealed R#1 admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Parkinson ' s Disease with nervous system symptoms, diabetes, myasthenic syndromes, [CONDITION(S)] disease, peripheral vascular disease, overactive bladder, history of transient ischemic attacks, hypertension, and gastroesophageal reflux disease. Review of the most recent Quarterly MDS assessment dated [DATE] documented R#1 had a Brief Interview Mental Status score of 12 indicating some impairment to cognition. Review of functional status revealed extensive assistance with two persons physical assist for bed mobility, dressing, and personal hygiene. R#1 was assessed as total dependence with two-person physical assist for toilet use, locomotion on unit, transfer, and bathing. Review of an Incident/Witness Statement dated 6/29/2022 revealed CNA EE entered R#1's room in response to the call light being on. CNA EE and another CNA were reported as repositioning R#1 in bed. The other CNA left the room once R#1 was positioned in the bed. CNA EE remained in the room to clean R#1 after a bowl movement and to prepare for a shower. Licensed Practical Nurse (LPN) KK is reported as entering the room and asked about R#1's shower and bandage change. LPN KK is reported as calling R#1 by name and stated, I hope you holding on. The statement goes on to report that R#1 reported that she was falling. Per the statement CNA EE reported that she tried to grab R#1 by her waist but she slipped from her grasp. It further detailed that LPN KK was walking out of the door when R#1 hit the floor. Review of a handwritten statement dated 6/29/2022 by LPN KK who documented that she went into room to remind CNA that a new dressing would be applied to resident's bottom after her bath. The statement goes on to say that CNA was informed that there should be two people when turning the resident and LPN was walking out of the room to get another CNA to help when she heard someone yell out and turned around and R#1 was falling to the floor off of the bed. Review of nursing notes dated 6/29/2022 it was noted that LPN KK heard the resident yell as she was leaving the room and she looked back to see the resident falling off the bed to the floor. The nursing notes stated the resident was on her left side holding the right side of her forehead saying she fell hard. R#1 complained that her head was hurting and a raised area to the right side of her forehead was noted. The staff stayed with the resident until the Emergency Management Team (EMT) arrived. Review of hospital emergency room report dated 6/29/2022 revealed fall as the reason for the visit. Review of diagnostic imaging report results of the computed tomography (CT) brain without contrast revealed a new right anterior head and subgaleal hematoma but no underlying fracture with comparison to CT on 5/26/2022. Further review of the imaging reports revealed CT cervical spine without contrast with findings of a new flexion teardrop fracture of the anterior base of the C2 vertebral body. Review of statement dated 6/30/2022 and signed by Assistant Director of Nursing (ADON), it was reported that R#1 had experienced a fall and was sent to the emergency room (ER). It was further reported that R#1 had a hematoma and was vomiting. It is reported that CNA EE had begun to clean R#1 due to having a bowel movement. LPN KK is reported as telling resident I hope you are holding on and as soon as LPN KK left the room R#1 fell . The statement also reflected that CNA EE acknowledged rolling R#1 away from self for care as this is how she was taught but should have been facing resident to provide care. During an interview with the Administrator on 8/9/2022 at 10:20 a.m., she stated this was a Standard of Care problem that was immediately addressed. An investigation began interviewing multiple staff and CNA EE. The Administrator then contacted the agency to let them know CNA EE could not return to the facility. The Administrator also stated at this time that if a resident was coded for two persons assist on the MDS, she expected that the facility staff would use two people to assist this resident. She explained that if one person was assisting the resident the resident should have been positioned towards the side of the bed with the rail and staff should have also been on that same side of the bed. The Administrator further reported that some of the CNAs could change R#1 by themselves, but they used a proper technique by going to the other side of the bed or by having two people assist in the care. During an interview by phone with CNA EE on 8/9/2022 at 11:39 a.m., she stated that she was changing the resident and cleaning her up to get ready to take her to the shower room. CNA EE indicated that LPN KK had entered the room to tell her to take off the old dressing and that she would put a new one on after the resident 's shower. It is reported that LPN KK looked at the resident on her side being changed and stated, hope you ' re holding on, and then she walked to the door to leave. CNA EE stated that she was on the left side of the bed, used the draw sheet to pull the resident to roll her on her side in a position that she could be cleaned. CNA EE then stated she lost her grip on the resident and the resident began to fall as the nurse was walking out, going down headfirst off the bed. CNA EE questioned why LPN KK didn't stay to help her if she thought the resident might fall. During an interview with the MDS Coordinator II, on 8/9/2022 at 2:48 p.m., she confirmed that she completed the MDS assessment for R#1. She verified that R#1 was coded for the use of two person assist for late loss (bed mobility, transfer, eating and toileting) Activities of Daily Living (ADL). She reported that during the look back period the highest level of care is what was captured and that was with two-person assistance for most ADLs.

Based on observations, record review, staff interviews, and review of the policy titled, Pharmacy Services Medication Storage in the Care Center the facility failed to discard expired biologicals prior to the expiration date printed on the medications in two of three medication storage rooms inspected. Findings include: Review of the facility policy titled Pharmacy Services Medication Storage in the Care Center (not dated) revealed: #18. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, reordered from the pharmacy, if current order exists. On 6/6/19 at 9:09 a.m. an observation and inspection made of the Station Two Medication Room with Licensed Practical Nurse (LPN) MM revealed two bottles of aspirin 325 milligrams (mg) had an expiration date of (MONTH) 2019 printed on the bottle. An interview with LPN MM, at this time, verified the meds were expired. She stated when meds are expired they are removed from supply and put in the medication disposal box located on Unit One. On 6/6/19 at 9:20 a.m. an observation and inspection made of the Station One Medication Room with Registered Nurse (RN) NN revealed one bottle of [MEDICATION NAME] coated aspirin 325 mg had an expiration date of (MONTH) 2019 printed on the bottle and two bottles of [MEDICATION NAME] 5 mg had an expiration date of (MONTH) 2019 printed on the bottle. An interview with RN NN, at this time, verified the medications were expired and should have been pulled and put in the medication disposal box located in Unit One. An interview on 6/6/19 at 9:31 a.m. with the Pharmacy Consultant OO revealed when she comes to the facility she checks the refrigerators in the drug rooms but does not check for expired medications. She stated a nurse consultant comes out quarterly from the pharmacy and checks the medication carts and medication rooms. An interview on 6/6/19 at 12:01 p.m. with the Director of Nursing (DON) revealed the 11p.m. -7 a.m. nurses are responsible for checking the drug rooms during their shift and the Unit Supervisors are responsible for checking them during the day. She did not have any verification this was completed. Her expectations were to not have any expired medications in the medication rooms or in the medication carts.

Based on record review, staff interviews, and review of the facility policy titled, Advanced Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for Do Not Resuscitate Consents for two of 30 people reviewed (R#199 and R#131). Findings include: 1. Review of the medical record for R#199 revealed a Do Not Resuscitate (DNR) Consent for a person without decision making capacity signed on 5/22/19 by family members who were not the health care agents and one physician. In the signature line for a concurring physician there was a note indicating a verbal consent received from a concurring physician on 5/22/19 at 2:15 p.m. Interview with the Administrator on 6/5/19 at 3:33 p.m. revealed that nursing reported that R#199 began to take a sudden decline and verbal consents were received from two physicians because of the sudden decline. However, in reviewing the residents medical record the Administrator revealed that since R#199 did not pass, until a week later, that staff actually would have had time to get a concurring physician's signature. Interview on 6/5/19 at 5:42 p.m. with Nurse Lead Licensed Practical Nurse (LPN) FF it was revealed that R#199 had a change in condition and imminent death was perceived. It was reported that as a result of the decline the family was conferred, and a decision was made not resuscitate. Nurse Lead LPN FF revealed that she received instructions from the Assistant Director of Nursing that verbal consent from both physicians is all that was needed. Nurse Lead LPN FF reported that she should have gotten two signatures on the form. 2. Review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] revealed a Brief Interview of Mental Status score of one, indicating that the resident was severely cognigitley impaired. Review of [DIAGNOSES REDACTED]. Review of the Do Not Resuscitate (DNR) Consent Form for a person without decision making capacity revealed a consent signed on 11/8/18. The form was signed by one physician and the responsible party. Review of the Physician Orders revealed an order for [REDACTED]. An interview on 6/5/19 at 10:03 a.m. with the Admissions Coordinator CC confirmed that there was only one physician signature on the DNR consent form and there was not a Durable Power of Attorney (DPOA) for R#131 in the E-chart or in her office. Review and interview on 6/5/19 at 10:04 a.m. with LPN/MDS Coordinator HH confirmed that there was not a copy of a DPOA on the hard copy chart for R#131. Interview, and review of the Advance Directives, on 6/5/19 at 10:18 a.m. with the Admissions Coordinator CC revealed that her role in obtaining Advance Directives was to clarify if the resident had written wishes or if they wish to discuss Advanced Directives with anyone. She stated that the Financial Coordinator would go through the admission book with the residents and or their family members and she also clarified if the resident had an Advanced Directive at the time of Admission. She stated that Social Services (SS) was also involved in obtaining the Advanced Directives. Interview on 6/5/19 at 10:27 a.m. with the Social Service Director II revealed that her role in obtaining Advanced Directives was that during the resident's care plan meeting the Advance Directive wishes were reviewed with the family. During the care plan meeting if the resident had not previously expressed an interest in a DNR, they were asked if their preference had changed. She stated that for a DNR to be legal for a resident without decision making capacity, the resident's physician, a concurring physician and the responsible party must sign it. She stated that several people were responsible for obtaining Advanced Directives including SS, the MDS nurse, and nursing. She confirmed that there was no DPOA and only one physician signature for R#131. An interview on 6/5/19 at 10:37 a.m. with the Director of Nursing (DON) revealed that for a DNR without decision-making capacity to be legal there had to be two physician signatures. Her expectation was that this form would contain the family signature, two physician signatures and a Physician order for [REDACTED]. A review of the policy titled, Advanced Directives revealed on page 2 under Do Not Resuscitate, Paragraph B that a DNR order for a person without decision-making capacity, first determined that a resident was a candidate for non-resuscitation and this was determined by the physician and a concurring physician signing in agreement.

Based on record review and staff interview, the facility failed to get signatures on the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-coverage (NOMNC) for one of three residents (R# 15) and failed to provide advance notice to one of three residents (R#52) discharged from Medicare Part A services. Findings include: 1. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R# 15 was discharged off Part A services on 3/18/19 and remained in the facility with benefit days remaining. Further record review revealed that the SNFABN and NOMNC were provided to R#15 on 3/18/19 and there was not any evidence that advance notification provided. 2. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #52 was discharged off Medicare Part A skilled services on 4/4/19. Further review of the record revealed that the SNF ABN was not signed by the resident or the family representative and there was not any evidence that this form was discussed. Review of the NOMNC revealed that on 3/29/19 a verbal notification was provided to the representative for R#52. However, there is no documentation or evidence that R#52 or representative received copies of these notices. Interview on 6/5/19 at 5:45 p.m. with Minimum Data Set (MDS) Coordinator QQ revealed that typically a three-day notice is provided to residents when discharging from Medicare Part A skilled services. It was further reported that a copy of the notification is left at the front desk for the family representatives to receive. However, if the family does not want a copy of the notification it is noted in the resident's medical record. Interview on 6/6/19 at 3:05 p.m. with MDS Coordinator QQ who confirmed that SNF ABN and NOMNC were not provided to R# 52 and/or family member because notice was given via the telephone. MDS Coordinator also reported that the family declined wanting to receive a copy of the notice; however, there was not any evidence of any documentation that the SNF ABN was refused. Further interview with the MDS Coordinator QQ revealed that MDS Coordinator QQ could not explain why an advanced notice was not provided to R#15.

Based on record review, and staff interview, the facility failed to provide the family or the resident with a written summary of the reason for transfer to the hospital for one of three residents (R#26) reviewed for hospitalization . Findings include: Review of the Minimum Data Sets (MDS) for resident (R)#26 revealed a discharge assessment on 2/28/19 to an acute hospital with an entry MDS to the facility dated 3/2/19 documenting readmission from the hospital. Review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 04 indicating that R#26 was severely cognitively impaired. Review of the Nurses Progress Note dated 2/27/19 documented that the resident had a cough with congestion and was medicated with cough syrup that was ordered as needed. The resident was assessed with [REDACTED]. Review of the Nurses Progress Note dated 2/28/19 revealed further deterioration in the resident's condition with the resident being admitted to an acute hospital on [DATE]. An interview on 6/5/19 at 2:25 p.m. with Licensed Practical Nurse (LPN) JJ and LPN KK revealed that when a resident was sent to the hospital that they assessed the resident and then notified the charge nurse of a change in condition. They stated that the charge nurse then assessed the resident also and was the one responsible for making sure that the appropriate paperwork was sent with the resident on transfer to the hospital. An interview on 6/6/19 at 8:29 a.m. with the Admissions Coordinator CC revealed that the families and/or the resident were not notified in writing of the reason for transfer to an acute care hospital. She stated that the nurses call the family and notify them verbally that the resident was being transferred. An interview on 6/6/19 at 8:37 a.m. with the Social Service Director II revealed that nursing staff notified the residents family by phone of why the resident was sent to the hospital, but nothing was sent in writing to the family and/or to the resident summarizing why the resident was sent to the hospital. An interview on 6/6/19 at 9:07 a.m. with the Administrator revealed that the family of residents, that are transferred to the hospital, are notified by the nurse calling the family member. She stated that a summary explaining to the family and/or the resident the reason for transfer was not sent out. Interview on 6/6/19 at 10:14 a.m. with the Administrator confirmed that a summary was not sent out to the family or given to the resident about the reason for the resident being transferred to the hospital. The Administrator stated that the transfer paper work was sent with the resident to the hospital, but stated she was unfamiliar with where the paperwork went or to whom the paperwork was given when the resident arrived at the hospital. The Administrator revealed that she thought that the resident was given the transfer form which would provide a summary statement.

Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was complete for one of four days in the main building. Findings include: During a tour of the facility on 6/5/19 at 4:30 p.m. the nurse staff posting was observed near the receptionist desk at the entrance of the facility. Interview with Receptionist PP on 6/06/19 at 4:13 p.m. who reported that staffing information is posted daily by the receptionist. Upon review of the nurse staff postings for the week it was confirmed that total hours were not documented on the form or on the board that displayed the information. Receptionist PP revealed that she did not know the hours and that someone in corporate may be responsible for them. During an interview with the Administrator on 6/6/19 at 4:23 p.m., it was confirmed that the nurse staffing form did not have total hours. The Administrator reviewed the posted staffing template that was in the nurse staffing book and confirmed that the total hours were not being posted this week. The Administrator further reported that she was not sure why the total hours were not being posted.

Based on observations and staff interviews, the facility failed to ensure expired medications were disposed of timely in two (2) of five (5) medication storage rooms (Hall 700 and Hall 800) and two (2) of eight (8) medication carts (Hall 300 and 500). Findings include: Observation conducted 9/11/14 at 8:00 a.m. of medication storage on the 700 hall, the following medications were found to be expired: One (1) unopened bottle of Q:PAP (Acetaminophen) liquid with an expiration date of August 2014 One (1) unopened bottle of Natural Fiber Powder with an expiration date of July 2014. Interview on 9/11/14 at 8:10 a.m. with charge nurse "CC", revealed the medications were expired. Observation on 9/11/14 at 8:15 a.m. of medication storage on 800 hall revealed the following medications were found to be expired: One (1) unopened bottle of Q:PAP liquid with an expiration date of August 2014 One (1) unopened bottle of Natural Fiber Powder with an expiration date of July 2014. Interview on 9/11/14 at 8.20 a.m. with charge nurse "BB" revealed the medications were expired. Observation on 9/11/14 at 8:30 a.m. of the medication cart on 500 hall revealed one (1) opened bottle of M:PAP (Acetaminophen) liquid with an expiration date of June 2014. An Interview on 9/11/14 at 8:30 a.m., at the time of the observation, with the medication nurse "DD" revealed this medication was expired. Observation on 9/11/14 at 9:15 a.m. of the medication cart on 300 hall revealed two (2) Lantus Insulin vials and one (1) Humalog Insulin vial were open with no opened date. Interview on 9/11/14 at 9:20 a.m. with the Licensed Practical Nurse (LPN) "AA", acknowledged the vials were open and not dated. She revealed that the nurse who opened the insulin should date and initial the insulin vials. Review of the facility policy/procedure for "Insulin Administration" indicated that ALL insulin vials should labeled with the date of first puncture and be replaced twenty-eight (28) to thirty (30) days after first use.

Based on staff interview and record review, it was determined that the licensed nursing staff failed to consult with the physician about potential side effects from an increase in dosage of antipsychotic medication and to clarify physician's orders [REDACTED]. Findings include: According to the "Georgia Practical Nurses Practice Act," the practice of a licensed practical nurse included the administration of medications under the supervision of a physician [MEDICATION NAME] medicine or a registered nurse [MEDICATION NAME] in accordance with applicable provisions of law. The licensed practical nurse was to participate in the implementation and evaluation of the delivery of health care services. However, licensed nursing staff failed to evaluate potential side effects of a medication, to consult with a physician about those side effects, and clarify an ordered dosage of an antipsychotic medication for resident #50. Resident #50 had a [DIAGNOSES REDACTED]. There was a 9/14/12 order for a 4.6 milligram (mg) patch of Excelon to be applied every 24 hours. Prior to 9/28/12, nursing staff was ordered to give the resident half (1/2) of a 0.25 milligrams (mg) tablet of [MEDICATION NAME] twice a day at 8 a.m. and 8 p.m. This meant that the resident was being given 0.125 mg of [MEDICATION NAME] at those times. The 9/28/12 consulting psychiatrist's progress note about the resident having 'sundowning" included an order for [REDACTED]. However, the nurse incorrectly transcribed that order on the September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further down on that MAR, a nurse wrote to give [MEDICATION NAME] 0.25 mg 1/2 tablet (.125 mg) after lunch 1 p.m. There was no nursing staff documentation on the resident's September MAR indicated [REDACTED]. There was no documentation by nursing staff to indicate that the resident was given any [MEDICATION NAME] on 9/30/12. Although licensed nursing staff documented on 9/30/12 that the resident was weak and was reporting that he/she might pass out, there was no evidence that the nurse consulted with the physician about it or that [MEDICATION NAME] had not been given to the resident. There was a phone order transcribed on the October 2012 physician's orders [REDACTED]. because of lethargy. Although the 10/3/12 physician's assistant's progress note included his/her plan to decrease the resident's [MEDICATION NAME] from 0.25 mg to 0.125 mg of [MEDICATION NAME] twice a day to address the lethargy, the resident was already on that dose. There was no evidence that the resident had ever received 0.25 mg of [MEDICATION NAME]. Upon receiving the physician's assistant's 10/3/12 order to decrease the resident's dosage to 0.125 mg of [MEDICATION NAME], there was no evidence that the nurse clarified that order with the physician and informed him about the increase in the dosage of the Excelon patch. There was a 10/09/12 physician's progress note that the resident had lethargy. According to documentation in the 11/01/12 nursing notes, the resident appeared "very confused and weak." During an interview on 11/06/12 at 2:30 p.m., Charge nurse " AA " reviewed the resident's clinical record and said that the nurse had not correctly transcribed the (9/28/12) order for [MEDICATION NAME]. In an interview on 11/07/12 at 10:30 a.m., the Director of Nurses (DON) stated that she was unsure of reason why the physician's assistant had written the 10/3/12 order for 0.125 mg of [MEDICATION NAME].

Based on record review, it was determined that the facility failed to implement a care plan intervention to address one resident's (#246) [MEDICAL TREATMENT] related needs in a total sample of 38 residents. Findings include: Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Staff had updated the resident's care plan on 9/13/12 to address his/her needs related to receiving [MEDICAL TREATMENT] services three times a week. Staff documented on the resident's care plan that he/she had an AV/[MEDICAL TREATMENT] placed in his/her upper left arm on 5/13/11. Facility staff developed an intervention for nursing staff to assess the resident's [MEDICAL TREATMENT] for signs and symptoms of infection and for patency every day and as needed (prn). However, there was no evidence that the nursing staff had implemented that planned intervention. See F309 for additional information regarding resident #246.

Based on staff interviews and record review, it was determined that the facility had failed to follow a physician's order to assess a resident's [MEDICAL TREATMENT] (shunt) for one resident (#246) in a total sample of 38 residents. Findings include: Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility updated the resident's care plan (9/13/12) to include the resident's problem of being given [MEDICAL TREATMENT] services three times a week. Facility staff documented on that care plan that the resident had an AV/[MEDICAL TREATMENT] placed in his/her left upper arm on 5/13/11. One of the care plan intervention was that the nursing staff was supposed to assess the resident's [MEDICAL TREATMENT] (shunt) every day and as needed (p.m.) for signs and symptoms of infection and for patency. There was a physician's order since 12/20/11 for nursing staff to assess the resident's [MEDICAL TREATMENT] (shunt) daily and as needed. However, there was no evidence that the nursing staff had followed that order and care plan intervention. During an interview on 11/7/12 at 9 a.m., licensed nurse "Y" said that the 3-to-11 p.m. shift nurses checked the [MEDICAL TREATMENT] (shunt) of residents, who were receiving [MEDICAL TREATMENT] services, and initialed their Medication Administration Records (MAR) to indicate that it had been done. However, despite the order to "check [MEDICAL TREATMENT] daily and prn" being printed on resident #246's MARs for June, August, September, October and November, 2012, there were not any nursing staff's initials documented to indicate that they had assessed it. There were not any nursing staffs' initials on the July MAR for eight (8) of 31 days (the 23rd through the 31st) to indicate that nursing staff had assessed the [MEDICAL TREATMENT]. With the exception of the 9/7/12 nursing note, there was not any evidence in the nurse's notes for June, eight (8) days in July (the 23 rd through the 31st), August, September, October and November 2012 that nursing staff had assessed the resident's [MEDICAL TREATMENT] (shunt). During interviews on 11/6/11 at 3:45 p.m. and on 11/7/12 at 9:15 a.m., when she was asked what nursing staff would have to do for resident #246 upon his/her return from [MEDICAL TREATMENT], nurse "Z" replied that nothing special was done for residents who returned being given [MEDICAL TREATMENT] other than to record his/her weight which would be provided by the [MEDICAL TREATMENT] center. In an interview on 11/07/12 at 9:00 a.m., licensed nurse "Y" said that there was not anything in particular that (nursing staff) needed to do for the resident when he/she returned from [MEDICAL TREATMENT]. However, during the review of the resident's November MAR indicated , it was observed that there was an printed entry for nursing staff to to check the resident's [MEDICAL TREATMENT] (shunt) daily and as needed but there were not any initials in the boxes for any day to indicate that they had been checked it. Nurse "Y" said that the nurse should have initialed it. Despite the physician's order since 12/10/11 and the care plan since 9/12/12 for nursing staff to check the resident's [MEDICAL TREATMENT] daily and as needed, one nurse, who was interviewed, did not know that it was supposed to be done and the other nurse assumed that nurses on another shift were doing it. There was no evidence in the nursing notes or on the MARs from June until November 7th, 2012 that nursing staff had assessed the site as ordered.

Based on staff interview, and review of the facility's "Skilled Nursing Facility Advance Beneficiary Notice" forms, it was determined that the facility failed to provide the estimated cost of continued services to three residents, who had been discharged from Medicare Part A services, in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of those services. Findings include: According to the CMS' instructions on the 70.4.3.5- "Providing Cost Estimations for Items or Services on the Form CMS- Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)," estimated cost amounts could be provided either with the description of extended care items and services (i.e., in the "Items or Services" section) or on the "Estimated Cost" line. The facility believed that three residents were to be discharged from Medicare Part A services because they no longer required skilled rehabilitation and/or skilled nursing services. The facility had issued CMS form to those residents or authorized representatives on 12/08/10, 2/26/11, and 3/12/11. However, the facility failed to include the estimated cost for the continuation of the services for the three residents in order to allow them to make an informed decision about whether or not they wanted to pay for those services themselves. The facility's "Skilled Nursing Facility Advance Beneficiary Notice" forms (CMS ) for those three residents had no estimated cost and no contact information on the form. During an interview on 6/9/11 at 10:55 a.m., financial staff "OO" stated that the estimated cost (for the continuation of skilled services) was only filled out on the notice of discharge form for the Medicare Part B residents. She said that she had not ever provided that information to residents on the CMS forms.

Based on record review and staff interview, it was determined that the facility failed to ensure that each resident was provided adequate supervision to prevent accidents for one resident (#19) in a total sample of 30 residents. This failure resulted in the actual harm of a hip fracture for resident #19. It was therefore determined that a period of noncompliance existed from 11/15/09 to 11/20/09 when the facility took action to correct the deficient practice. Findings include: Resident #19 was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. The resident had a plan of care since 9/10/09 for being at risk for falls and/or injuries related to his/her confusion and poor decision making skills. There were interventions for the Certified Nursing Assistants (CNAs) to provide stand-by/hands-on assistance of 1 to 2 persons for transfers. On the 9/7/09 initial MDS, the licensed nurse coded the resident as being dependent upon staff for transfers (3/2), ambulation (3/3), dressing (4/2), hygiene (4/2) and bathing (4/2). On the 9/7/09 Resident Assessment Protocol (RAP) for Falls, the licensed nurse documented that the resident had fallen three times since his/her admission to the facility. Review of the licensed nursing staff's documentation on the "Nurse's Note for Occurrence" form revealed that on 11/5/09 the resident had fallen from the toilet onto the floor with a licensed nurse at his/her side. During an interview on 1/07/10 at 11:00 a.m., the Assistant Director of Nursing (ADON) stated that the resident had gotten up from the toilet so quickly that the nurse was unable to assist him/her. The resident did not sustain an injury from that fall. The Falls Committee reviewed the fall on 11/11/09 but, no new interventions were developed. Review of the "Nurse's Note for Occurrence" form for 11/15/09 revealed that the resident again fell from the toilet. The resident was sent to the hospital emergency room and was diagnosed as having sustained a fracture to his/her right hip. The resident was hospitalized due to the fracture from 11/15/09 to 11/19/09. During an interview on 1/07/10 at 11:00 a.m., the ADON stated that on 11/15/09, CNA "CC" had left the resident unattended on the toilet in his/her room and he/she fell . Based on the above, a period of past noncompliance existed from 11/15/09-11/20/09. Review of the facility's relevant documents revealed that the facility had taken the following actions to correct the deficient practice: 1. Certified Nursing Assistant (CNA) "CC" was terminated for leaving a dependent resident (#19) unattended on the toilet which resulted in a fall with a right hip fracture. 2. All nursing staff were inserviced that any resident who required direct supervision with toileting was to have stand by assistance when toileting and was not to be left unattended during the toileting. 3. All residents that required stand by assistance when toileting had their plans of care updated to reflect that intervention. The facility had implemented the interventions listed above and ensured that the actions remained in effect for the continued correction of the deficient practice prior to and during the standard survey conducted from 1/05/10-1/07/10.