Every finding on record at Christian Heights Nursing and Rehabilitation Cente

Based on observation and interview, the facility failed to store drugs under proper temperature controls, and failed to provide separately locked, permanently affixed compartments for storage of controlled drugs. This affected Resident (R)29. The findings include: Observation of the facility's only medication storage room was conducted on 03/26/2026 at 4:20 PM, with the Director of Nursing (DON). The Pixis system (Automated medication dispensing system using secure computerized cabinets to store and dispense medication) and three unlocked refrigerators were observed on the shelves of the medication storage room. Temperature logs for the refrigerators were checked with no concerns noted. However, there was no controlled substance affixed lock box present inside the refrigerators. Also, there were no controlled drugs in the refrigerators. The DON stated R29 had new comfort measures and was prescribed Ativan (Medication used for short term relief of severe anxiety). The DON further stated R29's Ativan was kept on the medication cart as the medication did not require refrigeration. Observation of Hall 2's Medication Cart 1's controlled substance drawer, on 03/26/2026 at 4:25 PM, revealed a zip-lock bag with a bright pink label stating Refrigerate, which contained a single 30 milliliter bottle of oral Ativan in its carton prescribed to R29. The carton was labeled on the front to store between two and eight degrees Celsius. Registered Nurse (RN) 1, who was assigned to the medication cart stated she was uncertain whether oral liquid Ativan required cold storage after opening. Interview was conducted on 03/26/2026 at 6:11 PM, with the Administrator to address earlier findings. He stated medication should be refrigerated as specified on the storage instructions.

Based on observation, interview, and review of facility policy, the facility failed to protect residents from misappropriation of property (medication) for 1 of 9 sampled residents observed during medication administration, Resident (R)38. The findings include: Review of the facility policy, titled Abuse Prohibition Standard of Practice, revised 07/2022, revealed the definition of misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of the resident's belongings or money without the resident's consent. Further review revealed all new and current team members would receive education/training at the time of employment/initial orientation, annually, and through on-going in-service programs to include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; and identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Review of R38's Face Sheet, revealed the facility admitted the resident on 10/14/2020 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic pain syndrome, dysphagia and essential hypertension. Review of R30's Face Sheet, revealed the facility admitted the resident on 02/28/2020 with diagnoses including COPD, schizophreniform disorder, anxiety disorder and essential hypertension. Observation of medication pass, on 03/26/2026 at 9:15 AM, on Hall 2, revealed R30 was out of Metoprolol succinate extended release (ER) 25 milligram (mg) tablets (Medication used to treat high blood pressure, and angina). Registered Nurse (RN)1 locked the cart, closed the computer and went to Hall 1. She stopped to get the medication cart keys from Kentucky Medication Aide KMA3. Further observation revealed RN 1 went to the medication cart on Hall 1 and pulled a tablet of Metoprolol succinate ER 25 mg from R38's medication card and placed the tablet in the cup of medication for R30. After closing and locking the medication cart, RN1 went back to Hall 2 and administered the medication to R30. In an interview, on 03/26/2026 at 9:20 AM with RN1, she stated if someone was out of a medication, it was normal practice to just get it from another resident. RN1 further stated, when the resident that loaned the medicine ran out of medication, then she would just borrow medication from another resident. In an interview, on 03/26/2026 at 5:50 PM, with the Director of Nursing (DON), she stated she was aware of the incident of misappropriation which occurred earlier in the day. She stated Borrowing medication from another resident was not normal practice. She further stated, RN1 was a new nurse and was nervous. In addition, she stated RN1 was originally from [NAME] and there was a slight understanding barrier. Further, the DON stated RN1 received education after the incident, and the facility planned to do re-education with all staff related to what to do if a resident runs out of medication. In continued interview with the DON, on 03/26/2026 at 5:50 PM, she stated if it was discovered a resident was out of a medication, nursing staff should first check the Pyxis (Automated medication dispensing system using secure computerized cabinets to store and dispense medication). She stated if the medication was not in the Pyxis, the dose would not be administered and would be documented as such. In continued interview, she stated if a dose of medication was missed, the nurse should notify the physician. Also, the DON stated there was a refill button in the Medication Administration Record (MAR) section of Visual (the electronic medical record system the facility utilized) to request a refill of medication. Further, she stated the pharmacy delivered medications at least twice a day. In an interview, on 03/26/2026 at 4:08 PM, with the Administrator, he stated he had been made aware of the medication misappropriation that occurred this morning. He stated the practice of borrowing medication from one resident for another was absolutely not approved by the facility. He further stated RN 1 was a brand new nurse and after the incident, the nurse was educated on the process of what to do when a resident runs out of medication.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food items were not sealed and/or covered to prevent contamination. Opened food items were not dated as required. Food maintained on ice during lunch meal service exceeded the required 41-degree Fahrenheit temperature limit for cold food items. The facility's failure had the potential to affect 56 of the facility's 57 residents who consumed food from the kitchen. The findings include: 1. Review of the undated facility policy, titled, Labeling and Dating, revealed proper labeling and dating ensured that all foods were stored rotated, and utilized in a first in-first out manner. Further review revealed all foods should be dated upon receipt before being stored and opened or leftover items must be labeled and dated with the date they are prepared or opened, and the use by date. Review of the facility policy titled, Food Storage; Dry Goods, revised 02/2023, revealed all dry goods would be appropriately stored in accordance with the Food and Drug Administration (FDA) food code. Further review revealed all packaged food items would be kept clean, dry, and properly sealed. Review of the facility policy titled, Food Storage; Cold Foods, revised 02/2023, revealed all foods would be stored wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Observation of the kitchen, on 02/20/2025 at 9:30 AM, revealed the following: a. Dietary staff were preparing sandwiches for lunch on an island in the middle of the kitchen. A tray with twelve baked cookies was sitting out, uncovered and unattended. Continued observation revealed a heating/cooling duct system with seven discolored vents blowing over the top of the island where food was being prepared. b. Refrigerator 3 contained cheese slices which were stored in a plastic container and were exposed to contamination, due to an unsecured lid. A bag of shredded mozzarella cheese was opened but was not labeled with the received date, the open date, or a use by date. c. The dry pantry storage area with freezers located across the hall from the kitchen revealed Freezer 3 was also soiled with food particles. A box of frozen beef patties was opened but unsealed and exposed to potential contamination. The box was not marked with the required received date, opened date, or use by date. Further observation of dry storage goods revealed a bulk box of rice in its original container which was not covered and was exposed to possible contamination. In an interview with [NAME] 2, on 02/21/2025 at 2:00 PM, he stated he was aware of the processes for food safety which included labeling, dating, and storing food items. He stated every food item received should have a receive date, open date, and use by date. He added that any food items should also be sealed properly to prevent cross contamination. [NAME] 2 stated that all kitchen staff were responsible for ensuring that foods were labeled, dated, and stored correctly. [NAME] 2 further stated there was potential for bacteria growth on foods that were cross contaminated, and residents were at risk if staff were not following facility policies and processes. In an interview with [NAME] 1, on 02/21/2025 at 2:15 PM, she stated the cookies left out on the counter should have been covered to prevent exposure of airborne particles. She stated all items that were opened should be sealed properly and have a receive date, open date, and use by date to prevent serving food past its shelf life. She stated cross contamination was potentially harmful to the residents and could cause sickness. In an interview with the Dietary Manager, on 02/21/2025 at 2:30 PM, he stated expectations for the dietary staff was to ensure that all food items that were received had a receive date. Further, if an item was opened, it would require an open date and a use by date to ensure freshness. He stated there were signs posted throughout the kitchen as a reminder to staff of the importance of marking those required dates on the food products. Additionally, any food item that had been opened should be sealed correctly whether in the pantry, refrigerator, or freezer to prevent residents from receiving food that was freezer burned or exposed to cross contamination which could result in resident illness. Furthermore, if those policies and procedures were not being followed, it would prevent staff from providing the residents the best homelike experience in the facility and that was priority. In an interview with the District Dietary Manager, on 02/21/2025 at 2:30 PM, he stated his expectations were that staff were following facility policy and procedures to ensure food safety. Interview with the Administrator, on 02/21/2025 at 4:00 PM, revealed his expectations were that staff ensured food was stored according to facility policy which included dating food items with a receive, open, and use by date. He stated ensuring foods were sealed properly was just as important as storage dates, as both affected the quality of the food. 2. Review of the undated facility policy titled, Time and Temperature Control and Recording, revealed bacteria and other foodborne pathogens can grow quickly in the temperature danger zone of 41 to 135 degrees Fahrenheit. Further review revealed proper holding and transport of food was critical for resident safety and wellness. Review of the facility policy titled, Food Storage; Cold Foods, revised 02/2023, revealed all perishable foods would be maintained at a temperature of 41degrees Fahrenheit or below except during necessary periods of preparation and service. Observation of the kitchen, on 02/20/2025 at 11:45 AM, revealed lunch was being served and food items were maintained on a steam table. At this time, the District Dietary Manager assisted with temping both hot and cold food items. All hot foods were 186 degrees Fahrenheit (F) or higher. However, observation revealed that two foods to be served cold were over 41 degrees F. A pan with ice on the end of the steam table contained mayonnaise-based broccoli salad and mayonnaise-based potato salad. The broccoli salad was 72 degrees F, and the potato salad was 45 degrees F. In an interview with [NAME] 2, on 02/21/2025 at 2:00 PM, he stated that the steam table was to be held at 145 degrees Fahrenheit for hot foods but was not aware of the temperature for the cold food items that were maintained on the cold side of the steam table. He stated potential concerns for residents being exposed to food not being maintained at proper temperatures could cause salmonella or other sickness. In an interview with [NAME] 1, on 02/21/2025 at 2:15 PM, she stated she had temped every meal on the steam table prior to meal service. She stated hot foods were to be held at 165 degrees Fahrenheit, and confirmed cold foods were to be held at 41 degrees Fahrenheit or below. In an interview with the District Dietary Manager, on 02/21/2025 at 2:30 PM, he stated his expectations were that staff were following facility policy and procedures to ensure food safety. Further interview with the District Dietary Manager revealed that the temperatures for the two cold salads were not acceptable and indicated that staff needed further training. Interview with the Administrator, on 02/21/2025 at 4:00 PM, revealed there could be harmful outcomes for residents if staff were not following the facility policies and processes regarding appropriate temperatures for both hot and cold foods to prevent bacteria growth, or potential salmonella illness. Additionally, practicing proper food safety processes were important as it would ensure residents were provided the best quality of care in a homelike environment.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a functional, sanitary, and comfortable environment for 20 of 57 residents (Resident (R) 7, R10, R16, R19, R22, R25, R26, R33, R35, R38, R40, R42, R43, R46, R47, R48, R49, R50, R55, and R110.) Resident rooms had broken and/or missing floor tiles, peeling paint, and/or holes in walls. Four residents (R19, R46, F47, and R50) were noted to have an unsanitary commode in poor repair. The findings include: Review of the facility policy, Resident Rights Standard of Practice, originated 04/2024, revealed the facility follows the guidance of Regulatory Group 483.10, F550-F586, which includes the right to a safe, clean, comfortable, and homelike environment. Review of the facility policy, Homelike Environment Standard of Practice, last reviewed 10/2020, revealed the facility shall maximize, to the extent possible, characteristics of the facility to reflect a personalized, homelike setting. This shall include cleanliness and order and pleasant, neutral scents. Observation of the facility during an initial tour on 02/18/2025, beginning at 10:55 AM. revealed the following: a. R48 and R55's room had chipped paint and gouge marks on the door and doorframe. The rubber baseboard was pulled away from the wall, and there were yellow/orange stains on the floor. During an interview with R48 on 02/21/2025 at 4:00 PM, he stated it would be nice if the peeling paint and poor condition of the walls and floor was repaired. Review of a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/01/2024 revealed the resident was cognitively intact, based on a Brief Interview for Mental Status (BIMS) score of 15/15. b. R25 and R40's room had a hole in the bathroom door. The baseboard was pulled away from the wall. The walls had a large area of chipping paint. In an interview on 02/21/2025 at 4:05 PM with R40, she stated she would like to see it fixed, referring to the condition of the walls, floors, and paint. Review of an MDS, with an ARD of 02/15/2025, revealed R40 was cognitively intact, based on a BIMS score of 14/15. c. R110 and R16's room had a strong odor of urine. The floor had broken tile and was uneven. Food particles were noted on the floor. d. R43 and R10's room had broken tiles in the floor. e. R42 and R49's room had multiple broken and missing tiles in the floor. f. R19 and R47's room had chipped paint on the wall. There were yellow/brown stains down the wall and onto the floor under the sink. A corner of the door threshold was crumbling and there was a debris pile in the floor. g. The wall in R38's room had paint that was coming off from where a wallpaper boarder had been painted over. The outside environment was visible around the heating/air conditioning unit. h. R35's room had a wall corner that was crumbling and there was a pile of debris in the floor. The shower for this room was missing six tiles, four of which were stacked to the side. The caulking around the sink was discolored brown and was peeling away from the sink. i. R7 and R22 had missing tile in the bathroom. j. The handrail outside of the Director of Nursing's (DON) office had a pile of dust/debris build up. The pile was still present at approximately 3:30pm on 02/21/2025. k. Food particles on the floor and on the tops of the tables in the dining room. Additional observations made on 02/21/2025 at approximately 3:15 PM revealed the following: l. R26's bathroom flooring around the base of the toilet was caked with in a reddish/brown substance. m. R33's room had chipped paint on the walls. The caulking around the sink was discolored brown and had a substance built up on it. n. Observation on 02/18/2025 at 11:05 AM revealed the toilet in the bathroom shared by R19, R47, R50, and R46 was not functioning or in good repair. The toilet was filled with a brown/yellow substance, and there was a strong odor indicative of feces and urine. There was also a yellow dried substance on the toilet seat, indicative of urine. The toilet seat was broken and was hanging sideways from the toilet. A plumber's snake and plunger with duct tape were present. On 02/20/2025 at 10:05 AM, the snake and plunger were gone, but the toilet was still filled with a brown/yellow substance which continued to smell strongly of feces and urine. In an interview on 02/20/2025 at 11:00 AM with Housekeeper (H) 1, she stated she is responsible for cleaning resident rooms daily. She cleans bathrooms every day and stated the shared bathroom of R19, R47, R50 and R46 has a problem of stopping up. H1 stated she had reported this to her housekeeping manager and thought she reported it to maintenance. In an interview on 02/20/2025 at 5:00 PM with the Maintenance Director, regarding the bathroom for R19, R47, R50, and R46, he stated, It's a brand-new toilet. We are having an issue with a resident continuously stopping up a toilet. The Maintenance Director added that he was trying to get another type of toilet that will help prevent that from happening, but it had not yet been ordered. The Maintenance Director stated that Currently it must be unstopped one to two times a day. It has gotten to the point that work orders are not being put in because I know I must check it every day. Regarding the condition of the walls, floors, and paint throughout the facility, he stated it was his preference to complete all repairs in one room before moving to another Further interview revealed that at this point, only one room had received all its necessary repairs. The Maintenance Director indicated that repairs needed to be made relative to the observed gouges in the walls, adding he had plans to place a vinyl material on the walls of the resident rooms to a height of approximately four to five feet from the floor. The Maintenance Director added that once funding was available, he planned to continue renovating room by room. However, until that time, nothing was being done to repair the walls/paint. He stated floor tiles were being purchased a few at a time to place in areas that were missing tile. The Maintenance Director added, They may not match when we get them, but it will be better than nothing. During an interview with the Environmental Services Director (ESD) on 02/21/2025 at 3:20 PM, she provided the Project and Deep Clean Calendars, stating that each room was scheduled for a monthly deep clean. Per the ESD, the monthly deep clean of each room consists of removing the curtains and washing them, cleaning the blinds, removing everything from the walls and cleaning the walls, cleaning under the furniture, and removing bedding and mattress from the bed frame for cleaning. During an interview on 02/21/2025 at approximately 5:00 PM, the Administrator stated his expectation was for the facility to create a clean, comfortable, and homelike environment for the residents. Per the Administrator, this expectation included cleanliness as well as physical appearance.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure one (1) of two (2) sampled residents was provided adequate supervision (Resident #1). The facility assessed and care planned Resident #1 to be a high risk for elopement and a wanderguard was placed on the resident on [DATE]. However, on [DATE] at approximately 4:00 PM, Resident #1 was able to exit the facility without staff's knowledge. Resident #1 was observed to be across the road from the facility on the sidewalk by a staff member that was leaving work. The resident crossed a busy highway, went into a convenience store, bought a lottery ticket, and walked approximately fifty (50) yards, then crossed back across the busy street. The resident was returned to the facility with no injuries noted. The facility's failure to have an effective system in place to provide adequate supervision to prevent an elopement, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on [DATE] and the facility was notified of the Immediate Jeopardy on [DATE]. The facility submitted an Allegation of Compliance (AoC) on [DATE] alleging the Immediate Jeopardy was removed on [DATE], prior to the State Survey Agency entering the building on [DATE], indicating past noncompliance. The State Survey Agency (SSA) determined the facility had corrected the deficiency on [DATE] prior to the SSA entering the building on [DATE]; resulting in the determination of Past Jeopardy. However, after supervisory review it was determined the facility was not in substantial compliance on [DATE]. Record review and interview revealed the first elopement drill was not held until [DATE] and a Quality Assurance meeting had not been held since [DATE] to review the facility's monitoring to ensure compliance was achieved. Therefore, the State Survey Agency determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D for CFR 4[AGE].25 Quality of Care at F689; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Accidents and Incidents dated [DATE] revealed the purpose of the Incident and Accident Process is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines. The facility's Administrator will ensure incidents are reported to the appropriate State agency in compliance with the State reporting criteria. Notification of physician and responsible party will be completed with any accident/incident. Incident/Accidents, including elopement, is investigated by the IDT and reported according to regulatory guidelines. Assessments and investigations are done in a systematic manner: Identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The resident's Care Plan and Certified Nurse Aide Kardex or Care Card is to be updated as interventions are implemented. Record review revealed the facility admitted Resident #1 on [DATE] with a [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated [DATE] and faxed to the facility on [DATE], revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Per family his/her living conditions were poor. He/She lived by self and had a history of [REDACTED]. Resident was admitted several days ago for potential placement or assistance at home; however, he/she eloped from hospital. This resulted in police being called and the resident was found at home. Review of Resident #1's Elopement Evaluation dated [DATE] revealed he/she was assessed at a ten (10) which indicated the resident was a high risk for elopement. Further review revealed the resident had a history of [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition was severely impaired with a Brief Interview for Mental Status (BI[CONDITION]) score of three (3) which indicated the resident was not interviewable. Further review of the assessment in Section E Behavior, revealed the resident was assessed to have wandering behaviors that occurred one (1) of three (3) days. Review of the Activities of Daily Living functional status found the resident was independent with supervisory oversite. Review of Resident #1's Nursing Notes, dated [DATE] at the time of admission, revealed a wander guard was placed due to history of wandering prior to admission. Review of Resident #1's [DATE] Physician order [REDACTED]. Review of the Comprehensive Care Plan for Wandering/Elopement related to exit seeking behaviors, packing of belongings, and wandering behavior, dated [DATE], revealed goals that Resident #1 will wander in a safe environment, resident will not wander outside of the facility, resident will be redirected to a safer area, wandering episodes will decrease in ninety (90) days, and the resident will adjust and accept nursing placement. Further review revealed interventions to attempt to determine needs when speaking of leaving, attempt to distract, attempt to have resident complete crossword puzzles as will, distract with programs or general conversation, engage resident in group activities to decrease wandering, involve family/significant other in care planning, notify Medical Doctor of any change in resident's condition, redirect during wandering episode, and staff to be alert for hoarded food/drinks in room, remove as needed and offer snack/drink to replace ones removed. In addition, it was noted on the care plan the resident liked to read the Bible, eat snacks and converse with others and had a Wander guard bracelet. Review of Resident #1's Nursing Progress Note, dated [DATE] at 7:10 PM by Licensed Practical Nurse (LPN) #1 revealed, at approximately 4:00 PM, the resident was noted outside of the facility by a staff member and was returned to the facility. The door alarm sounded with reentrance into facility. The resident was dressed appropriately for outside weather conditions and was placed on one on one watch with staff immediately following entrance to facility. There was no injury noted with visual examination. A full head to toe body audit was completed by signee with no new areas of concern noted at this time. No new bruising, discolorations, [MEDICAL CONDITION], open areas, or new areas were noted. Signee called Guardian and left voice mail. The MD was alerted and no new orders were received. Blood pressure was ,[DATE], Pulse [AGE], and Respirations 18, even and nonlabored. Temporal temperature was [AGE].3 and Oxygen saturation was [AGE]% on room air. Review of the facility's Investigation Report dated, [DATE], revealed based on resident and staff interviews, the resident was observed to be out of the Center, near the Dollar store by a staff member who was leaving the building after completing her shift. The staff member approached the resident and assisted the resident back into the building. The resident stated he/she left the Center to buy him/herself a lottery ticket. The investigation revealed the resident did in fact purchase a lottery ticket from the convenience store across the street from the facility. Upon returning to the facility, the resident was placed on 1:1 supervision. Resident assessment indicated no change in condition and no injuries noted. Further review revealed the facility determine the resident exited the building without staff's knowledge but were unable to determine through which door and how. According to website timeanddate.com, the temperature on [DATE] was 48 degrees Fahrenheit and sunny at 12 noon and 41 degrees Fahrenheit at 6:00 PM. Observation on [DATE] at 1:50 PM by this surveyor and Administrator revealed Resident #1 walked approximately ninety-five (95) yards (verified by Administrator with range finder) to the convenient store, then walked approximately fifty (50) yards to where he/she was first seen by staff. The speed limit for the highway the resident crossed was thirty-five (35) miles per hour (mph). The road is historically busy since it is the main road to and from the county seat. Interview with the Human Resources employee, on [DATE] at 1:43 PM revealed on [DATE] she left work around 3:55 PM. She stated she turned left out of parking lot and noted Resident #1 on the sidewalk across the road past the facility so she pulled into a parking lot of the gym and she then noted the resident had walked back across the road. She stated she also crossed the road and asked the resident to go with her back to the facility, and they both crossed the road again and she got the resident into her car and drove back to the facility. She revealed she text the Activities Director who met her at the door with the Assistant Director of Nursing and LPN #1. She further revealed she was glad she saw the resident and returned him/her back to facility. Interview with Activities Director on [DATE] at 2:24 PM revealed she received a text from the Human Resources Employee at 4:10 PM and met them at the door. She stated when she opened the door, Resident #1 walked back into the facility, and the resident's wanderguard alarm sounded. She also revealed she had witnessed the resident walking the halls earlier on [DATE] prior to the elopement. Interview (Post Survey) with Certified Nurse Aide (CNA) #5 on [DATE] at 1:10 PM revealed she was caring for Resident #1 on [DATE], the day of the elopement. She stated she did not see the resident trying to leave facility but did see him/her going from the lobby back and forth to the room in a calm manner which was calmer than usual for the resident. She revealed the resident usually goes back and forth to call her family at the lobby nurses station. She stated she did not see resident with a coat on that day and the last time she saw him/her, he/she was around his/her doorway at 3:45 PM. She further revealed she did not remember hearing a wander guard alarm sound that day or hear an alarm sound when resident came back to building. She stated when the resident wanders, we redirect him/her with snacks and activities including word search books or puzzles. Interview with LPN #1 (who was assigned to Resident #1 on [DATE]), on [DATE] at 10:55 AM revealed she had noted Resident #1 walking up and down the halls on [DATE]. She stated she did not remember the alarm going off that day around 3:45 PM to 4:00 PM; however, she was at the door when the resident returned and the wanderguard alarm sounded when he/she approached the door. Interview (Post Survey) with CNA #6 on [DATE] at 1:20 PM revealed she was assigned to Resident #1's hall but not the resident. She stated she saw Resident #1 walking up and down hallway as usual but did not see him/her trying to get out of the facility. She revealed the resident was easily distracted by striking up a conversation with him/her and would sit for a while. She further revealed the resident liked word search books. She stated the last time she saw Resident #1 was at 3:20 PM when she clocked out and the resident was sitting on the couch in the lobby speaking with another resident. She further stated she did not hear any wander guard alarms go off that day. Interview with CNA #3 (not assigned to hall with resident) on [DATE] at 4:55 PM revealed she worked on [DATE] and saw Resident #1 walking up and down the halls on that date. She also revealed she saw the resident at the lobby nurses station talking on the phone. She stated she did not hear the wanderguard alarm sound that date nor did she see the resident leave the building. She further revealed the resident was always visiting with other residents. Interview with Director of Culinary Services on [DATE] at 3:30 PM revealed Resident #1 likes to visit in her office. She stated she had seen the resident in her coat and he/she told her he/she wanted to go to church outside of facility. She stated she heard the door alarm on [DATE] around noon, went to the side door where visitors come in and found Resident #1 trying to open the door. She revealed she directed the resident to back away from the door and then opened the door for visitors. She stated she was aware the resident's wanderguard alarm had not sounded and took the resident immediately to LPN #1 and tested the resident's wanderguard and found it was working; however, when the resident was taken to the outside door, the alarm did not sound. She stated the wanderguard was removed and replaced, and the new wanderguard bracelet was validated to be working properly. Further review of the resident's plan of care revealed on [DATE] an intervention was added that wander guard bracelet replaced. Interview with LPN #1 on [DATE] at 10:55 AM revealed she remembered changing the resident's wanderguard bracelet that date. She stated it was around lunch time but unable to recall exact time. Interview with the Maintenance Supervisor on [DATE] at 2:39 PM revealed he clocked out on 3:51 PM at the nurses station in the lobby and Resident #1 was on the phone at the nurses station with his/her coat and hat on. He stated the resident liked to move around and talk with people. He revealed the resident's wanderguard had been replaced earlier that day due to it not working at the outer doors and the replacement wanderguard was validated and worked properly. He stated there were wanderguard alarms on each outside egress to the facility, and he checks the doors daily and they have been working correctly. He further revealed on [DATE] he actually checked the doors three (3) times due to the resident's wanderguard not working. He revealed in his opinion, the door was probably opened by a visitor and the resident walked out the door. He believed the alarm sounded but no one checked to see if a resident was leaving. He revealed he could not prove that but since the alarms systems were working, that was his conclusion. Interview with the Assistant Director of Nursing (ADON) on [DATE] at 12:50 PM revealed when Resident #1 returned to the facility, the resident was dressed appropriately for outside with a coat and hat on. The ADON stated when the resident walked back into the building the resident's wanderguard alarmed. She revealed a head to toe assessment was completed with no new injuries identified. She further revealed the resident stated he/she was not aware he/she could not leave the facility and just wanted a lottery ticket. She stated a full facility head count was completed when the resident returned and all residents were accounted for. She also revealed the resident had a history of [REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 2:10 PM revealed it was not determined what door the resident left from; however, when she interviewed the resident on [DATE] at 5:15 PM, the resident stated he/she went out the left upper side door and went to buy a lottery ticket. She stated the resident said, I went out with everyone else. The DON further revealed, if resident went out the front side door, then he/she took the drive to the road, and walked across the road to the convenience store across from facility. Interview with Resident #1's Guardian, on [DATE] at 12:01 PM revealed the MD orders from the hospital were for the resident to go to a secured facility because of Dementia/Alzheimer's and the resident had wandered off from the hospital. She stated she was under the assumption the facility was secured. Interview with the Advanced Practice Registered Nurse (APRN) #1 on [DATE] at 10:39 AM revealed she was not aware the resident had eloped from the hospital prior to admission and did not know the history of wandering off from home. She revealed this facility was not a memory care unit which appeared the resident required. Interview with the DON on [DATE] at 3:47 PM revealed if she had known the resident was an elopement risk prior to the admission, she would have turned down the admission. She stated she was unaware the resident had eloped from the hospital prior to admission and admissions were usually an IDT decision if the resident had a history of [REDACTED]. Further review of Resident #1's record revealed the facility reassessed the resident's BI[CONDITION] score on [DATE] and assessed Resident #1's cognition as moderately impaired with a BI[CONDITION] score of nine (9) which indicated the resident was interviewable. Interview and observation with Resident #1 on [DATE] at 12:15 PM revealed the resident had a sitter at bedside. When asked, the resident revealed he/she did not know they could not leave the facility. The resident revealed he/she liked to buy lottery tickets and would be sad if he/she could not buy them. Further interview with the resident on [DATE] at 10:16 AM revealed he/she would not leave the facility unless someone took him/her. The resident stated they went out the door but did not recall which door or if alarm sounded or not. **The facility implemented the following actions to correct the deficient practice: 1. A complete head to toe assessment was conducted for Resident #1 including but not limited to a complete set of vital signs. This was completed by LPN #1 on [DATE]. 2. A new Elopement Risk Assessment was completed on Resident #1 on [DATE] and [DATE] by the MDS Coordinator. 3. Resident #1's Wanderguard was checked for function and placement by LPN #1 on [DATE]. 4. The DON and LPN #1 notified Resident #1's MD and resident representative he/she exited the facility on [DATE]. 5. Resident #1's Plan of Care and CNA Plan of Care was updated per DON/Licensed Nurse on [DATE]. 6. The IDT team reviewed Resident #1's entire plan of care to determine if all interventions were in place per the plan of care on [DATE]. 7. The DON completed interviews with all staff on duty at the time of the incident related to the whereabouts of Resident #1 and their response to the door alarm on [DATE]. 8. A timeline was completed from [DATE] through [DATE] by the DON and Social Services Director to determine when staff last saw Resident #1 and what he/she was doing at the time. 9. Documented in investigation what resident was wearing, what the temperature and weather conditions were outside and how long resident was outside facility. This was completed by DON, Administrator, Social Services Director, and LPN #1 on [DATE]. 10. The revised care plan interventions for Resident #1 were communicated to the staff by LPN #1, DON, and Social Services Director on [DATE]. 11. A complete head count of all current residents was completed by LPN #1 on [DATE] with all residents accounted for. 12. New Elopement Risk Assessments were completed for all current residents by the MDS Coordinator on [DATE]. 13. All residents with the risk for elopement were audited to determine that the following items were in place for each resident at risk: Wander guard order for placement check and function each shift and signed off appropriately, each resident at risk for elopement has a wander guard in place and not expired, each resident at risk for elopement has behavior monitoring for exit seeking behaviors and person centered non pharmacological interventions, and each resident at risk for elopement has a care plan for exit seeking/elopement risk that is current and reflects the residents' person-centered, non-pharmacological behavior interventions, wander guard, etc. This was completed by the DON, Administrator, Staff Development Coordinator (SDC), LPN #1, and Social Services Director (SSD). This was started on [DATE] and completed by [DATE]. 14. All Elopement Binders were audited to validate that all current residents at risk have a picture that accurately reflects the residents' current appearance and resident identification information. This was completed on [DATE] by DON and SSD. 15. A Complete assessment of all exit doors to verify doors and door alarms were functioning appropriately was completed on [DATE] by the Maintenance Director. 16. The Door and Wanderguard alarm vendor was contacted to have system function verified. The contact was made by the Administrator on [DATE] and system function completed on [DATE] by vendor. 17. All staff was re-educated on the Elopement Process and response to all door alarms by the DON, Administrator, Staff Development Coordinator (SDC) and LPN #1 and education was completed on [DATE]. 18. The DON, SSD, SDC, LPN #1 and Administrator completed an elopement drill on each shift to evaluate staff response to the wander guard alarms on [DATE]. 19. Maintenance completed an assessment of the alarms systems and doors to determine all were functioning as per manufacturer guidelines and audible to staff. This was assessed for completion by the Administrator on [DATE]. 20. A certified technician from a vendor checked functioning of exit doors/panels on [DATE] and it was confirmed by the Administrator on [DATE]. 21. The DON added signs to exit doors on [DATE] to alert visitors/staff upon exiting and entering to not let anyone out without checking with staff. 22. The Administrator and/or Director of Nursing will complete an elopement drill on alternating shifts weekly times four (4) weeks, then monthly times two (2) months, and then at least quarterly moving forward. They will assess the staff response then provide additional education or guidance based on that response. This will be completed by the Administrator, DON and SSD and will be ongoing. 23. A summary of the monthly Elopement drills and door alarm checks will be submitted to the Quality Assurance Committee for further review and recommendations. This will be completed by the Administrator and/or the DON. 24. An Ad Hoc QAPI meeting was held with the Administrator, Director of Nursing, and Medical Director (include others as needed) to review the incident, action plan and findings. This was completed by Administrator, SSD, DON, and the Medical Director on [DATE]. 25. A monthly QA meeting will be reviewed for current status of Action plan. This will be completed by Administrator, SSD, DON, and the Medical Director on [DATE]. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's facility medical record dated [DATE] revealed a head to toe assessment with vital signs within normal limits was completed by LPN #1. 2. Review of Resident #1's medical record revealed an Elopement Risk Assessment completed on [DATE] by the MDS Coordinator. The elopement risk evaluation on [DATE] revealed a score of twenty (20) which was considered high risk for elopement. The elopement risk evaluation on [DATE] by the MDS Coordinator revealed a score of thirty (30) which revealed a high risk for elopement. However, a revision was completed on that assessment by the MDS Coordinator and a score of fifty (50) was determined. 3. Review of Resident #1's [DATE] Treatment Administration Record revealed the wanderguard was checked for function and placement on [DATE] and every shift as ordered. Observation of Resident #1 on [DATE] at 10:16 AM with one on one staff at bedside found resident laying in bed with Wanderguard Bracelet in place. At 10:55 AM on [DATE], surveyor observed LPN #1 checking the wanderguard for function and the Wanderguard passed testing. 4. Review of Resident #1's Nurse's Notes revealed the resident's guardian and MD was notified on [DATE]; however, a message was left for the guardian, and the facility did not speak with the guardian until [DATE]. This was completed by LPN #1 and the DON. Interview with LPN #1 on [DATE] at 10:55 AM revealed she had left a message for the guardian and this was verified by phone conversation with the guardian on [DATE] at 12:01 PM. 5. Review of Resident #1's Comprehensive and CNA care plan revealed they were updated on [DATE] by the DON and LPN #1. 6. Review of Resident #1's Comprehensive and CNA care plans revealed all interventions were in place per the care plan on [DATE]. This was reviewed by the IDT team on [DATE]. 7. Review of the Incident Report for the elopement, revealed all staff on duty at the time of the incident were interviewed about their response to door alarms and the resident's location. This was verified by the staff list for [DATE] and written statements of staff found in the incident notebook. These were completed by the Director of Nursing and the Administrator on [DATE]. 8. Review of the elopement timeline of Resident #1 completed by the DON and Social Services Director, revealed it started on [DATE] and was completed on [DATE]. 9. Review of documented evidence in the elopement incident notebook compiled by the facility, revealed resident's clothing, temperature, weather conditions and approximate time the resident was outside of facility. This was completed by Director of Nursing, Social Services Director and Administrator on [DATE]. 10. Review of staff education documentation related to Resident #1's revised care plans and interventions revealed all staff was educated on [DATE] by the Social Services Director, DON and LPN #1. Interviews on [DATE] with LPN #1 at 3:54 PM, RN #1 at 4:35 PM, RN #2 at 4:40 PM, CNA #1 at 4:49 PM, CNA #2 at 4:58 PM, CNA #3 at 4:59 PM, and CNA #4 at 5:04 PM revealed they were educated on Resident #1's care plan revisions. 11. Review of documented evidence in the elopement notebook revealed a complete head count of all residents was conducted on [DATE] at 4:30 PM by LPN #1 with all residents accounted for. Interviews on [DATE] with the DON at 3:47 PM; and on [DATE] with LPN #1 at 3:54 PM, revealed they verified the head count in the facility of all residents on [DATE]. 12. Record review for ten (10) residents revealed Elopement Risk Assessments were completed before [DATE] by the Social Services Director (SSD). Interview and review of audit tool with the SSD on [DATE] at 3:38 PM revealed Elopement Risk Assessments were completed. 13. Review of Resident #1 and #2's records revealed there was a Wander guard order for placement check and function each shift and signed off appropriately, a wander guard in place and not expired, had behavior monitoring for exit seeking behaviors and person centered non pharmacological interventions, and had a care plan for exit seeking/elopement risk that is current and reflects the residents' person-centered, non-pharmacological behavior interventions and wanderguard. Resident #1 and #2 were the only residents identified at risk for elopement. Review of the audit completed by the DON, MDS Coordinator and Social Services Director revealed the audit for the above information was completed on [DATE]. Interviews on [DATE] with the DON at 11:15 AM, SSD at 1:15 PM, and MDS Coordinator at 2:20 PM revealed the audits were completed and the Wander Guard Bracelet had been checked for function and placement each shift. 14. Review of the facility's Elopement Binders revealed, they were audited on [DATE] by the DON and Social Services Director to ensure all residents had pictures and identifying information. Interviews on [DATE] with LPN #1 at 10:55 AM, DON at 11:15 AM, and SSD at 1:15 PM revealed the Elopement Binders had been updated. Review of the Elopement Binders at each nurse's station, revealed pictures and identifying information of the residents at risk for elopement were in the binder. 15. Review of Exit doors and wanderguard alarms audits revealed they were completed by the Maintenance Director on [DATE]. Observation and interview with the Maintenance Director on [DATE] at 11:38 AM revealed the Maintenance Director used the Wanderguard checker to ensure the doors worked properly. The doors locked down and alarm started sounding when he got within four to six feet of the door. 16. Review of Vender assessments dated [DATE] revealed the Manufacturer of Door and Wanderguard alarm vendor came on site and verified the doors were working properly with no concerns. 17. Review of Education In-service records dated [DATE] and completed on [DATE] revealed all employees were educated on the Elopement Process and response to door alarms, and following exit seeking interventions on care plans, by administrative staff which included the DON, Administrator and Staff Development Coordinator. Interviews on [DATE] with Payroll at 1:43 PM, Activities Director 2:24 PM, Maintenance Director at 2:39 PM, ADON at 12:50 PM, Director of Culinary Services at 3:30 PM, and DON at 3:47 PM; and, interviews on [DATE] with LPN #1 at 3:54 PM, RN #1 at 4:35 PM, RN #2 at 4:40 PM, CNA #1 at 4:49 PM, CNA #2 at 4:58 PM, CNA #3 at 4:59 PM, CNA #7 at 5:04 PM, Human Resources Director at 5:24 PM, and Medical Records Director at 5:29 PM revealed the staff was able to verbalize education. 18. Review of the Elopement Incident Notebook revealed Elopement drills were completed on all shifts starting on [DATE] through [DATE] by the DON, Social Service Director, Administrator, and Staff Development Coordinator. Interviews on [DATE] with Payroll at 1:43 PM, Activities Director 2:24 PM, Maintenance Director at 2:39 PM, ADON at 12:50 PM, Director of Culinary Services at 3:30 PM, and DON at 3:47 PM; and, interviews on [DATE] with LPN #1 at 3:54 PM, RN #1 at 4:35 PM, RN #2 at 4:40 PM, CNA #1 at 4:49 PM, CNA #2 at 4:58 PM, CNA #3 at 4:59 PM, CNA #7 at 5:04 PM, Human Resources Director at 5:24 PM, and Medical Records Director at 5:29 PM revealed elopement drills were conducted. 19. Review of the alarm systems audits per the Maintenance Director revealed the audit was conducted on [DATE] with no concerns identified. Further review revealed the Administrator had verified the audits had been completed with notation the alarms were in correct working condition. The Administrator verified this with documentation in the elopement notebook. 20. Record review validated the certified technician checked functioning of doors/panels for proper functioning per documented evidence of vendor notation on [DATE]. 21. Observation on [DATE] revealed there were signs on all exit doors to alert visitors/staff/vendors at exiting to not allow residents out of doors and to check with staff. 22. Review of the Elopement Drill documentation revealed the first weekly elopement drill was held on [DATE] at 11:00 AM by the Administrator and DON. There were ten (10) staff involved. 23. Interview (Post Survey) with the Administrator on [DATE] at 2:22 PM revealed summaries of the elopement drills would be completed monthly and reviewed by the QA committee. 24. Review of the Ad Hoc QAPI meeting minutes revealed the meeting was held on [DATE] with the Administrator, DON, and Medical Director. Interview with the DON on [DATE] at 3:47 PM revealed she attended the QAPI meeting and the attendees reviewed the information gathered r (TRUNCATED)

Based on interview, record review and review of the facility policy and procedure, it was determined the facility failed to develop and implement a person-centered comprehensive care plan to meet each of the medical, nursing, mental, and psychosocial needs identified on the resident's comprehensive assessment for one (1) of fourteen (14) sampled residents (Resident #26). Resident #26's was hosptalized on [DATE], 04/05/18, and 02/12/18 with [DIAGNOSES REDACTED]. However, review of the Comprehensive Care Plan revealed the facility failed to revise the care plan to address the resident's Pneumonia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The findings include: Review of the facility policy, Comprehensive Care Plans Standard of Practice, last revised (MONTH) (YEAR), revealed it is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. The facility will ensure residents who display or are diagnosed with [REDACTED]. Record review revealed the facility admitted Resident #26 on 01/03/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/14/18, revealed the facility assessed Resident #26's cognition as intact with a Brief Inventory of Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Review of Resident #26's Nurses Notes revealed he/she was admitted to the hospital on the following dates; 02/12/18, 04/05/18, and 08/04/18, with Pneumonia, [MEDICAL CONDITIONS], and [MEDICAL CONDITIONS]. However, review of the Comprehensive Care Plan last revised 08/17/18, revealed the care plan was not revised to include a person centered care plan with individualized interventions to reflect how staff will meet the resident's care needs related to [MEDICAL CONDITIONS], and Pneumonia to minimize the likelihood of re-hospitalization . In addition, staff failed to include measurable objectives, and timeframe's. Interview with the MDS Coordinator, on 11/01/18 at 2:30 PM, revealed the Interdisciplinary Team (IDT) members are responsible to update care plans, and any discipline is able to update the care plan based on problem identified. The MDS Coordinator stated, We (staff) carry the care plan books to morning stand-up meetings and update care plans at that time. A resident with a [DIAGNOSES REDACTED]. Interview with Director of Nursing (DON), on 11/01/18 at 2:20 PM, revealed all Interdisciplinary Team (IDT) members are responsible to update care plans, and various disciplines are able to do so. The DON stated it is not necessarily indicated for a resident to have a care plan for [DIAGNOSES REDACTED]. The DON stated, care areas may be covered in Physician Orders carried out as well as other interventions to meet the resident care needs. Interview with Regional Clinical Nurse Consultant (RCNC), on 11/01/18 at 2:25 PM, revealed a resident may have a new diagnosis; however, she would expect the Physician Orders to reflect resident changes in condition with orders to provide care related to the resident's condition. The RCNC stated, I would expect staff to follow Physician Orders related to resident care needs, it's not necessary that the [DIAGNOSES REDACTED]. needs.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of ten (10) sampled residents that addressed the services that were to be provided to the resident when he/she returned from the hospital with an indwelling urinary catheter (Resident #5). The findings include: Review of the facility policy Care Plans-Comprehensive, not dated, revealed assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition changes. The Care Planning/Interdisciplinary Team is responsible for the review and update of care plans: When there has been a significant change in the resident's condition and when the resident has been readmitted to the facility from a hospital stay. Record review revealed the facility admitted Resident #5 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 06/12/17 revealed the facility assessed Resident #5's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further record review revealed on 07/26/17, Resident #5 was admitted to the hospital and returned on 08/14/17 with an indwelling urinary catheter for comfort care. Review of the Physician Orders, dated 08/15/17, revealed to provide urinary catheter care every shift and as needed (PRN) and to use a urinary catheter #16 french to closed drainage; can be replaced PRN due to blockage or dislodgement. However, review of the Comprehensive Care Plan revealed there was no documented evidence the care plan had been updated to reflect the presence of an indwelling urinary catheter or for the maintenance and care of the catheter upon his/her return from the hospital. Interview with the Director of Nursing (DON), on 09/07/17 at 10:05 AM, revealed that any changes to resident care are discussed in morning clinical meetings, and it is primarily the MDS Coordinator's responsibility to update the care plans. The DON stated some nurses update the care plans as changes occur, but it is her expectation that the MDS Coordinator oversees and assures that the care plans are updated appropriately.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with the written plan of care for one (1) resident that was not in the selected sample of ten (10) residents (Resident A). Unsampled Resident A was care planned for a bed alarm for safety due to a risk for injury related to falls; however, observations on 09/05/17 and 09/06/17 revealed the bed alarm was in place but not functioning. The findings include: Review of the facility's policy titled,Care Plans-Comprehensive, not dated, revealed an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Further review revealed it also stated each resident's comprehensive care plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems and assessments of residents are ongoing. Record review revealed the facility admitted Unsampled Resident A on 04/25/17 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for risk for injury related to falls, dated 07/11/17, revealed an intervention for a bed alarm for safety; however, observations on 09/05/17 at 9:00 AM revealed Unsampled Resident A was lying in bed with a bed alarm under the bed, but no lights were lit on the alarm to indicate the alarm was working. Further observation on 09/06/17 at 8:25 AM revealed the resident was sitting up in his/her wheel chair, however, the bed alarm was still lying under the bed with no lights lit on alarm. Interview with Certified Nursing Assistant (CNA) #1, on 09/06/17 at 10:40 AM, revealed she did not remember if she checked Unsampled Resident A's bed alarm yesterday (09/05/17) to ensure it was working. She stated she is supposed to check bed alarms each shift. Interview with Licensed Practical Nurse (LPN) #1, on 09/06/17 at 8:28 AM, revealed the alarm needed new batteries. LPN #1 stated it was everyone's responsibility to check bed alarms to ensure they are working and have batteries. Interviews on 09/06/17 with the Director of Nursing (DON) at 3:20 PM and with the Administrator at 3:21 PM revealed they would expect staff to follow the care plan and ensure alarms were functioning.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure their system to provide adequate supervision and assistive devices to prevent accidents for one (1) resident not in the selected sampled of ten (10) residents (Unsampled Resident A). Unsampled Resident A was care planned to have a bed alarm and had Physician's Orders to ensure the bed alarm was in place and functioning. Staff initialed the September 2017 Treatment Administration Record (TAR) indicating the alarm was in place and functioning on 09/05/17 and 09/06/17. However, observations on both days revealed the bed alarm was under the bed and was not functioning. The findings include: Review of the facility policy titled, Incident and Accident Process, dated October 2015, revealed the purpose of the policy is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulation guidelines. Further review revealed assessments and investigations are done in a systematic manner: Identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, monitoring for effectiveness, and modifying interventions when necessary. Record review revealed the facility admitted Unsampled Resident A on 04/25/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/10/17, revealed the facility assessed Unsampled Resident A's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive assistance of one (1) staff for transfers and for toileting. Review of the Comprehensive Care Plan for risk for injury related to falls, dated 07/11/17, revealed an intervention for a bed alarm for safety. Further review revealed the resident sustained [REDACTED]. Review to the September 2017 Physician's Orders revealed an order to check placement and function of bed alarm every shift. Review of Unsampled Resident A's September 2017 Treatment Administration Record (TAR) revealed the bed alarm was to be checked at 9:00 AM and 9:00 PM. Further review of the TAR revealed Licensed Practical Nurse (LPN) #1 had initialed she checked the alarm on 09/04/17 and 09/05/17 at 9:00 PM; and LPN #2 had initialed she checked the alarm on 09/05/17 at 9:00 AM. Additionally, the TAR had been initialed the batteries were last changed on 09/01/17. Observations on 09/05/17 at 9:00 AM revealed Unsampled Resident A was lying in bed with a bed alarm under the bed, but no lights were lit on the alarm to indicate the alarm was working. Further observation on 09/06/17 at 8:25 AM revealed the bed alarm was still lying under the bed with no lights lit on alarm and the resident was sitting up in his/her wheelchair. Interview with Certified Nursing Assistant (CNA) #1, on 09/06/17 at 10:40 AM, revealed she did not remember if she checked Unsampled Resident A's bed alarm yesterday (09/05/17) to ensure it was working. She stated she is supposed to check bed alarms each shift. Interview with Licensed Practical Nurse (LPN) #1, on 09/06/17 at 8:28 AM revealed the alarm needed new batteries and the batteries were usually kept in the medication room. LPN #1 stated it is everyone's responsibility to check bed alarms to ensure they are working and she did not know why the bed alarm was not working and had not been checked. Interviews on 09/06/17 with the DON, on 09/06/17 at 3:20 PM and with the Administrator at 3:21 PM, revealed they would expect staff to check bed alarms when residents are checked and make sure alarms are working.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide services in accordance with each resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned for two (2) staff for transfers, positioning, and hygiene care; however, on 02/28/17, Certified Nurse Aide (CNA) #3 provided incontinent care to the resident without another staff's assistance which caused the resident to fall out of bed sustaining injuries (two {2} centimeter {cm} hematoma to the forehead and an eight {8} cm crescent shaped skin tear to the left upper arm). The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, dated November 2016, revealed it is the facility practice to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review revealed the facility readmitted Resident #1 on 02/10/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Comprehensive Care Plan, dated 07/25/16 and last reviewed prior to fall on 01/20/17, revealed interventions for two (2) staff to assist resident with transfers, toileting, and positioning. Further review of the Comprehensive Care Plan revealed an intervention to ensure Resident #1 is positioned in middle of the bed. However, interview with CNA #3, on 03/22/17 at 11:24 AM, revealed she was providing incontinent care to Resident #1 without the assistance of another staff when she rolled the resident on his/her left side in an attempt to apply an adult brief. The resident positioned his/her right leg over the left leg and the right leg came off the bed and the resident proceeded to fall out of bed and on to the floor. Review of a Nursing Note (late entry), dated 03/01/17 at 5:17 AM for 02/28/17 at 10:15 AM, revealed CNA #3 called the nurse in to the Resident #1's room and the resident was lying on the on his/her right side with the bed in the raised position. She noted Resident #1 a quarter sized raised area to the mid to left forehead and skin tear to left elbow. A dressing was applied to the skin tear. Spouse was notified and did not want the resident sent to hospital. Further interview with CNA #3, on 03/22/17 at 11:24 AM, revealed she did not know the resident was care planned for (2) staff assistance with positioning and hygiene care because she did not look at the care plan. Interview with CNA #1, on 03/22/17 at 10:45 AM revealed Resident #1 requires (2) staff assistance for positioning, transferring, and providing hygiene care. She stated staff members identify residents care needs in the care plan book, Kiosk, and shift report. Interview with the Senior Director of Nursing (SDON), on 03/23/17 at 3:10 PM, revealed she would expect staff to review the resident's care plan to identify resident care needs and follow the interventions implemented while providing the resident's care.

Based on interview, record review, and facility policy review, it was determined the facility failed to provided adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed and care planned as a high falls risk with interventions developed to provide assistance of two (2) staff for transfers, bed mobility, positioning, and when hygiene care provided; however, on 02/28/17, staff failed to provide adequate supervision when one Certified Nurse Aide (CNA) provided incontinent care without another staff's assistance. Resident #1 fell out of bed during incontinent care and sustained a two (2) centimeter (cm) hematoma to the forehead and an eight (8) cm crescent shaped skin tear to his/her left upper arm. The findings include: Review of the facility's policy titled, Incident & Accident Process, last revised October 2015, revealed the purpose of the policy is to ensure the facility environment is as free from accident hazards over which the facility has control and that each resident receives adequate supervision and assistive devices to prevent avoidable accidents according to regulatory guidelines for F323. Record review revealed the facility readmitted Resident #1 on 02/10/17 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/18/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Inventory of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable and capable of making his/her own decisions. Further review of the MDS (Section G- Functional Status) revealed Resident #1 required extensive assistance of (2) persons for bed mobility, transfers, and when hygiene care provided. Review of Resident #1's Fall Risk Data Set, dated 01/17/17, revealed the facility assessed the resident as a high risk for falls with a score of fifteen (15). Review of Resident #1's Comprehensive Care Plan, dated 07/25/16 and last reviewed prior to fall on 01/20/17, revealed to provide (2) person assist with transfers, toileting, and positioning. Further review of the Comprehensive Care Plan revealed an intervention to ensure Resident #1 was positioned in middle of the bed. Interview with CNA #3, on 03/22/17 at 11:24 AM, revealed she rolled Resident #1 on to his/her left side in attempt to apply an adult brief on the resident while providing incontinent care. Further interview revealed the resident positioned his/her right leg over the left leg when the right leg came off of bed and the resident proceeded to fall out of bed and on to the floor. Interview with CNA #1, on 03/22/17 at 10:45 AM revealed Resident #1 requires (2) staff assistance for positioning, transferring, and providing hygiene care. Review of a Nursing Note (late entry), dated 03/01/17 at 5:17 AM for 02/28/17 at 10:15 AM, revealed CNA #3 called the nurse in to Resident #1's room and the resident was lying on his/her right side with the bed in the raised position. She noted Resident #1 had a quarter sized raised area to the mid to left forehead and a skin tear to left elbow. A dressing was applied to the skin tear. Spouse was notified and did not want the resident sent to hospital. Interview with Resident #1's spouse, on 03/22/17 at 3:10 PM, revealed she was made aware of the resident's fall on day of incident. Resident #1's spouse stated the resident requires (2) person assistance due to 'being tall and the resident rolled off of bed. Further interview revealed she was informed only one (1) staff member was caring for the resident when he/she fell out of bed. Interview with Registered Nurse (RN) #2, on 03/22/17 at 3:45 PM, revealed Resident #1 does become resistive to care at times and will flail his/her arms and legs suddenly at times when receiving care. Interview with the Senior Director of Nursing (SDON), on 03/23/17 at 3:10 PM, revealed she would expect for staff to obtain assistance of another staff member if required. The SDON stated she would expect staff to review the residents care plan to identify resident care needs.

Based on observations, interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure medications/treatments were administered per the physician's orders [REDACTED].#1, Resident #6, and Resident #8). On 01/18/17, Resident #1 had a physician order [REDACTED]. Resident #6 had physician's orders [REDACTED]. In addition, Resident #8 had a physician's orders [REDACTED]. The findings include: Review of KBN AOS #14 Patient Care Orders, last revised October 2010, revealed Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) practice includes the administration of medication or treatment as authorized by a physician, physician assistant, dentist or advanced practice registered nurse. Review of facility policy titled, Administering Medications, last revised December 2012, revealed medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. 1. Record review revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Hospital Discharge Summary, compilation date of 01/18/17, revealed to administer Regular Insulin Human ([MEDICATION NAME] R) before meals and at bedtime per low dose sliding scale as follows: 61-150=0 units, 151-200=0 unit, 201-250=2 units, 251-300= 4 units, 301-350=6 units, 351-400=8 units, above 400=12 units, less than 60 or greater than 450, call medical doctor. However, review of the January 2017 Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1, on 02/06/16 at 3:30 PM and on 02/07/17 at 11:18 AM, revealed she could not get the insulin into the computer system and she had passed the order to LPN #2 and he couldn't do it either. She stated she asked another nurse and the DON but they were busy so Resident #1 missed his/her insulin and it was not put in to the system when the resident was admitted . Additionally, RN #1 revealed that Resident #1 came from the hospital and they had to fax the orders to the facility with the RN putting the orders all in but the system would not let her put the insulin in the computer. She stated she had called the pharmacy for the medications but the resident's blood sugars were fine and the resident did not require coverage. Interview with the Director of Nursing (DON), on 02/17/17 at 11:55 AM, revealed insulin should have been available when needed and she was unable to find any documented evidence Resident #1's accu-checks were conducted from 01/18/17-01-21/17 and the accu-checks should have been done per physician's orders [REDACTED].>2. Record review revealed Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the February 2017 Physician order [REDACTED]. However, review of January 2017 MAR indicated [REDACTED]. Further review [MEDICATION NAME] milligram (mg) tablet (1) one tablet at bedtime was not provided for Resident #6 on 01/10/17. 3. Record review revealed the facility readmitted Resident #8 on 10/19/16 with [DIAGNOSES REDACTED]. Review of January 2017 Physician order [REDACTED].#8 [MEDICATION NAME] 1.5 at 60 milliliters (ml) for fourteen (14) hours daily; on at 8:00 PM, off at 10:00 AM. However, observation on 02/02/17 at 11:30 AM revealed Resident #8 was sitting in wheelchair with tube feeding attached and running. Interview with Licensed Practical Nurse (LPN) #4, on 02/03/17 at 3:55, revealed Resident #8 should not be receiving his/her tube feeding at 11:30 AM as the feeding was supposed to run from 8:00 PM till 10:00 AM. Interview with LPN #5, on 02/03/17 at 4:05 PM, revealed the time needs to be changed on the feeding because it is a problem when the resident is in bed, he/she slides down in it. Interview with the DON, on 02/07/17 at 11:55 AM, revealed she expected medications/feedings to be administered per the physician's orders [REDACTED].

Based on interview, record review and facility policy review it was determined the facility failed to notify the family/Guardian for one (1) of nine (9) sampled residents (Resident #9). Resident #9 had a fall on 01/16/17 and sustained a hematoma to his/her forehead; however, the facility failed to notify the Guardian until 01/18/17. The findings include: Interview with the Director of Nursing (DON), on 02/07/17 at 9:40 AM, revealed the facility had no policy to address physician and/or family notification; however, the Nurse's Notes and Situation/Background/Appearance/Review (SBAR)) were utilized to document notifications of physician and family. Record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Incident Report prepared by Licensed Practical Nurse (LPN) #1, dated 01/16/17 at 5:36 AM, revealed Resident #9 had slid off the bed to the floor and sustained a hematoma to right side of forehead approximately one and one-half (1.5) times one (1) inch in diameter. The resident was assessed head to toe to include motor function and neuro checks. Further review revealed the physician was notified on 01/16/17 at 7:20 AM. However, there was no documented evidence the guardian was notified. Review of the Departmental Notes for Resident #9, dated 01/16-01/18/17 revealed there was no documented evidence the family/guardian was made aware of the fall. Attempts to interview LPN #1 on 02/03/17 at 2:41 PM, on 02/06/17 at 11:00 AM, and on 02/07/17 at 7:05 AM and 8:16 AM were unsuccessful. Interview with Resident #9's Guardian, on 02/03/17 at 1:47 PM, revealed she had not been informed of Resident #9's fall until 01/18/17 and she expected to be informed of the fall at the time of the fall. Interview with Social Services, on 02/06/17 at 4:13 PM, revealed she spoke with the guardian of Resident #9 on 01/18/17 and informed the guardian of Resident #9's emergency room visit results and of the fall on 01/16/17. Interview with LPN #2, on 02/04/17 at 3:56 PM, revealed when a resident has a fall/accident, then staff should notify the resident's Guardian/Power of Attorney/family member, Physician and Director of Nursing (DON). Interview with the DON, on 02/07/17 at 9:40 AM and 12:15 PM, revealed staff should notify the physician, guardian, POA of any falls.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to store food under sanitary conditions. Observation revealed a container of chicken and dumplings and coleslaw in the refrigerator with no date of preparing or use by date. Additionally, there was a quart of milk and a bottle of teriyaki sauce not dated when opened. Review of the facility Census and Condition, dated 08/30/16, revealed thirty-nine (39) of forty (40) residents received their meals from the kitchen. The findings include: Review of the facility's policy and procedure titled, Food Storage: Cold, last revised 05/2014, revealed the Food Services Director/Cook ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation during a tour of the kitchen of the refrigerator, on 08/30/16 at 8:15 AM, revealed a container of chicken and dumplings and coleslaw with no date of which it was prepared or a use by date. Additionally, there was a quart of milk and a bottle of teriyaki sauce not dated when opened. Interview with the Dietary Manager and District Dietary Manager, on 08/31/16 at 11:15 AM, revealed the policy indicated food was to be labeled and dated when placed in the refrigerator. They stated the milk should have been dated when opened.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure a feeding tube was utilized in accordance with current clinical standards of practice and services to prevent complications to the extent possible related to placement of the tube not being assessed prior to administering a medication one (1) unsampled resident not in the sample of ten (10) (Resident B). The findings include: Review of the facility's policy and procedure, titled Administering Medications through an Enteral Tube, last revised 12/2012, revealed for staff to check tube placement for gastrostomy (G) tubes and when correct tube placement have been verified, flush tubing with fifteen (15) to thirty (30) milliliters (ml) water (or prescribed amount). Record review revealed the facility admitted Unsampled Resident B, on 07/29/16, with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 08/04/16, revealed the facility assessed Unsampled Resident B's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4), indicating the resident was not interviewable. Review of the Comprehensive Care Plan, dated 08/16/16, revealed the resident exhibited a behavior of pulling the peg tube apart. During an observation of a medication pass, on 08/31/16 at 2:22 PM, revealed Registered Nurse (RN) #1 administered a medication via a G tube to Unsampled Resident B and did not check the tube placement prior to providing the first flush, medication administration, and last flush. Interview with RN #1, on 08/31/16 at 2:25 PM, revealed she was aware she should have checked the tube placement prior to administering the flushes and medication. Interview with the Director of Nursing (DON), on 08/31/16 at 2:40 PM, revealed she expected the nurse to check tube placement prior to administering medications. Interview with the Administrator, on 09/01/16 at 10:24 PM, revealed she expected tube placement to be checked prior to medication administration.

Based on observation, interview, record review and facility policy and procedure review, it was determined the facility failed to ensure residents were cared for in a manner and in an environment that maintained/enhanced each resident's dignity and respect for one (1) of ten (10) sampled residents (Resident #5) and one (1) resident not in the sample (Resident B). Registered Nurse (RN) #1 failed to pull the privacy curtain and close the door when administering medications via peg tube to Unsampled B, leaving the resident exposed to his/her roommate and to anyone in the hallway. In addition, Licensed Practical Nurse (LPN) #2, failed to close the resident door to the hallway or pull the privacy curtain while providing peg tube (feeding tube) care to Resident #5, leaving the resident exposed to his/her roommate and anyone in the hallway. The findings include: Review of the facility's policy and procedure, titled Resident Rights under Federal Law, not dated, revealed the resident has the right to a dignified existence, self-determination, communication with, and access to persons and services. 1. Record review revealed the facility admitted Unsampled Resident #B on 07/29/16 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) Assessment, dated 08/04/16, revealed the facility assessed Unsampled Resident B's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4), indicating the resident was not interviewable. Observation during a medication pass, on 08/31/16 at 2:22 PM, revealed RN #1 administered a medication to Unsampled Resident B via a peg tube. Upon entering the resident's room, RN #1 did not close the door to the hallway nor did she pull the privacy curtain between Resident B and the roommate leaving the resident in view of his/her roommate and to persons witnessed walking down the hallway. Interview with RN #1, on 08/31/16 at 2:25 PM, revealed she was aware of the need to close the door and pull the privacy curtain before providing care related to privacy and dignity issues. 2. Record review revealed the facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment, dated 07/21/16, revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Observations of peg tube care being provided by Licensed Practical Nurse (LPN #2) on 08/31/16 at 1:20 PM revealed the LPN did not close the resident ' s door to the outside hallway or pull the privacy curtain to restrict visibility from the hallway during the procedure. Interview with LPN #2, on 08/31/16 at 1:30 PM, revealed she was aware to close the door and pull the privacy curtain but was rushing and got distracted. Interview with Director of Nursing (DON), on 08/31/16 at 2:20 PM, revealed she expected the nurse to follow the facility policy and procedure related to shutting the door and pulling the privacy curtain anytime providing care for the residents. Interview with the Administrator, on 09/01/16 at 10:24 AM, revealed she expected privacy and dignity would be maintained during resident care.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure the resident's rights to have confidentiality of his/her clinical record for one (1) of ten (10) sampled residents (Resident #1) and one (1) resident not in the sample. Observation of a medication pass revealed Licensed Practical Nurse (LPN #1) left Resident #1's and Unsampled Resident A's Medication Administration Records (MAR) open on top of the medication cart in the hallway, visible to anyone who passed by the medication cart. The findings include: Review of the facility's policy and procedure titled, Resident Rights Under Federal Law, not dated, revealed the facility should protect and promote the rights of each resident, including the right to personal privacy and confidentiality of his/her personal records. Observation of a medication pass, on 08/30/16 at 12:30 PM, revealed LPN #1 prepared medications to be administered to Resident #1 and Unsampled Resident A and left each of their MARs open on top of the medication cart making it visible to the public, other residents, and staff members. Interview with LPN #1, on 08/30/16 at 1:30 PM, revealed she thought she had closed it, and she tried to be careful and close it each time. Interview with Director of Nursing (DON), on 08/31/16 at 2:20 PM, revealed she expected staff to cover the MARs when they are passing medication to prevent the resident's personal information from being visible to anyone on the hallway during the medication pass. Interview with Administrator, on 09/01/16 at 10:25 AM, revealed she absolutely expected the resident ' s privacy and dignity to be maintained at all times when staff were providing care.

Based on observation, interview, and review of the facility's policy and procedures, it was determined the facility failed to ensure the facility established and maintained an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for two (2) of ten (10) sampled residents (Resident #8 and Resident #5). Observation of a medication pass revealed Licensed Practical Nurse (LPN#2) dropped a pill on the medicine cart and proceeded to pick up the pill with her bare hands and then administered it to Resident #8. In addition, observations revealed Certified Nursing Assistant (CNA #1) failed to remove contaminated gloves and wash her hands after providing incontinent care for Resident #5 and LPN #2 failed to remove contaminated gloves and wash her hands after providing peg tube (feeding tube) care for Resident #5. The findings include: 1. Review of the facility's policy and procedure titled, Administering Medications (revised December 2012), revealed medications shall be administered in a safe and timely manner, and as prescribed. Further review revealed staff shall follow established infection control procedures (e.g., handwashing, antiseptic technique etc.) for the administration of medications, as applicable. Observation of a medication pass on 08/31/16 at 1:10 PM, revealed Licensed Practical Nurse (LPN #2) preparing medications for administration to Resident #8, dropped a pill on top of the medication cart and then picked the pill up with her bare hands and administered it to the resident. Interview with LPN #2 on 08/31/16 at 1:30 PM, revealed she knew she should have thrown the pill away but was not thinking at the time. Interview with Director of Nursing (DON) on 08/31/16 at 2:20 PM, revealed she would have expected the nurse to discard the pill and get another one to administer to the resident. She further revealed she expected the nurse to treat the pill as if it had fallen on the floor. 2. Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene (revised April 2012), revealed this facility considers hand hygiene the primary means to prevent the spread of infections. Further review revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Continued review revealed employees must wash their hands of at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: C. Before and after direct resident contact, before and after changing a dressing, after removing gloves or aprons. Review of the facility's policy titled Perineal Care (Revised October 2010), revealed the purposes of this procedure are to provide cleanliness and comfort to the residents, to prevent infections and skin irritation, and to observe the residents skin condition. Further review revealed, after completing incontinent care and discarding disposable items into designated containers you are to remove gloves and discard into designated containers. Wash and dry hands thoroughly then reposition the bed covers, make the resident comfortable. Record review revealed the facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 07/21/16 revealed the facility assessed Resident #5's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review revealed the resident was incontinent of bowel and bladder and received tube feeding through a peg tube to supplement nutritional intake. Review of Wound Culture results, dated 08/23/16, of drainage around the residents peg tube site, revealed the presence of three (3) different infectious organisms. Review of physician's orders [REDACTED]. Observation on 08/30/16 at 10:45 AM, revealed CNA #1 providing incontinent care for Resident #5, who was incontinent of bowel and bladder. Prior to starting incontinent care the CNA's long hair had fallen down and was touching the resident perineal area. After CNA #1 completed incontinent care, she failed to remove the contaminated gloves and wash her hands. Further observation revealed CNA #1 proceeded to replace the residents brief and then redressed the resident and assist the resident out of bed all while wearing the contaminated gloves. Interview with CNA #1 on 08/30/16 at 1:50 PM, revealed she had been educated to remove her gloves and wash her hands but forgot to do it. She also revealed she normally kept her hair pulled back but she took it down yesterday and forgot to put it back up. Observation on 08/31/16 at 1:20 PM revealed LPN #2 providing peg tube care for Resident #5. Further observation revealed LPN #1 entered the resident ' s room and did not wash her hands prior providing peg tube care. LPN #1 put on the disposable gloves without washing her hands and proceeded to remove the resident's dressing covering the peg tube. Further observation revealed the nurse did not remove the contaminated gloves or wash her hands after removing the dirty dressing and proceeded to apply ointment and replaced the dressing all while wearing the same pair of contaminated gloves. Interview with LPN #2 on 08/31/16 at 1:30 PM, revealed she was aware of the importance of washing her hands prior to starting the procedure. She stated she realized it was not good practice and she was just rushing and got distracted. Interview with DON, on 08/31/16 at 2:20 PM, revealed she expected the staff to follow the facility's policy and procedure and wash hands as needed.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to store, prepare, distribute and serve food under sanitary conditions. Observation revealed staff were thawing meats in still water with a temperature of eighty (80) degree Fahrenheit (F) temperature. Additionally, the staff failed to wear a hair net when in the kitchen. Review of the facility's Census and Condition, dated 08/26/15, revealed there were thirty-eight (38) residents in the building and all of the residents received food that was prepared in the kitchen. The findings include: Review of the facility policy titled, Food Handling Guidelines (HACCP), not dated, revealed staff should wear proper hair restraint when on duty. Thawing of foods should be completed in the refrigerator at forty-one (41) degrees F or below or under running water at seventy (70) degrees F water for no longer than two (2) hours. Additionally, temperatures are to be maintained in the refrigerators of forty-one (41) degrees F. Observation of the kitchen, on 8/25/15 at 9:22 AM, revealed: 1. There was a five (5) pound package of ground beef and pork chops being thawed in still water in the sink. The temperature of the water was checked using the facility thermometer and the temperature was eighty (80) 80 degrees F. 2. The Milk refrigerator did not contain a thermometer. 3. The Assistant Director of Nursing (ADON) entered the kitchen and walked into the food prep area without a hair net on. Interview with the Dietary Manager, on 8/25/15 at 9:35 AM, revealed all meats should be thawed in the refrigerator or under running cold water. The Dietary Manager stated no one should enter the kitchen without a hair net and a thermometer should be in the milk refrigerator. Interview with the ADON, on 08/26/15 at 9:48 AM, revealed staff should not enter the kitchen without hair nets. She stated she did enter the kitchen on 8/25/15 without a hair net. Interview with the Director of Nursing (DON), on 08/25/15 at 10:05 AM, revealed no one should enter the kitchen without a hair net. Interview with the Administrator, on 08/25/15 at 10:10 AM, revealed no one is to be in the kitchen except dietary staff and they should always have a hair net. The Administrator stated all food should be prepared per federal and state guidelines. The Administrator further stated she expected the refrigerators to be monitored with a thermometer per the facility policy.

Based on observation, interview, facility policy review and Material Data Safety Sheet review, it was determined the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observations revealed one (1) housekeeping cart stored on the resident hallway with the keys to the storage compartment containing chemicals left laying on top of the cart within residents reach. The findings include: Review of the facility policy titled, Proper Storage of Chemical Supplies, not dated, revealed chemicals must be stored behind locked doors. On 8/26/15 at 10:34 AM, an observation revealed a housekeeping staff left keys to the housekeeping cart on top of the cart with chemicals stored in it and accessible to residents. Further observation revealed the cleaners stored in the cart were a Dollar Store Cleaner with Bleach, Emerald #412, NuAge Dimethyl Bentzyl, Glance NA Glass Cleaner, Fabuloso All Purpose Cleaner, and Virex II 256. Review of the Material Safety Data Sheets for the following items revealed the Dollar Store Cleaner with Bleach was hazardous to health; Emerald #412 was hazardous if there was contact with skin or eyes; NuAge Dimethyl Bentzyl was hazardous if there was contact with skin, eyes or mouth; Glance NA Glass Cleaner may be hazardous with contact with eyes; Fabuloso All Purpose Cleaner may be hazardous if contact with eyes, skin, or if swallowed; and Virex II 256 was hazardous with contact to eyes, skin, and if inhaled and is a corrosive and can cause permanent damage and may be irritating to the mouth, throat and stomach. Interview with Housekeeper #1, on 08/26/15 at 12:43 PM, revealed she should have placed the keys in her pocket and leaving the keys on the cart was danger for the residents. Interview with the Environmental Manager, on 08/26/15 at 12:45 PM, revealed the housekeeping carts should always be locked and the keys should be secured so the residents would not be able to get into the chemicals.

Based on interview, record review, and review of the Administrator Job Description, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of seven (7) sampled residents (Resident #15) and one (1) unsampled residents (Resident F). The facility failed to have an effective system in place to ensure medications were available and/or administered according to the physician's orders [REDACTED]. Resident #15 did not receive two (2) doses of [MEDICATION NAME] (medication for nerve pain) on 08/14/14 and 08/15/14 and one (1) dose of Klonopin (medication for anxiety) on 08/14/14 as ordered by the physician due to the facility not providing the appropriate documentation to the pharmacy for administration. Unsampled Resident F had a physician's orders [REDACTED]. . The findings include: Review of the Job Description for the Administrator (no date) revealed the purpose was to direct the day to day functions of the facility in accordance with current Federal, State and Local standards, guidelines and regulations that govern nursing facilities to ensure the highest degree of quality care can be provided to the residents at all times. Essential functions of the position included: Ensure excellent care for residents is maintained by overseeing and monitoring patient care services delivered. Review of the facility's Plan of Correction for the survey dated 06/13/14 with an alleged compliance date of 07/11/14, revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON) or Unit Manager would complete medication administration observations three (3) times per week to assure medications were administered correctly and to ensure medications were available. In addition, the Plan of Correction stated the Pharmacy would audit all current residents' Medication Administration Records (MARs) and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two (2) weeks for eight (8) weeks beginning on 06/09/14. Further review revealed the DON, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Nurse or the Unit Managers would complete an audit of all MARs to ensure professional standards of practice for clinical record documentation were followed five (5) times per week for twelve (12) weeks. The results of the audits would be forwarded to the facility QAPI committee for review. 1. Review of Resident #15 's August 2014 MAR indicated [REDACTED]. Interview with the Director of Nursing, on 09/06/14 at 11:15 AM and at 4:15 PM, revealed Resident #15 had returned from a hospitalization with new admission orders [REDACTED]. 2. Record review revealed Unsampled Resident F had a physician's orders [REDACTED]. Interview with the Pharmacy Registered Nurse/Account Executive, on 09/06/14 at 2:55 PM, revealed the pharmacy had received the new admission orders [REDACTED]. Interview with the Administrator on 09/06/14 at 4:30 PM, revealed the facility had audits in place to identify when medications were not available for administration per physician's orders [REDACTED]. He further stated the facility's system had not been effective in identifying the issues; however, he was working to put new tools in place to monitor for the future.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure nine (9) of seventeen (17) sampled residents (Residents #2, #3, #10, #11, #12, #14, #15, #13 and #17) and one (1) unsampled resident (Resident A) were free from significant medication errors. Resident #10 did not receive a "now" dose of Potassium that was ordered on [DATE], until [DATE] and required hospitalization for [DIAGNOSES REDACTED]. Resident #11 did not receive Solu-Medro (steroid) intramuscular (IM) "stat" (immediately), and [MEDICATION NAME] (antibiotic) Intravenously (IV) "stat" as ordered on [DATE] until [DATE]. Resident #12, who had a [MEDICAL CONDITION] disorder, did not receive [MEDICATION NAME] [MEDICATION]) for six (6) doses and experienced a [MEDICAL CONDITION] requiring hospitalization . Additionally, after returning to the facility on [DATE], with a physician's order to change the [MEDICATION NAME] milligrams (mg) from 500 mg to 1000 mg twice a day, the resident only received 500 mg for a total of thirty five (35) doses. Resident #14 did not receive a total of fourteen (14) doses of [MEDICATION NAME] (digestive enzyme) 5000 Units from [DATE] through [DATE] due to the Physician's Medicaid number being expired and the pharmacy not sending the medication. Resident #15 who had [DIAGNOSES REDACTED]. Resident #3 did not receive seven (7) doses of [MEDICATION NAME] (blood pressure medication). Resident A did not receive ten (10) doses of [MEDICATION NAME] (anti- [MEDICAL CONDITION]) and eleven (11) doses of Pantoprazole (gastrointestinal medication). Resident #13 did not receive [MEDICATION NAME] (anti-anxiety medication) for a total of six (6) doses. Resident #2 did not receive four (4) doses of [MEDICATION NAME] (yeast rash) from [DATE] through [DATE]. Additionally, during a medication pass observation, Licensed Practical Nurse (LPN) #1 was observed to draw up seven (7) units of [MEDICATION NAME] regular insulin instead of the five (5) units as per the physician's order for sliding scale insulin for Resident #17. The LPN was about to administer the seven units of insulin but another LPN (#6), who was in shadowing LPN #1 pointed out the resident should only receive five (5) units. A second medication pass revealed Resident #18 did not receive [MEDICATION NAME] (anti-hypertensive) 10 mg and had not received the medication for nine (9) days prior. The facility's failure to ensure residents were free from significant medication errors caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the facility policy and procedure titled, "Medication Shortages/Unavailable Medications" last revised [DATE], revealed actions to take upon discovery that the facility has an inadequate supply of medication to administer to a resident included staff taking immediate action to obtain the medication. If a medication shortage was discovered during normal Pharmacy hours, the nurse should call the pharmacy to determine the status of the order. If the medication has not been ordered, place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, obtain the medication from the Emergency Medication Supply to administer the dose. If the medication was not available in the Emergency Medication Supply, notify the pharmacy and arrange for an emergency delivery. If a medication shortage was discovered after normal pharmacy hours, staff should obtain the ordered medication from the Emergency Medication Supply and if it was not available in the Emergency Medication Supply, the nurse should call the pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. The action may include emergency delivery or the use of an emergency (back-up) third party pharmacy. If an emergency delivery is unavailable, the nurse should contact the attending physician to obtain orders or directions. If the nurse was unable to obtain a response from the attending physician/prescriber in a timely manner, the nurse should notify the nursing supervisor and contact the facility's Medical Director for orders/direction while making sure to explain the circumstances of the medication shortage. When a missed dose is unavoidable, the nurse should document the missed dose and the explanation for such missed dose on the MAR or Treatment Administration Record (TAR) and in the Nurse's Notes per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy's response upon notification and the action(s) taken. 1. Record review revealed Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Laboratory Report revealed a routine laboratory test was conducted on [DATE] and revealed the resident's Potassium level was 3.2 millimoles/Liter (mmol/L) and normal value was between 3XXX,[DATE].50 mmol/L. On [DATE], the resident was placed on Intravenous Fluids (IVFs) at 75 ml/hour to end on [DATE] and a "now" dose of Potassium 40 milliequivalents (meq) was administered. The Potassium level was rechecked on [DATE] with a result of 3.5 mmol/L. On [DATE], Licensed Practical Nurse (LPN) #3 received an order to administer Potassium 40 meq by mouth now and recheck Potassium level in twenty-four (24) hours. However, review of the [DATE] MAR revealed the order for the Potassium 40 meq was not documented on the MAR until [DATE] at 9:00 AM (one day later) at which time it was administered. Record review revealed a repeat Potassium level was obtained on [DATE] with a Panic Level of 2.4 mmol/L. The Physician Assistant was notified and the resident was sent to the emergency room . Resident #10 was admitted to the hospital on [DATE] at 8:50 PM with [DIAGNOSES REDACTED]. The licensed staff (LPN #3) failed to transcribe the order to the MAR and failed to administer the medication when ordered on [DATE]. Review of Hospital Admission History and Physical, dated [DATE], revealed Resident #10 was admitted to the hospital because of a Potassium level of 2.4 and was diagnosed with [REDACTED]. Interview conducted with LPN #3, on [DATE] at 3:00 PM, revealed on [DATE] she had not notified the physician about Resident #10 but the nurse for Resident #10's physician had called the facility and gave her an order for [REDACTED]. LPN #3 revealed she forgot to put the medication order on the MAR and did not administer the Potassium as ordered. She faxed the order to the pharmacy and also called the pharmacy about the Potassium order sometime before lunch on [DATE]. She stated she did not know if the Potassium was in the Emergency Drug Kit (EDK) as she was unaware of what medications were available in the EDK and she did not look in there for the medication. Interview with the Director of Nursing (DON), conducted on [DATE] at 9:30 AM, revealed LPN #3 had failed to place the order for the one (1) time dose of Potassium on Resident #10's MAR and had forgotten to administer it on [DATE] when it was ordered. The DON revealed the resident's Potassium level was at "Panic Level" of 2.4 on [DATE] and the resident was sent to the hospital and admitted for treatment of [REDACTED].#3 failed to obtain the medication from the EDK. Interview with Resident #10's Physician on [DATE] at 2:30 PM, revealed Resident #10's Potassium was low and depending on how low "could be life threatening". He expected the Potassium to have been given when ordered. 2. Record review revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. On [DATE], Resident #11 had a change in condition and was having respiratory distress and a "stat" order for Solu [MEDICATION NAME] IM and IV antibiotics was obtained. The medications were not administered until the following day, seventeen (17) hours later. The resident continued to decline and expired in the facility on [DATE]. Review of Nursing Notes, dated [DATE] at 10:57 PM, revealed Resident #11 was noted to have labored breathing and an oxygen saturation of 91% on 2/Liters of oxygen. Lung sounds were diminished bilateral lower lobes and the Advanced Practice Registered Nurse (APRN) was notified and orders were received. Review of the Physician's Order, dated [DATE] at 11:30 PM, revealed administer "stat" (immediately) Solu [MEDICATION NAME] 40 milligrams (mg) IM and IV (intravenous) [MEDICATION NAME] 500 mg, however, review of the [DATE] MAR revealed the medication was not administered until [DATE] at 5:49 PM. Interview with LPN #5, on [DATE] at 3:20 PM, revealed she received the stat order, wrote it out and put it in the computer. The oncoming nurse was already on duty and it was time for LPN #5 to leave and she gave report to the oncoming nurse. LPN #5 revealed she felt the Physician had ordered Solu [MEDICATION NAME] as a stat order because it helped with breathing and it works in twenty to thirty minutes. Review of Nursing Notes, dated [DATE] at 5:49 PM, revealed documentation by Licensed Practical Nurse (LPN) #1 to include the antibiotic was taken from EDK box and a peripheral IV was started with antibiotic administered. The residents lungs had rhonchi noted in the upper lobes. Interview conducted with the Administrator, on [DATE] at 3:20 PM, revealed LPN #5 had noted Resident #11 having respiratory distress on [DATE] prior to her leaving the facility from a split shift. LPN #5 had written the stat order and given report to LPN #8, who was picking up the split shift. LPN #8 failed to obtain the stat Solu [MEDICATION NAME] which was in the EDK box. Solu [MEDICATION NAME] was obtained from the back up pharmacy sometime around 4:00 AM, but the vial was reported to be compromised and was not used and another one was ordered. She further stated LPN #8 still did not obtain the Solu [MEDICATION NAME] from the EDK box and should have. LPN #1 administered the medication on [DATE] at 5:49 PM (approximately seventeen hours later) after retrieving the medication from the EDK box. The Administrator stated she expected if a stat order was not available on the medication cart, that staff would follow procedure and obtain that medication from the EDK box if it was available there. LPN #8 did not check the EDK box. The Administrator suspended LPN #8 by phone on [DATE] and recommended she be terminated. Interview with Resident #11's Physician, on [DATE] at 4:35 PM, revealed a stat order was for a special need and meant "now". He stated a routine order would be provided with routine orders. He additionally stated he expected medications and treatments that were ordered "stat" would be provided "stat". Interview conducted with the Assistant Director of Nursing, on [DATE] at 1:30 PM, revealed she remembered getting a call from LPN #5 on [DATE] sometime before midnight related to Resident #11 who she recalled was having breathing problems. It was almost time for LPN #5 to leave and the ADON instructed LPN #5 to have LPN #8 carry out the orders. She stated she was not aware the resident did not receive the medication until the next day. Interview with Advanced Registered Nurse Practitioner (ARNP), on [DATE] at 1:30 PM, revealed she remembered receiving a call from LPN #5 on [DATE] and had given LPN #5 orders for the next nurse to carry out as it was time for LPN #5 to leave. She stated Resident #11 was End Stage [MEDICAL CONDITION] and was having wheezing so she ordered Solu [MEDICATION NAME] "stat" because it works within an hour. 3. Record review revealed the facility admitted Resident #12 on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated [DATE], revealed the facility assessed the resident as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Nurse's Notes, revealed the resident experienced a [MEDICAL CONDITION] on [DATE] at 11:45 AM. The resident was transported to the emergency room for evaluation and admitted for treatment. Record review revealed he/she returned to the facility on [DATE] with Physician Orders for [MEDICATION NAME] (anti-convulsant) 500 mg by mouth twice daily at 9:00 AM and 9:00 PM. Review of the [DATE] MAR revealed there was no documentation the [MEDICATION NAME] was administered as prescribed from [DATE] through [DATE] (total of seven (7) doses). Further review of the Nurse's Notes, revealed the resident experienced another [MEDICAL CONDITION] on [DATE] and was transported back to the emergency room and was admitted . Record review revealed Resident #12 was readmitted to the facility on [DATE] with Physician's Orders for [MEDICATION NAME] 500 mg tablets, 1000 mg twice daily. Review of the resident's [DATE] MAR revealed the resident had been administered [MEDICATION NAME] 500 mg twice daily from [DATE] through [DATE] instead of the 1000 mg twice daily as prescribed on [DATE] (a total of thirty-five (35) doses). Interview with the DON, on [DATE] at 10:10 AM and on [DATE] at 1:45 PM, revealed the [MEDICATION NAME] dosage given [DATE] through [DATE] was incorrect. Interview with the Administrator, on [DATE] at 10:30 AM, revealed the MAR indicated [MEDICATION NAME] was not given as prescribed for [MEDICAL CONDITION] activity and the administration of medications should be accurately recorded in the medical record. 4. Record review revealed the facility admitted Resident #14 on [DATE] with [DIAGNOSES REDACTED]. The resident was ordered [MEDICATION NAME] (digestive enzyme) 5000 units, one (1) at meals and one (1) before bedtime. Review of the [DATE] MAR revealed the resident did not receive the medication on [DATE], [DATE], [DATE] and [DATE], a total of fourteen (14) doses. The back of the MAR revealed documentation the pharmacy was notified the medication was not available on [DATE] however, the MAR indicated the medication was still not available on [DATE]. Interview with Resident #14, on [DATE] at 2:25 PM, revealed the [MEDICATION NAME] had not been available for several days because the insurance would not pay for it even though he/she had been taking the medication for years and it was covered by the insurance. Interview with the DON, on [DATE] at 3:35 PM, revealed she was currently investigating why this resident received other medications but did not receive the [MEDICATION NAME]. The Pharmacist had informed the DON the Physician's Medicaid number was expired and that was why the medication was not sent. There was no explanation as to why the pill bottle dated [DATE] was in the drawer empty. Interview with a Pharmacy Representative, on [DATE] at 3:00 PM, revealed the Physician's provider enrollment was not updated in the Medicaid system. She stated when they did an update in their system, that was when they started rejecting. The system notified the physician's license was not updated. 5. Record review revealed the facility admitted Resident #15 on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment revealed the facility assessed the resident with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the [DATE] Physician's Order, revealed the resident was to have [MEDICATION NAME] 25 mcg/hr patch every 72 hours. However, review of the [DATE] MAR, revealed no [MEDICATION NAME] was administered on [DATE], [DATE] and [DATE]. Interview with Resident #15, on [DATE] at 11:30 AM, revealed he was currently hurting "bad". Observation of an assessment at the time, by the ADON, revealed there was no [MEDICATION NAME] in place. Resident #15 was unaware there was not a patch in place. The resident stated the patch helped as he/she always had pain. Interview with LPN #3, on [DATE] at 3:00 PM, revealed Resident #15 did not have the prescribed [MEDICATION NAME]es available in the medication cart drawer on [DATE] and another time at the beginning of the month. The LPN stated she called the pharmacy and was told the [MEDICATION NAME] was not covered by the resident's insurance but [MEDICATION NAME] would be. The LPN revealed she called the ARNP who said she did not want to change the resident to [MEDICATION NAME] because the resident had been on the [MEDICATION NAME] for some time. LPN #3 stated Resident #15 had "Hit me at the door complaining of pain and had never complained of pain like that before and that's how I knew it was missed". The LPN revealed the pharmacy will not send a medication if it was not covered by insurance and the residents go a day or two without". Interview with Pharmacy Representative #2, on [DATE] at 3:20 PM, revealed he verified the facility notified the Pharmacy on [DATE], but had not notified the Pharmacy on [DATE] or on [DATE]. The [MEDICATION NAME] was not delivered to the facility, and available for administration, on [DATE], [DATE] or [DATE]. 6. Observation of a medication pass performed by LPN #1, on [DATE] at 11:00 AM, revealed LPN #1 obtained a 229 blood sugar reading for Resident #17 and drew up seven (7) units of Regular insulin and prepared to administer it to the resident. LPN # 6, who was new to the facility and shadowing LPN #1, informed LPN #1 that she thought the insulin amount should be five (5) units and not the seven (7) units as was prepared. LPN #1 then re-checked the resident's MAR and determined the resident was to have five (5) and not seven (7) units of insulin. Interview with LPN #1 at the time revealed she had another resident's sliding scale insulin orders and had drawn up and prepared to administer the wrong amount of insulin to Resident #17. She stated she would have to fill out a medication error report. Review of Resident #17's [DATE] Physician's Orders, revealed the amount of Regular insulin to be administered when the blood sugar reading was between ,[DATE] would be five (5) units. Interview conducted with the DON, on [DATE] at 1:10 PM, revealed she expected nurses to go by the orders on the resident's MAR and thought the nurse would have double checked. The DON was not aware of what was in the facility policy related to administration of sliding scale insulin. 7. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Physician's Order, revealed to administer [MEDICATION NAME] (blood pressure) 10 mg every day. However, review of the [DATE] MAR revealed this medication was initialed and circled from [DATE] through [DATE] (seven doses) which indicated the medication was not given. Further review of the back side of the MAR revealed no documentation related to why the medication was not given. 8. Record review revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of a Physician's Order, dated [DATE], revealed the Advanced Practice Registered Nurse (APRN) ordered [MEDICATION NAME] 100 mg by mouth every day for five (5) days for a yeast rash. Review of the [DATE] Medication Administration Record (MAR) revealed the medication was not given on ,[DATE]-[DATE] a total of five days. 9. Record review revealed the facility admitted Resident #13 on [DATE] with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated , [DATE], revealed the facility had assessed the resident's cognition as severely impaired with a BIMS score of six (6) and required extensive assistance with activities of daily living. Review of Physician's Order, dated [DATE], revealed to administer [MEDICATION NAME] 5 mg twice a day. Review of the [DATE] MAR revealed the resident did not receive the [MEDICATION NAME] until [DATE] indicating six (6) doses were missed. The back of the MAR revealed documentation dated [DATE] at 9:00 AM that indicated the [MEDICATION NAME] would be available that evening. The first dose was documented as administered on [DATE] at 9:00 PM. 10. Resident A was observed during a medication pass on [DATE] at 9:20 AM. Resident #18 did not receive [MEDICATION NAME] 10 mg as ordered as it was not available. Review of the [DATE] Physician Orders revealed to administer [MEDICATION NAME] 10 mg and Pantoprazole 20 mg every day. However, review of the [DATE] MAR revealed the resident did not receive [MEDICATION NAME] 10 mg on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (total of ten doses). There was no documentation on the back of the MAR to indicate the rationale for the medication not being administered. Additionally, Resident #18 did not receive Pantoprazole 20 mg eleven (11) times per the [DATE] MAR. The MAR revealed initials circled indicating not received on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The back of the MAR revealed six (6) days documentation for Pantoprazole not available on [DATE]th, 23rd, 24th, 25th, 26th and 27th. The five (5) remaining missed doses had no documentation to indicate the reason the medication was not administered. Interview with LPN #3, on [DATE] at 10:05 AM and 10:25 AM, who performed the medication pass ([DATE]), revealed she called the Pharmacy and was told the [MEDICATION NAME] was last sent from the Pharmacy on [DATE]. Interview with the DON, on [DATE] at 1:10 PM, revealed if medications were not available for administration for a resident, the pharmacy should be called. She stated medications could be ordered STAT and the pharmacy could send them from the back up pharmacy as needed. A Post Survey interview with the DON, on [DATE] at 9:20 AM, revealed the nurses should have have notified the pharmacy the medication was not available for administration and documented the pharmacy was notified on the back of the MAR. The DON stated some of the medications were not given because the nurse failed to reorder the medication and some of the resident's medication was not available due to the physician's Medicaid number not being renewed. Interview with the Administrator, on [DATE] at 3:20 PM, revealed some of the resident's medications were not being delivered from the pharmacy due to a Physician needing to update his provider number. She stated the pharmacy should have continued to send the medications until the problem was resolved and the facility was currently working with the pharmacy on that. However, when staff was unable to carry out a physician's order, he/she would have expected the staff to report to the nurse in charge, and stated staff should have called the pharmacy and checked the EDK box to ensure medications were available for administration. Post Survey interviews with the Administrator, on [DATE] at 9:45 AM, 2:55 PM and 5:00 PM, revealed the MAR and TAR reviews were implemented on [DATE] due to identifying admission medications were not available for administration, but there was nothing put in place to ensure the MAR and TAR reviews were being conducted to ensure the facility would identify when medications were not available for administration and administered per physician's order. *The facility implemented the following actions to remove the Immediate Jeopardy: On [DATE], the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's Order for Residents #3, #10, #11, #12, #13, #14, #15, #16 and #17. On [DATE], the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician Orders for the previous thirty (30) days to assure all orders were correct on the MAR. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On [DATE], the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On [DATE], the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after [DATE] without having had this re-education and competency test. On [DATE], two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of [DATE], the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on [DATE] to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On [DATE] at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to ,[DATE] days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On [DATE] at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on [DATE] regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On [DATE] at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On [DATE] at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On [DATE] at 11:46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily wr

Based on interview, record review, and review of the facility's policy and procedures it was determined the facility failed to ensure one (1) of seven (7) sampled residents (Resident #15) was free of significant medication errors. Resident #15 did not receive two (2) doses of [MEDICATION NAME] (medication for nerve pain) and one (1) dose of Klonopin (medication for anxiety) as ordered by the physician due to the medication not being available for administration. The findings include: Review of the facility's policy and procedure titled, "Medication Availability Protocol", not dated, revealed if staff were unable to provide the physician ordered medication, the physician should be notified and the notification should be documented. Additionally, when medications were not available to be administered, the time on the MAR indicated [REDACTED]. Any missed dose of medication except for medication refusals required an incident report to be completed, and the physician, resident's family should have been notified. Record review revealed the facility readmitted Resident #15 on 08/14/14 with [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #15's cognition as moderately impaired with a Brief Interview Mental Status (BIMS) score of ten (10), indicating he/she was interviewable. Review of a Readmission physician's orders [REDACTED]. Review of the August Medication Administration Record [REDACTED]. Further review revealed Klonopin 0.5 mg was not administered at 9:00 PM on 08/14/14. Review of the Medication Notes, dated 08/14/14 at 9:00 PM, revealed [MEDICATION NAME] 50 mg, and Klonopin 0.5 mg were unavailable, and the pharmacy and physician had been notified. Review of the Nursing Notes and physician's orders [REDACTED]. Additional review revealed on 08/15/14 at 9:00 AM, the [MEDICATION NAME] 50 mg was unavailable; however, there was no documentation that the physician or the pharmacy had been notified per the facility's policy and procedures. Interview with the Director of Nursing (DON), on 09/06/14 at 11:15 AM and at 4:15 PM, revealed an incident report was not completed for the medications that were not administered on 08/14/14 and 08/15/14. The DON stated when the nurse identified the [MEDICATION NAME] and Klonopin had not been received from the pharmacy an incident report should have been completed. In addition, the DON stated the Physician's directions related to the missed doses of medication should have been documented. The DON revealed the medication had not been sent by the pharmacy because the pharmacy had not received the original signed written script from the physician. Interview with the Administrator, on 09/06/14 at 4:30 PM, revealed the omitted doses of medication was a medication error and the facility's policy and procedure should have been followed for medication errors which included notifying the physician as well as completing an incident report. He stated this should have been completed and it was not done.

Based on interview and record review, it was determined the facility failed to provide pharmaceutical services to meet the needs of seven (7) of seventeen (17) sampled residents (Residents #3, #10, #11, #13, #14, #15 and #16) related to the unavailability of routine and emergency medications for administration. The facility failed to ensure staff followed procedures to obtain a "Stat" order for Solu Medrol (steroid) intramuscular (IM) and Levaquin (antibiotic) intravenous (IV) for Resident #11 when experiencing labored breathing. Resident #10 did not receive Potassium (when prescribed due to a low Potassium level) until the following day and was admitted to the hospital with [REDACTED].#15 was not administered a Fentanyl patch (narcotic for pain) for pain three (3) times in May 2014 because the medication was not obtained from the Pharmacy. Residents #3, #13, #14 and #16 did not receive various medications as prescribed due to the unavailability of the medication, and or the failure to administer the medication. The facility's failure to provide pharmaceutical services to meet the needs of the residents caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on 06/02/14 and determined to exist on 05/05/14. The facility was notified of the Immediate Jeopardy on 06/02/14. The findings include: 1. Record review revealed the facility admitted Resident #10 on 05/16/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 05/23/14, revealed the facility assessed the resident with severe cognitive impairment. Review of the resident's record revealed a routine laboratory test was conducted on 05/20/14, which revealed the resident's Potassium level was 3.2 millimoles/Liter (mmol/L) and normal value was between 3.5-5.50 mmol/L. On 05/21/14, the resident was to receive intravenous fluids and a "Now" dose of Potassium 40 milliequivalents (meq) was administered. The Potassium level was rechecked on 05/22/14 with a result of 3.5 mmol/L. On 05/29/14, Licensed Practical Nurse (LPN) #3 received an order to administer Potassium 40 meq by mouth "Now" and recheck Potassium level in twenty-four (24) hours. Further review of the May 2014 MAR revealed the order for the Potassium 40 meq was not documented on the MAR until 05/30/14 at 9:00 AM (one day later) at which time it was administered. Record review revealed a repeat Potassium level was obtained on 05/30/14 with a Panic Level of 2.4 mmol/L. The Physician Assistant was notified and the resident was sent to the emergency room . Resident #10 was admitted to the hospital on [DATE] at 8:50 PM with a [DIAGNOSES REDACTED]. LPN #3 failed to transcribe the order to the MAR; and, failed to administer the medication when ordered on [DATE]. Review of the Hospital Admission History and Physical, dated 05/30/14, revealed Resident #10 was admitted to the hospital because of a Potassium level of 2.4 indicating [DIAGNOSES REDACTED] and would be treated with IV hydration and replacement of the Potassium. Interview conducted with LPN #3, on 05/31/14 at 3:00 PM, revealed on 05/29/14, the nurse for Resident #10's physician had called the facility and given her an order for [REDACTED]. LPN #3 stated she forgot to put the medication order on the MAR and did not administer the Potassium as ordered. She faxed the order to the pharmacy and also called the pharmacy about the Potassium order sometime before lunch on 05/29/14. She stated she did not know if the Potassium was in the Emergency Drug Kit (EDK) as she was unaware of what medications were available in the EDK and she did not look in there for the medication. The medication was available in the EDK. Interview with the Director of Nursing, conducted on 05/31/14 at 9:30 AM, revealed LPN #3 had failed to place the order for the one time dose of Potassium on Resident #10's MAR and had forgotten to administer it on 05/29/14 when it was ordered. The DON revealed the resident's Potassium level was at Panic Level of 2.4 mmol/L on 05/30/14. The resident was sent to the hospital and admitted for treatment of [REDACTED]. A Post Survey interview conducted with the Administrator, on 07/02/14 at 2:55 PM, revealed staff was educated during orientation when hired on medication administration and the EDK box, which included where the box was located, the contents and the protocol to follow. She stated the staff was educated that the EDK box was located in the medication room and there was a list kept in the box that listed the medications that were available for administration. Interview with the Medical Director, on 06/02/14 at 2:15 PM, revealed nurses should know their duties, know what they were doing; and, the supervisors needed to know what was going on. He stated, "Can't wait twenty four hours to find out a medication has not been given. " 2. Record review revealed Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, dated 05/03/14, revealed the facility assessed the resident with moderately impaired cognition. On 05/21/14 at 10:57 PM, LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The APRN was notified on 05/21/14 at 11:30 PM and orders were received to medicate the resident with Solu-Medrol 40 milligrams (mg) intramuscularly (IM), Levaquin 500 mg IV every 24 hours, Prednisone 40 mg by mouth times two (2) doses, DuoNeb every 4 hours, check vital signs every 4 hours, a chest radiograph (x-ray) and a complete blood count (CBC) "Stat". The chest x-ray which was read by the Radiologist revealed there were defined infiltrative shadows in the left infrahilar and lower lobe suggestive of Pneumonia. However, review of the Nursing Notes, and the May 2014 MAR, revealed the resident received the Solu-Medrol 40 mg IM and the Levaquin IV on 05/22/14 at 5:49 PM after the Solu Medrol was taken from the Emergency Drug Kit (EDK) by LPN #1 instead of on 05/21/14. Review of the Nurse's Notes, dated 05/24/14 at 6:24 PM, revealed the resident was noted to have a fixed facial expression. Cardiopulmonary resuscitation (CPR) was initiated by staff and continued until Emergency Medical Services (EMS) arrival. Resuscitation was unsuccessful and the resident expired. Interview with the DON and Administrator, on 05/29/14 at 5:00 PM, revealed they did not know there was a problem with Resident #11 not getting medication until the next day after it was ordered "Stat". They stated the medication was available in the EDK box. 3. Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the May 2014 physician's orders [REDACTED]. 4. Record review revealed the facility admitted Resident #13 on 07/01/12 with [DIAGNOSES REDACTED]. The Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of six (6). The Comprehensive Care Plan, dated 07/16/13, related to impulse control lists an intervention to give medications as ordered. On 05/24/14, an order was received from the APRN for Buspar 5 mg per PEG tube twice daily routine. The medication was not given until 05/27/14 at 9:00 PM after it was unavailable for the first six (6) initial doses. 5. Record review revealed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan dated 01/27/14, revealed a comfort intervention to receive medications as ordered. Review of the May 2014 MAR revealed the resident did not receive a total of fourteen (14) doses of Pancrelipase 5000 units on 05/19/14, 05/21/14, 05/22/14 and 05/28/14. Review of physician's orders [REDACTED]. Interview with the resident on 05/28/14 at 2:25 PM, revealed he/she had been missing the medication but did not understand why as he/she has been on it for years. He/she was told that the medical card would not pay for it. 6. Record review revealed the facility admitted Resident #15 on 07/03/12, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of fourteen (14). Review of the Comprehensive Care Plan, dated 04/02/14, revealed to administer medications as ordered. Review of the May 2014 Physician order [REDACTED]. However, review of the May 2014 MAR revealed the resident did not receive his/her Fentanyl patch on 05/05/14, 05/14/14 and 05/29/14. Interview with Pharmacy Account Executive Customer Service Representative, on 06/02/14 at 3:20 PM, revealed he checked to see when the facility notified the Pharmacy related to Resident #15's Fentanyl patch and determined the facility did not notify the Pharmacy on 05/05/14 or on 05/14/14 that the resident's Fentanyl patch was not delivered and was not available for administration and they should have been notified. A Post Survey interview with the Pharmacy Account Executive Customer Service Representative, on 07/15/14 at 10:15 AM, revealed if the facility had notified the pharmacy and they were unable to deliver the medication a fax would have been sent to the facility indicating the reason a medication was not delivered as ordered. The Representative stated, "We don't just not send a medication." 7. Record review revealed the facility admitted Resident #16 on 09/19/13, with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) indicating the resident was interviewable. Review of the Comprehensive Care Plan, revised on 05/27/14 revealed a pain care plan which included interventions of the resident to receive medications as ordered. Review of the May 2014 Physician order [REDACTED]./14) and Percocet 10-325 mg every eight (8) hours routine. Further review of the May 2014 MAR revealed the following omissions from the MAR: Torsemide 30 mg on 05/18/14, 05/25/14 and 05/31/14, Allopurinol 50 mg on 05/14/14 and 05/26/14, Aspirin 81 mg on 05/11/14 and 05/20/14, Neurontin 400 mg on 05/17/14, 05/20/14 and 05/31/14, K-Dur 40 meq on 05/01/14, 05/06/14, 05/08/14, 05/09/14, 05/13/14, 05/19/14, 05/20/14, 05/27/14 and 05/31/14, Clindamycin 300 mg on 05/02/14 and 05/08/14, Vancomycin on 05/20/14 and Percocet on 05/18/14, 05/20/14 and 05/31/14. Interview on 05/30/14 at 2:45 PM with the Pharmacy Account Executive Customer Service Representative, revealed he was not aware of any recent problem with the availability of medications for residents in this facility. The facility staff was to fax orders by 5:30 PM Monday through Friday and by 3:30 PM on Saturday and the medication would be delivered that night. Orders received on Sunday have to be faxed and called to the Pharmacy and the back up Pharmacy would deliver. However, a Post Survey Interview on 07/18/14 at 10:07 AM with the Pharmacy Account Executive Customer Service Representative, revealed the pharmacy services main source of communication as the provider of pharmacy services to the facility was facsimile (fax). He stated there were multiple fax numbers that could be utilized to send faxes to various departments within the facility. He further stated, the pharmacy provider relied on the person receiving the fax to ensure it was routed to the appropriate person. There were no pharmacy protocols that necessitated the pharmacy provider to make verbal communication with the facility; however, occasionally it was practice to call the facility if there was a problem. He did not know if the facility was ever contacted other than by the means of a fax. He further stated, the chart reviews which would have been completed by the pharmacy consultant who makes rounds once a month, reviews medication interactions and compatibility and so forth, and the pharmacy consultant would not have identified if there were medications missing or not being delivered because the consultant does not look at the MARs. A Post Survey interview with the General Pharmacy Manager, on 07/02/14 at 10:35 AM, revealed there was an issue with the physician's license number being renewed in the system so Medicaid was rejecting some of the residents' medications. He stated a fax was sent to the facility when this would occur. He revealed the facility had contacted the Pharmacy, he thought sometime after the survey had started, and requested the Pharmacy to send the resident's medications that were rejected by Medicaid and the facility would cover the cost until the issue was resolved. He stated as far as he was aware this had been done. He stated when staff needed to reorder a medication, there were stickers on the labels of the residents' medications and the staff would need to peel the sticker off and place it on a reorder sheet and fax to the pharmacy when a medication was needed. Post Survey interview with the DON, on 07/02/14 at 9:20 AM, revealed the nurses should have checked the Emergency Drug Kit (EDK) and notified the pharmacy when a medication was not available for administration. The DON stated some of the residents' medications were not available due to the physician's Medicaid number not being renewed and the pharmacy faxed the facility to make them aware but the nurses did not give her the faxes. She stated other residents did not have their medication available for administration because the nurses had failed to reorder the medication. Interview with the Administrator, on 05/29/14 at 1:10 PM, revealed she had not been aware of a problem with obtaining medications from the pharmacy until 05/23/14. Further interview with the Administrator, on 05/30/14 at 4:00 PM, and 06/02/14 at 5:20 PM, revealed they had identified one of the Physicians needed to update his/her provider number for Medicaid because it was not showing up as active in the system. The Administrator stated the pharmacy was now supposed to continue to send the medications until the problem was resolved. A Post Survey interview, conducted on 07/02/14 at 2:55 PM, revealed the Pharmacy was sending the faxes to the facility informing the facility the medications would not be sent due to the physician needing to update his provider number but the faxes were going to the nurses on the floor and not to the Administrative staff. She stated they have now changed their system for all pharmacy faxes to be sent to the Administrator. *The facility implemented the following actions to remove the Immediate Jeopardy: On 06/04/14, the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's orders [REDACTED].#10, #11, #12, #13, #14, #15, #16 and #17. On 05/31/14, the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician order [REDACTED]. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On 06/01/14, the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On 06/01/14, the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after 06/04/14 without having had this re-education and competency test. On 06/02/14, two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of 06/09/14, the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on 06/03/14 to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On 06/12/14 at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to 3-5 days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On 06/12/14 at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on 06/12/14 regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On 06/12/14 at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On 06/12/14 at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On 06/12/14 at 11:46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On 06/12/14 at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On 06/12/14 at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On 06/12/14 at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On 06/12/14 at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On 06/12/14 at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On 06/12/14 at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On 06/12/14 at 2:40 PM, the DON verified through interview that she began education with licensed staff on 06/01/14 regarding medication administration and availability. The staff was required to complete a post test. On 06/12/14 at 2:50 PM, RN #3 verified through interview that he/she had received recent training on medication availability and administration. Reports that medication availability was covered to include checking the EDK box, calling the pharmacy and if unable to obtain the medication in a timely manner, the physician should be notified. RN #3 stated that medication availability was 100% better. If a medication supply is getting low, the sticker should be pulled and faxed to pharmacy. Medications were usually reordered when a three (3) day supply is left. Staff is to notify the physician if there are problems obtaining a medication or if the resident refuses a medication. RN #3 also verified the receipt of education regarding care plans. Staff should always follow the care plan and if unable should notify the physician as well as the DON. Care plans were updated by a RN; and, SRNA's care plans were updated by the RN or the DON. SRNAs use the Accunurse system to access information regarding a resident's plan of care. If a SRNA is unable to follow the care plan for a resident, the Charge Nurse or administration should be notified. On 06/12/14 at 3:08 PM, LPN #5 verified through interview that he/she had received recent education on medication availability and administration. A post test was completed after receiving inservice training. If a medication is not available, the EDK box should be checked and if the medication is not available there, the pharmacy should be called to get the medication STAT and the physician should be called for additional orders. Reordering resident medications should be done when there is a three (3) day supply of the medication left. The sticker should be pulled, placed on the reorder form and faxed to the pharmacy. LPN #5 revealed that medication availability has improved. The LPN verified that he/she has received recent education regarding care plans. If staff is unable to follow the plan of care for a resident, the Charge Nurse should be notified and will alert the DON and the physician. The computer or the Accunurse system can be utilized to view the resident's plan of care. On 06/12/14 at 3:34 PM, the pharmacy representative verified through interview that he and Certified Pharmacy Technicians completed a MAR to medication cart audits for all residents on 06/02/14 and 06/09/14. On 06/12/14 at 4:20 PM, an interview with the DON and the Administrator, revealed omissions on the June 2014 MAR for Resident #15 on 06/05/14 at 3:00 PM of a dose of Lortab and a 2:00 PM dose of Lyrica indicated the medications were not administered by LPN #1. It was revealed that LPN #1 was terminated related to the medication errors. On 06/11/14 at 5:00 AM, a dose of Levothyroxine was not documented as given by RN #4 and disciplinary action was pending related to the omission on the MAR. On 06/12/14 at 4:52 PM, the DON and the Administrator were interviewed regarding omissions on the June 2014 MAR for Resident #18. Review of the June 2014 MAR revealed no documentation for a 7:00 AM dose of Zantac on 06/09/14 and 5:00 PM doses of Depakote on 06/07/14 and 06/08/14. Interview on 06/12/14 at 5:15 PM with LPN #3 revealed that he/she had given the Zantac to Resident #18 on 06/09/14 but failed to document it on the MAR. The LPN stated she had signed a disciplinary action five (5) minutes prior to the interview. Interview on 06/12/14 at 5:24 PM with LPN #4 revealed that he/she had given the 5:00 PM Depakote doses to Resident #18 on 06/07/14 and 06/08/14 but failed to document the administration on the MAR. Further interview revealed the LPN received disciplinary action thirty (30) minutes prior to the interview. Interview with the DON on 06/12/14 at 5:48 PM, revealed that training and education were provided to staff as a part of a disciplinary action. Interview with the Administrator, on 06/12/14 at 5:50 PM, revealed that an additional, 3rd, MAR check was added on 06/12/14 to include staff at shift change checking MARs for omissions. Interview with the Administrator, on 06/13/14 at 9:15 AM, revealed that an additional, 3rd MAR check was initiated on 06/12/14. The Medical Director was notified and participated in a QA meeting/conference call regarding the plan. Interview with the Administrator, on 06/13/14 at 10:28 AM, revealed that LPN #4 had not worked and had been out of town and that disciplinary action was provided upon the first day of her return to work. Interview with the Administrator, DON and Regional RN, on 06/13/14 at 10:50 AM, revealed the medications for Resident #18 were available on the cart for administration. Staff interviews reveal that the medications were administered and available on 06/07/14, 06/08/14 and 06/09/14 and disciplinary action was administered according to the AOC. The number of

Based on interview, observation, record review, and review of the facility's policy and procedure, it was determined the facility failed to consult with the physician for eleven (11) of seventeen (17) sampled residents (Residents #1, #2, #3, #6, #10, #11, #12, #13, #14, #15 and #16). The facility failed to consult with the physicians when medications were not available for administration or when not administered for Residents #2, #3, #10, #11, #12, #13, #14, #15 and #16; and, when treatments were not provided for Resident #6. The physician was not notified when Resident #1 had an accident, which resulted in injury. The facility failed to notify the physician when Resident #10 did not receive a "now" dose of Potassium 40 milliequivalents (meq) which was ordered to be administered on [DATE], but was not given until [DATE]. Resident #11 did not receive Solu-[MEDICATION NAME] (steroid) 40 milligrams (mg) intramuscularly (IM) and [MEDICATION NAME] (antibiotic) 500 mg intravenously (IV) which was ordered "stat" (to be given immediately) on [DATE], but wasn't given until [DATE]. Resident #12, who had a [MEDICAL CONDITION] disorder, did not receive [MEDICATION NAME] [MEDICATION]) 500 mg by mouth twice daily from [DATE] through [DATE] for a total of six (6) doses and experienced a [MEDICAL CONDITION] and required hospitalization . Resident #14 did not receive a total of fourteen (14) doses of [MEDICATION NAME] (digestive enzyme) 5000 Units from [DATE] through [DATE]; Resident #15, who had a [DIAGNOSES REDACTED]. The resident presented with complaints of severe pain. Resident #16 did not receive [MEDICATION NAME] (diuretic) 30 mg daily, [MEDICATION NAME] (Gout) 50 mg daily, Aspirin (heart) 81 mg daily, [MEDICATION NAME] (anticonvulsant) 400 mg by mouth three (3) times daily, K-Dur (electrolyte supplement) 40 milliequivalents three (3) times daily, [MEDICATION NAME] (antibiotic) 300 mg three (3) times daily for 10 days, [MEDICATION NAME] (antibiotic) one (1) Gram twice daily for seven (7) days and [MEDICATION NAME] ([MEDICATION NAME]) ,[DATE] mg every eight (8) hours routine on multiple occasions according to the resident's Medication Administration Record (MAR). Resident #3 did not receive seven (7) doses of [MEDICATION NAME] (blood pressure medication) 10 mg every day from [DATE] - [DATE]. Resident #2's [MEDICATION NAME] (antifungal) 100 milligrams (mg) by mouth every day for five (5) days for a yeast rash was not administered from ,[DATE]-,[DATE]; and, the facility failed to notify the physician when Resident #13 did not receive [MEDICATION NAME] (anti-anxiety) 5 mg per PEG tube twice daily routine from [DATE] at 9:00 PM through [DATE] at 9:00 AM for a total of six (6) doses. Additionally, the facility failed to notify the physician on [DATE], when Resident #1's legs became tangled in the metal pieces on the lift while being transferred with a lift. The State Registered Nurse Aide (SRNA) failed to notify the nurse to ensure the physician was notified of the incident. Resident #1 complained of pain to the right foot; an x-ray was completed on [DATE] which identified that Resident #1 had sustained right acute nondisplaced fractures of the distal tibia and fibula (leg). The facility's failure to consult with the physician when medications were not available for administration and when a resident had a incident with a lift that caused possible injury caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the facility policy titled, Medication Shortages /Unavailable Medications, last revised on [DATE], revealed if medication was not available for administration and if an emergency delivery of medication was unavailable, the facility nurse should have contacted the attending physician to obtain orders or directions. The facility should have collaborated with pharmacy and the physician/prescriber to determine a suitable therapeutic alternate. 1. Record review revealed the facility admitted Resident #10 on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. On [DATE] at 9:40 AM, Licensed Practical Nurse (LPN) #3 received an order from the Physician to medicate the resident with Potassium 40 meq by mouth (po) "now" meaning immediately. Review of the [DATE] MAR revealed the Potassium dose was not administered until [DATE] at 9:00 AM by LPN #4. Further review of Resident #10's medical record revealed no documented evidence the Physician was made aware that the dose of Potassium was not administered on [DATE], as ordered. Interview, on [DATE] at 3:00 PM with LPN #3, revealed she forgot to put the medication order on the MAR and did not administer the Potassium as ordered. Review of a Laboratory Report, revealed a repeat potassium level was obtained on [DATE] at 1:45 PM and the result was 2.4 mmol/L (low). The result was phoned to the Physician's Assistant (PA) at 6:09 PM by the lab staff. Review of a Nurse's Note, revealed on [DATE] at 8:30 PM an order was received to send the resident to the emergency room for evaluation. Review of the Hospital History and Physical revealed the resident was evaluated in the Emergency Department on [DATE] at 8:59 PM and was subsequently admitted into the hospital with a [DIAGNOSES REDACTED]. Interview with Resident #10's Physician, on [DATE] at 2:30 PM, revealed he had not been made aware that the resident had not received his/her Potassium. He stated [DIAGNOSES REDACTED] was low Potassium and depending on how low, it could be life threatening. He stated he expected medications to be given as ordered. 2. Closed record review revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. Review of Nursing Notes, dated [DATE] at 10:57 PM, revealed LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The Advanced Practitioner Registered Nurse (APRN) was notified on [DATE] at 11:30 PM and "stat" (indicating immediately) orders were received to medicate the resident with Solu-[MEDICATION NAME] (steroid) 40 mg intramuscularly (IM) and [MEDICATION NAME] 500 mg IV every 24 hours. Review of the [DATE] MAR and Nurse's Notes revealed the medication was not administered until [DATE] at 5:49 PM; however, further review of Resident #11's medical record revealed no documented evidence the Physician was notified the medication was not administered on [DATE] "stat", as ordered. Review of the Nursing Notes, dated [DATE] at 6:24 PM, revealed the resident expired. 3. Record review revealed the facility admitted Resident #12 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Notes, dated [DATE] at 11:45 AM, revealed the resident experienced a [MEDICAL CONDITION] and was sent to the hospital and admitted . Review of Nurse's Notes, dated [DATE] at 5:38 PM, revealed Resident #12 was readmitted to the facility. Review of the admission orders [REDACTED]. Review of the [DATE] MAR revealed the first dose of [MEDICATION NAME] should have been administered on [DATE] at 9:00 PM, but there was no documented evidence the [MEDICATION NAME] was given after readmission to the facility on [DATE] through [DATE] (seven (7) doses) and there was no evidence the physician was notified the medication was not available for administration. Review of the Nurse's Notes revealed on [DATE], the resident experienced another [MEDICAL CONDITION] and was transported back to the emergency room and was admitted again. Interview with the Director of Nursing (DON), on [DATE] at 10:10 AM, revealed there was no way to verify the resident was administered the [MEDICATION NAME] as ordered from [DATE] through [DATE]. 4. Record review revealed the facility admitted Resident #15 on [DATE] with the [DIAGNOSES REDACTED].#15 as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) indicating the resident was interviewable. Review of the [DATE] Physician Orders revealed an order for [REDACTED]. Review of the [DATE] MAR revealed the resident did not receive his/her [MEDICATION NAME] on [DATE], [DATE] and [DATE] (a total of eight (8) days without a pain patch). However, further review of Resident #15's medical record revealed no documented evidence the Physician was notified the [MEDICATION NAME] was not available for administration. Interview with Resident #15, on [DATE] at 11:30 AM, revealed he/she was currently hurting "bad". The Assistant Director of Nursing, at that time, was observed to assess the resident and verified there was no [MEDICATION NAME] in place. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 3:00 PM, revealed she had called the Advanced Practical Registered Nurse (APRN) on [DATE] and was told the resident had been on [MEDICATION NAME] for some time and the APRN did not want to switch to [MEDICATION NAME] as the Pharmacy had recommended. LPN #3 stated she did not know if the physician had been notified when the [MEDICATION NAME] was not available to be administered on [DATE] and [DATE]. Interview with the APRN, on [DATE] at 1:30 PM, revealed she did not recall being made aware Resident #15 had not been administered his/her [MEDICATION NAME] three (3) different times in the month of May. The APRN stated there had been problems with Medicaid "kicking me and the Physician" out of the system but felt that was resolved. 5. Record review revealed the facility admitted Resident #13 on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated [DATE], revealed an order for [REDACTED]. Review of the [DATE] MAR revealed staff initials were circled on the MAR for [DATE] through [DATE], indicating the mediation was not given, per the Director of Nursing. There was no entry for the 9:00 PM dose on [DATE]. The 9:00 AM dose on [DATE] had a circled initial on the MAR. Review of the back of the MAR revealed the pharmacy was called on [DATE] at 9:00 AM to inquire about the medication and was told it would be in that night. Review of the [DATE] MAR revealed the medication was given on [DATE] at 9:00 PM; however, further review of Resident #13's Medical Record revealed there was no documented evidence the physician had been notified that the medication was not available for administration. 6. Record review revealed the facility admitted Resident #14 on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of the Physician's Orders for [DATE], revealed [MEDICATION NAME] 5000 unit capsule at meals and before bedtime. Review of the [DATE] MAR revealed the resident did not receive a total of fourteen (14) doses of [MEDICATION NAME] (enzyme) 5000 units on [DATE], [DATE], [DATE] and [DATE]. However, there was no documented evidence the physician was notified the medication was not available for administration. Interview with Resident #14, on [DATE] at 2:25 PM, revealed the facility had not given him/her the medication and he/she did not understand why as he/she has been on it for years. The resident stated he/she was told that the medical card would not pay for it. Observation of the medication cart, on [DATE] at 2:55 PM revealed there was no [MEDICATION NAME] available to be administered. Interview with the Director of Nursing (DON), on [DATE] at 3:35 PM, revealed she was currently investigating the situation and that he/she had authorized the pharmacy to fill the medication and bill it to the facility. 7. Record review revealed the facility admitted Resident #16 on [DATE], with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #16 as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of [DATE] Physician Orders revealed orders for [MEDICATION NAME] (diuretic) 30 mg daily, [MEDICATION NAME] (Gout) 50 mg daily, Aspirin (heart) 81 mg daily, [MEDICATION NAME] (anticonvulsant) 400 mg by mouth three (3) times daily, K-Dur (electrolyte supplement) 40 milliequivalents three (3) times daily, [MEDICATION NAME] (antibiotic) 300 mg three (3) times daily for 10 days (to end on [DATE]), [MEDICATION NAME] (antibiotic) one (1) Gram twice daily for seven (7) days (with last dose on [DATE]) and [MEDICATION NAME] ([MEDICATION NAME]) ,[DATE] mg every eight (8) hours routine. Review of the [DATE] MAR revealed the following omissions from the MAR: [MEDICATION NAME] 30 mg on [DATE], [DATE] and [DATE] (three doses): [MEDICATION NAME] 50 mg on [DATE] and [DATE] (two doses): Aspirin 81 mg on [DATE] and [DATE] (two doses); [MEDICATION NAME] 400 mg on [DATE] at 6:00 AM, [DATE] at 2:00 PM and [DATE] at 2:00 PM and 10:00 PM (four (4) doses); K-Dur 40 meq one dose on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], all three (3) doses on [DATE], one (1) dose on [DATE] and two (2) doses on [DATE] for a total of twelve (12) doses; [MEDICATION NAME] 300 mg on [DATE] and [DATE] at 5:00 PM (two (2) doses) ; [MEDICATION NAME] on [DATE] (one dose) and [MEDICATION NAME] on [DATE] at 6:00 AM, [DATE] at 2:00 PM and [DATE] at 2:00 PM and 10:00 PM (four (4) doses). However, review of Resident # 16's medical record revealed no documented evidence the Physician was notified these medications were not administered. Interview with Resident #16, on [DATE] at 2:23 PM, revealed the resident reported the presence of pain while not receiving his/her medications as ordered. 8. Record review revealed the facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Order Sheet, dated [DATE], revealed an order for [REDACTED]. Review of the [DATE] Medication Administration Record (MAR) revealed the medication was not given on [DATE]-[DATE]. Review of the Shipment Detail Report from the pharmacy revealed the medication was not delivered until [DATE] at 11:57 PM, three (3) days after the medication was ordered. Further review of Resident #2's medical record revealed no documented evidence the physician was made aware the medication was not available for administration, as ordered. Interview with Resident #2, on [DATE] at 4:00 PM, revealed he/she did not receive his/her medication. 9. Record review revealed the facility admitted Resident #3 on [DATE], with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated [DATE], revealed an order to administer [MEDICATION NAME] (blood pressure medication) 10 milligrams (mg) every day. Review of the [DATE] MAR revealed this medication was initialed and circled from [DATE] through [DATE] (seven (7) doses) which indicated the medication was not given. However, further review of Resident #3's medical record revealed no documented evidence the Physician was notified the medication was not available for administration. 10. Record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Treatment Administration Record (TAR) revealed there was no documented evidence the treatments were completed on the 6:00 AM-6:00 PM shift on [DATE] through [DATE]. Further record review revealed there was no documented evidence the physician was notified of the failure to provide these treatments. Interview with LPN #1, on [DATE] at 3:25 PM, revealed the order for the cleansing of the JP drain site was not on the original TAR and it wasn't done. Interview with the DON, on [DATE] at 1:10 PM, revealed medications could be ordered "STAT" and the pharmacy could send medications from the back up pharmacy as needed. The DON further reported if a medication or treatment wasn't documented, it wasn't done and the Physician should be notified. In further interview, the DON stated the Medical Director was made aware on [DATE], by the Administrator, of the concerns of medications not being available. Interview with the Administrator, on [DATE] at 3:20 PM, revealed when staff was unable to carry out a physician's order, he/she would expect the staff to report to the nurse in charge and/or to the Physician. 11. Review of the facility policy titled, "Safe Handling and Movement Policy", last revised [DATE], revealed that injuries from patient handling and movement should be reported. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated [DATE], revealed the facility assessed Resident #1 as cognitively intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Review of the facility's final report of the investigation revealed Resident #1 was transferred by State Registered Nurse Assistant (SRNA) #1 using a mechanical lift without assistance on [DATE]. While being transferred, the resident's right foot became tangled, and due to the resident's [MEDICAL CONDITION], he/she was unable to feel pain to his/her leg. The SRNA did not report the incident to nursing staff to ensure the Physician was notified of the incident. Resident #1 had complaints of foot pain and an x-ray of the right foot was ordered on [DATE] and completed on [DATE] by the mobile x-ray service. Review of the Radiology Report, dated [DATE], revealed a reading of right acute nondisplaced fractures of the distal tibia and fibula. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 3:51 PM, revealed she had been notified by the DON the resident was having leg pain. The LPN stated the physician was notified and an order was received for a radiograph (x-ray) of the right foot. The LPN stated the physician was not notified until the resident complained of pain to the foot because the SRNA had not notified anyone of the fall with the lift. Interview with the Assistant Director of Nurses (ADON), on [DATE] at 4:33 PM, revealed if medications weren't available from the pharmacy he/she would expect the staff to notify the DON, ADON and the Physician. Interview with the DON, on [DATE] at 1:10 PM, revealed if a medication or treatment wasn't documented, it wasn't done. Interview with the Administrator, on [DATE] at 1:10 PM and on [DATE] at 3:20 PM, revealed when staff was unable to carry out a physician's order, he/she would expect the staff to report to the nurse in charge and/or to the Physician. She stated on [DATE], nurses started doing administrative MAR and TAR reviews; and, a conference call Quality Assurance meeting was held with the Medical Director on [DATE] related to the medications not being available for administration or not administered. Further interview with the Administrator, on [DATE] at 4:30 PM, revealed she could not say the Physician was notified each time, about every resident who did not receive his/her medication as ordered. During the interview with the Medical Director, on [DATE] at 2:15 PM, he stated "nurses should know their duties, know what they are doing and the supervisors should know what is going on." He stated, "Can't wait twenty-four (24) hours to find out a medication was not given." *The facility implemented the following actions to remove the Immediate Jeopardy: On [DATE], the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's Order for Residents #3, #10, #11, #12, #13, #14, #15, #16 and #17. On [DATE], the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician Orders for the previous thirty (30) days to assure all orders were correct on the MAR. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On [DATE], the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On [DATE], the DON began education with Licensed Nurses on "Medication "Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after [DATE] without having had this re-education and competency test. On [DATE], two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of [DATE], the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on [DATE] to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On [DATE] at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to ,[DATE] days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On [DATE] at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on [DATE] regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On [DATE] at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On [DATE] at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On [DATE] at 11 :46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On [DATE] at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On [DATE] at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On [DATE] at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On [DATE] at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On [DATE] at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On [DATE] at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On [DATE] at 2:40 PM, the DON verified through

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure care was provided in accordance with the plan of care for eight (8) of seventeen (17) sampled residents (Residents #1, #3, #10, #11, #13, #14, #15 and #16 ). Resident #1,who was a paraplegic, was care planned to be transferred by one staff manually; however, on 03/30/14, State Registered Nurse Aide (SRNA) #1 transferred Resident #1 with a lift. The resident was not assessed or care planned for the use of the lift. Resident #1's foot became caught between two steel pieces of the lift and the resident sustained [REDACTED]. Residents #3, #10, #11, #13, #14, #15, and #16 were care planned to receive medications as ordered; however, the facility failed to administer the medications. Resident #10 did not receive a now dose of Potassium on 05/29/14 and was hospitalized with a [DIAGNOSES REDACTED].#11 did not receive Solu-Medro (steroid) intramuscular (IM) and [MEDICATION NAME] (antibiotic) Intravenous (IV) until 05/22/14 although the order was received as a "stat" order on 05/21/14. Resident #13 did not receive a total of six (6) doses of [MEDICATION NAME] (antianxiety) 5 mg. Resident #14 did not receive a total of fourteen (14) doses of [MEDICATION NAME] (digestive enzyme) 5000 Units from 05/19/14 through 05/28/14. Resident #15, who had a [DIAGNOSES REDACTED]. Resident #16 did not consistently receive [MEDICATION NAME] (diuretic), [MEDICATION NAME] (gout), Aspirin (heart), [MEDICATION NAME] ([MEDICAL CONDITION]), K-Dur ([MEDICAL CONDITION]), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (pain) according to the resident's Medication Administration Record (MAR). Resident #3 did not receive seven (7) doses of [MEDICATION NAME] (blood pressure medication). The facility's failure to provide care according to the resident's care plan has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 06/02/14 and determined to exist 05/05/14. The facility was notified of the Immediate Jeopardy on 06/02/14. The findings include: Review of an undated policy, titled Resident Comprehensive Care Plan, revealed the care plan should be viewed as an interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility and should always have realistic goals and approaches/interventions to address the residents' needs. 1. Record review revealed the facility admitted Resident #1 on 02/13/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 02/20/14, revealed the facility assessed Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) of fifteen (15) which indicated the resident was interviewable. The facility also assessed the resident as requiring the extensive assistance of two (2) staff for transfers. Review of the Comprehensive Care Plan for Activities of Daily Living, dated 04/24/14, revealed an intervention for one (1) person physical assist manually. Further review revealed there was no intervention to use a lift for transfers. Review of the facility's final report of the investigation, dated 04/10/14, revealed Resident #1 was transferred by State Registered Nurse Assistant (SRNA) #1 using a mechanical lift without assistance. Further review of the investigation revealed while being transferred, the resident's right foot became tangled in the metal frame of the lift. Due to the resident's [MEDICAL CONDITION], he/she was unable to feel pain to the leg. The resident's family member, who was present to take the resident out for the day, witnessed and assisted the SRNA to untangle the resident's leg. The incident was not reported by the SRNA. Record review revealed an x-ray of the right foot was ordered on [DATE] and completed on 04/04/14 by the mobile x-ray service which revealed the resident had a right fractured tibia and fibula. Following the investigation, it was determined the SRNA did not follow the resident's plan of care and did not have assistance operating a mechanical lift. Review of a physician's orders [REDACTED]. An x-ray of the right lower leg on 04/04/14 at 10:30 PM, revealed a radiologist interpretation of diffuse severe osteopenia with oblique comminuted, minimally displaced fractures involving the distal tibia and fibula. Interview with Resident #1, on 05/21/14 at 9:00 AM, revealed while being transferred with the lift, his/her leg got caught. The resident reported he/she should have been transferred using two (2) assist. A telephone interview with a family member, on 05/22/14 at 10:22 AM, revealed on 03/30/04, he/she was at the facility to take the resident out for a while. Further interview revealed the staff person picked him/her up with the lift and caught the resident's leg between the two (2) steel pieces. He/she had to raise the lift to get the resident's foot out. She further stated the staff was working alone. Interview with the Administrator, on 05/21/14 at 11:10 AM, revealed the resident was not care planned for the use of a lift, according to the care plan the resident was to have the manual assistance of one person. 2. Record review revealed the facility admitted Resident #10 on 05/16/14 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 05/23/14, revealed the facility assessed the resident to have severe cognitive impairment. Review of the Comprehensive Care Plan for Alteration in Nutrition, dated 05/16/14, revealed "Meds/labs as ordered". Review of a physician's orders [REDACTED].#3, to medicate the resident with Potassium 40 meq "now" (immediately) and recheck Potassium level four (4) to twenty-four (24) hours after administration. Review of the May 2014 Medication Administration Record (MAR) revealed the Potassium was not administered until 05/30/14 at 9:00 AM by another nurse, Licensed Practical Nurse (LPN) #4. Interview with Licensed Practical Nurse (LPN) #3, the nurse who received the order, on 05/31/14 at 3:30 PM, revealed she forgot to put the medication order on the MAR and did not administer the Potassium as ordered. The missed potassium dose was not administered until 05/30/14 at 9:00 AM by LPN #4. Review of a Laboratory Report for a repeat Potassium level which was obtained on 05/30/14 at 1:45 PM revealed the result was 2.4 mmol/L (normal 3.5 to 5.0). The result was phoned to the Physician's Assistant (PA) at 6:09 PM by the lab staff. An order was received at 8:30 PM to send the resident to the emergency room for evaluation. Record review revealed the resident was evaluated in the Emergency Department on 05/30/14 at 8:59 PM and subsequently admitted into the hospital with a [DIAGNOSES REDACTED]. 3. Record review revealed the facility admitted Resident #11 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Nutrition related to [MEDICAL CONDITION], dated 05/03/14, revealed an intervention to provide "medication and treatment as ordered". Review of a Nurse's Note, dated 05/21/14 at 10:57 PM, revealed LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The Advanced Practice Registered Nurse (APRN) was notified on 05/21/14 at 11:30 PM and an order was received to medicate the resident with Solu-[MEDICATION NAME] 40 mg intramuscularly (IM), [MEDICATION NAME] 500 mg IV every 24 hours, [MEDICATION NAME] 40 mg by mouth times two (2) doses, [MEDICATION NAME] every 4 hours, check vital signs every 4 hours, a chest radiograph (x-ray) and a complete blood count (CBC) stat. However, review of the May 2014 MAR and Nurse's Notes revealed the resident did not receive the Solu-[MEDICATION NAME] 40 mg IM and the [MEDICATION NAME] 500 mg IV until 05/22/14 at 5:49 PM (next day) after it was taken from the emergency drug kit (EDK) by LPN #1. Review of the radiology report of the chest x-ray, dated 05/22/14, revealed defined infiltrative shadows in the left infrahilar and lower lobe suggestive of Pneumonia. 4. Record review revealed the facility admitted Resident #15 on 07/03/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Pain, dated 04/02/14, revealed an intervention to "administer pain medications as ordered". Review of the May 2014 Physician order [REDACTED]. Review of the May 2014 MAR revealed the resident did not receive his/her [MEDICATION NAME] on 05/05/14, 05/14/14 and 05/26/14 which caused the resident to go without a patch in place for eight (8) days. 5. Record review revealed the facility admitted Resident #14 on 10/11/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 04/24/14, revealed the facility assessed Resident #14 as cognitively intact with a BIMS score of fourteen (14) indicating the resident was interviewable. Review of the Comprehensive Care Plan for Risk for Alteration in Nutrition, dated 04/24/14, revealed an intervention to receive medications as ordered. Review of the May 2014 physician's orders [REDACTED]. Review of the May 2014 MAR revealed the resident did not receive [MEDICATION NAME] on 05/19/14, 05/21/14, 05/22/14 and 05/28/14 for a total of fourteen (14) missed doses. Interview with Resident #14, on 05/28/14 at 2:25 PM, revealed he/she had been missing the medication but did not understand why as he/she has been on it for years. The resident stated he/she was told that the medical card would not pay for the medication. Interview with the Director of Nursing (DON), on 05/28/14 at 3:35 PM, revealed she was investigating the situation and that she had authorized the pharmacy to fill the medication and bill it to the facility. 6. Record review revealed the facility admitted Resident #13 on 07/01/14 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan related to Impulse Control, dated May 2014, revealed an intervention to give medications as ordered. Review of the physician's orders [REDACTED]. Review of the May 2014 MAR revealed the medication was not given 05/24/14 through 05/27/14 at 9:00 AM. Interview, on 06/02/14 at 2:38 PM, with the Pharmacy Account Representative, revealed the [MEDICATION NAME] order was received on 05/24/14 and if it was faxed before 3:30 PM, it would have been delivered that night. He stated after 3:30 PM, a call should have been placed as well as the fax to have the medication available. Further interview revealed for normal delivery, the medication would have been delivered on the night of 05/26/14. 7. Record review revealed the facility admitted Resident #3 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for Hypertension, dated 04/10/14, revealed the resident should receive medications as ordered. Review of the physician's orders [REDACTED]. Review of the May 2014 MAR revealed the [MEDICATION NAME] 10 mg. was initialed and circled from 05/23/14 through 05/29/14 (seven doses) which indicated the medication was not given. 8. Record review revealed the facility admitted Resident #16 on 09/19/13 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 05/01/14, revealed the facility assessed the resident as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Alteration Of Comfort, last revised on 05/27/14, revealed an intervention for "medications as ordered". Review of May 2014 physician's orders [REDACTED]./14) and [MEDICATION NAME] 10-325 mg every eight (8) hours routine. Review of the May 2014 MAR revealed the following omissions from the MAR: [MEDICATION NAME] 30 mg on 05/18/14, 05/25/14 and 05/31/14, [MEDICATION NAME] 50 mg on 05/14/14 and 05/26/14, Aspirin 81 mg on 05/11/14 and 05/20/14, [MEDICATION NAME] 400 mg on 05/17/14, 05/20/14 and 05/31/14, K-Dur 40 meq on 05/01/14, 05/06/14, 05/08/14, 05/09/14, 05/13/14, 05/19/14, 05/20/14, 05/27/14 and 05/31/14, [MEDICATION NAME] 300 mg on 05/02/14 and 05/08/14, [MEDICATION NAME] on 05/20/14 and [MEDICATION NAME] on 05/18/14, 05/20/14 and 05/31/14. Interview with Resident #16, on 06/02/14 at 2:23 PM, revealed he/she reported the presence of pain while not receiving his/her medications as ordered. Interview with the Administrator and Director of Nursing (DON), on 06/02/14 at 4:30 PM, revealed the care plan interventions were developed from assessments and the DON was to ensure the care was provided per the plan of care and was monitored by the Administrator. A Post Survey interview with the DON, on 07/02/14 at 9:20 AM, revealed licensed staff conducted rounds to ensure care plans were being followed and if they identified any concerns it should be reported to her. A Post Survey interview with the Administrator, on 07/02/14 at 9:45 AM, revealed the licensed staff and Unit Managers on the floor observe to ensure staff are following the care plans and Administrative staff conduct clinical rounds to ensure staff are following the care plans. In addition, she stated the Administrative staff interview staff to ensure they have the supplies they need to provide the residents' care according to the care plan. No one had identified the medications were not available for administration during interviews. *The facility implemented the following actions to remove the Immediate Jeopardy: On 06/04/14, the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's orders [REDACTED].#10, #11, #12, #13, #14, #15, #16 and #17. On 05/31/14, the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician order [REDACTED]. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On 06/01/14, the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On 06/01/14, the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after 06/04/14 without having had this re-education and competency test. On 06/02/14, two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of 06/09/14, the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on 06/03/14 to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On 06/12/14 at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to 3-5 days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On 06/12/14 at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on 06/12/14 regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On 06/12/14 at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On 06/12/14 at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On 06/12/14 at 11:46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On 06/12/14 at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On 06/12/14 at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On 06/12/14 at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On 06/12/14 at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On 06/12/14 at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On 06/12/14 at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On 06/12/14 at 2:40 PM, the DON verified through interview that she began education with licensed staff on 06/01/14 regarding medication administration and availability. The staff was required to complete a post test. On 06/12/14 at 2:50 PM, RN #3 verified through interview that he/she had received recent training on medication availability and administration. Reports that medication availability was covered to include checking the EDK box, calling the pharmacy and if unable to obtain the medication in a timely manner, the physician should be notified. RN #3 stated that medication availability was 100% better. If a medication supply is getting low, the sticker should be pulled and faxed to pharmacy. Medications were usually reordered when a three (3) day supply is left. Staff is to notify the physician if there are problems obtaining a medication or if the resident refuses a medication. RN #3 also verified the receipt of education regarding care plans. Staff should always follow the care plan and if unable should notify the physician as well as the DON. Care plans were updated by a RN; and, SRNA's care plans were updated by the RN or the DON. SRNAs use the Accunurse system to access information regarding a resident's plan of care. If a SRNA is unable to follow the care plan for a resident, the Charge Nurse or administration should be notified. On 06/12/14 at 3:08 PM, LPN #5 verified through interview that he/she had received recent education on medication availability and administration. A post test was completed after receiving inservice training. If a medication is not available, the EDK box should be checked and if the medication is not available there, the pharmacy should be called to get the medication STAT and the physician should be called for additional orders. Reordering resident medications should be done when there is a three (3) day supply of the medication left. The sticker should be pulled, placed on the reorder form and faxed to the pharmacy. LPN #5 revealed that medication availability has improved. The LPN verified that he/she has received recent education regarding care plans. If staff is unable to follow the plan of care for a resident, the Charge Nurse should be notified and will alert the DON and the physician. The computer or the Accunurse system can be utilized to view the resident's plan of care. On 06/12/14 at 3:34 PM, the pharmacy representative verified through interview that he and Certified Pharmacy Technicians completed a MAR to medication cart audits for all residents on 06/02/14 and 06/09/14. On 06/12/14 at 4:20 PM, an interview with the DON and the Administrator, revealed omissions on the June 2014 MAR for Resident #15 on 06/05/14 at 3:00 PM of a dose of [MEDICATION NAME] and a 2:00 PM dose of [MEDICATION NAME] indicated the medications were not administered by LPN #1. It was revealed that LPN #1 was terminated related to the medication errors. On 06/11/14 at 5:00 AM, a dose of [MEDICATION NAME] was not documented as given by RN #4 and disciplinary action was pending related to the omission on the MAR. On 06/12/14 at 4:52 PM, the DON and the Administrator were interviewed regarding omissions on the June 2014 MAR for Resident #18. Review of the June 2014 MAR revealed no documentation for a 7:00 AM dose of [MEDICATION NAME] on 06/09/14 and 5:00 PM doses of [MEDICATION NAME] on 06/07/14 and 06/08/14. Interview on 06/12/14 at 5:15 PM with LPN #3 revealed that he/she had given the [MEDICATION NAME] to Resident #18 on 06/09/14 but failed to document it on the MAR. The LPN stated she had signed a disciplinary action five (5) minutes prior to the interview. Interview on 06/12/14 at 5:24 PM with LPN #4 revealed that he/she had given the 5:00 PM [MEDICATION NAME] doses to Resident #18 on 06/07/14 and 06/08/14 but failed to document the administration on the MAR. Further interview revealed the LPN received disciplinary action thirty (30) minutes prior to the interview. Interview with the DON on 06/12/14 at 5:48 PM, revealed that training and education were provided to staff as a part of a disciplinary action. Interview with the Administrator, on 06/12/14 at 5:50 PM, revealed that an additional, 3rd, MAR check was added on 06/12/14 to include staff at shift change checking MARs for omissions. Interview with the Administrator, on 06/13/14 at 9:15 AM, revealed that an additional, 3rd MAR check was initiated on 06/12/14. The Medical Director was notified and participated in a QA meeting/conference call regarding the plan. Interview with the Administrator, on 06/13/14 at 10:28 AM, revealed that LPN #4 had not worked and had been out of town and that disciplinary action was provided upon the first day of her return to work. Interview with the Administrator, DON and Regional RN, on 06/13/14 at 10:50 AM, revealed the medications for Resident #18 were available on the cart for administration. Staff interviews reveal that the medications were administered and available on 06/07/14, 06/08/14 and 06/09/14 and disciplinary action was administered according to the AOC. The number of pills available on the medication cart on 06/13/14 appeared to be adequate based on the date of delivery.

Based on interview, record review, and facility policy review, and review of the Kentucky Board of Nursing Advisory Opinion Statement, AOS #14, it was determined the facility failed to provide services, in accordance with acceptable standards of practice related to following physician's orders, for ten (10) of seventeen (17) sampled residents (Residents #2, #3, #6, #10, #11, #12, #13, #14, #15 and #16 ), and one (1) unsampled resident (Unsampled Resident A). Physician's orders had not been consistently followed related to medication administration and physician ordered treatments. It was determined the facility failed to ensure medications were administered as prescribed by their physician and according to acceptable standards of practice for nine (9) residents; and, the facility failed to provide a treatment as per the Physician's Order for a wound drain site for one resident. On [DATE], the physician ordered Resident #10 to receive a "now" dose of Potassium 40 milliequivalents (meq). However, the facility failed to administer the medication until [DATE]. The resident was sent to the hospital on [DATE] and diagnosed with [REDACTED]. On [DATE], the physician ordered Resident #11 to receive Solu-Medro (steroid) 40 milligrams (mg) intramuscular (IM) and [MEDICATION NAME] (antibiotic) 500 mg intravenously (IV) every 24 hours "stat" (immediately). However, the facility failed to administer the medication until [DATE]. The resident expired on [DATE]. On [DATE], Resident #12, who had a [MEDICAL CONDITION] disorder, was readmitted to the facility with a physician's order for [MEDICATION NAME] [MEDICATION]) 500 mg twice a day. However, the facility failed to administer the medication from [DATE] through [DATE] for a total of six (6) doses. The resident had another [MEDICAL CONDITION] on [DATE] and was hospitalized . The resident returned to the facility on [DATE], with a Physician's Order to change the milligrams from 500 mg to 1000 mg twice a day. The facility administered 500 mg (should have been 1000 mg) twice a day from [DATE] through [DATE] (total of thirty five doses). The physician ordered Resident #14 to receive [MEDICATION NAME] 5000 Units every meal and prior to bedtime. However, the facility failed to administer the medication on [DATE], [DATE], [DATE] and [DATE] for a total of fourteen (14) missed doses. Resident #15, who had a [DIAGNOSES REDACTED]. The facility failed to administer the patches on [DATE], [DATE] and [DATE] which resulted in the resident not having a pain patch in place for eight (8) days. The resident voiced complaints of severe pain. The physician ordered Resident #16 to receive [MEDICATION NAME] (diuretic) 30 mg daily, [MEDICATION NAME] (for Gout) 50 mg daily, Aspirin ([MEDICATION NAME]) 81 mg daily, [MEDICATION NAME] (anticonvulsant) 400 mg by mouth three (3) times daily, K-Dur (electrolyte supplement) 40 meq three (3) times daily, [MEDICATION NAME] (antibiotic) 300 mg three (3) times daily for ten (10) days (to end on [DATE]), [MEDICATION NAME] (antibiotic) one (1) gram twice daily for seven (7) days (with last dose on [DATE]) and [MEDICATION NAME] ([MEDICATION NAME]) ,[DATE] mg every eight (8) hours routine. However, the facility failed to administer the medication consistently. On [DATE], Resident #2's physician ordered [MEDICATION NAME] 100 mg by mouth every day for five (5) days for a yeast rash. The facility failed to administer the medication from [DATE] through [DATE]. The physician ordered Resident #3 to receive [MEDICATION NAME] (blood pressure) 10 mg every day. The facility failed to administer the medication from [DATE] - [DATE] for a total of seven (7) missed doses. The physician ordered Resident #13 to receive [MEDICATION NAME] (antianxiety) 5 mg per PEG tube twice daily routine. The facility failed to administer the medication from [DATE] through [DATE], for a total six (6) missed doses. The Physician ordered Unsampled Resident A to receive [MEDICATION NAME] (blood pressure medication) 10 mg Tablet, give one tablet by mouth daily. However, observation of a medication pass on [DATE] revealed the medication was not available for administration and the physician order was not followed. On [DATE], the physician ordered Resident #6's wound drainage sites to be cleansed with normal saline/soap and pat dry every shift. The facility failed to provide the treatments [DATE] through ,[DATE] on the 6a-6p shift. The facility's failure to administer medication and provide treatment per professional standards of quality of care and per Physician's Orders has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Interview with the Administrator, on [DATE] at 4:35 PM, revealed the facility based their standards of practice on the Kentucky Board of Nursing as well as the facility's policy, titled Medication Shortages/Unavailable Medications. Review of the facility policy and procedure titled, "Medication Shortages/Unavailable Medications" last revised [DATE], revealed actions to take upon discovery that the facility has an inadequate supply of medication to administer to a resident included staff taking immediate action to obtain the medication. If a medication shortage was discovered during normal Pharmacy hours, the nurse should call the pharmacy to determine the status of the order. If the medication has not been ordered, place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, obtain the medication from the Emergency Medication Supply to administer the dose. If the medication was not available in the Emergency Medication Supply, notify the pharmacy and arrange for an emergency delivery. If a medication shortage was discovered after normal pharmacy hours, staff should obtain the ordered medication from the Emergency Medication Supply and if it was not available in the Emergency Medication Supply, the nurse should call the pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. The action may include emergency delivery or the use of an emergency (back-up) third party pharmacy. If an emergency delivery is unavailable, the nurse should contact the attending physician to obtain orders or directions. If the nurse was unable to obtain a response from the attending physician/prescriber in a timely manner, the nurse should notify the nursing supervisor and contact the facility's Medical Director for orders/direction while making sure to explain the circumstances of the medication shortage. When a missed dose is unavoidable, the nurse should document the missed dose and the explanation for such missed dose on the MAR or Treatment Administration Record (TAR) and in the Nurse's Notes per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy's response upon notification and the action(s) taken. Review of the Kentucky Board of Nursing Advisory Opinion Statement, AOS #14, last revised [DATE], revealed "Registered Nursing Practice" and "Licensed Practical Nurse" were expected to administer medication and treatment as prescribed by physician, physician assistant, dentist or advanced practice registered nurse. Components of medication administration include, but are not limited to: Preparing and giving medication in the prescribed dosage, route, and frequency, including dispensing medications". 1. Record review revealed the facility admitted Resident #10, on [DATE], with [DIAGNOSES REDACTED]. Review of routine laboratory test results, conducted on [DATE], revealed the resident's Potassium level was 3.2 millimoles/Liter (mmol/L) and the normal value was between 3XXX,[DATE].50 mmol/L. On [DATE], the resident was placed on intravenous fluids (IVFs) at 75 ml/hour to end on [DATE] and a "now" dose of Potassium 40 milliequivilant (meq) was administered. The Potassium level was rechecked on [DATE] with a result of 3.5 mmol/L. Review of a Physician's Order, dated [DATE] at 9:40 PM, revealed an order from the physician to medicate the resident with Potassium 40 meq "now". Review of the [DATE] MAR revealed the Potassium dose was not administered on [DATE], according to the physician's order. Further review revealed the Potassium was not administered until [DATE] at 9:00 AM by LPN #4. Interview with Licensed Practical Nurse (LPN) #3, on [DATE] at 3:30 PM, revealed she was responsible to transcribe Physician's Orders onto the MAR and to administer medications per the Physician's Orders. She stated she should have placed the medication order on the MAR and administered the medication at that time because it was a "now" order but she forgot. Record review revealed a repeat potassium level was obtained on [DATE] at 1:45 PM and the result was 2.4 mmol/L (normal 3.5 to 5.0). The lab result was phoned to the Physician's Assistant (PA) at 6:09 PM by the lab staff. An order was received at 8:30 PM to send the resident to the emergency room for evaluation. The resident was evaluated in the Emergency Department on [DATE] at 8:59 PM and was subsequently admitted into the hospital with [DIAGNOSES REDACTED]. 2. Closed record review revealed the facility admitted Resident #11 on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 10:57 PM, per Nursing Notes, LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The Advanced Practitioner Registered Nurse (APRN) was notified on [DATE] at 11:30 PM and "stat" orders were received to medicate the resident with Solu-[MEDICATION NAME] 40 mg intramuscularly (IM), and [MEDICATION NAME] 500 mg IV every 24 hours. Review of the [DATE] MAR and Nursing Notes, revealed the medication was not administered stat on [DATE] as per the physician's order but was administered on [DATE] at 5:49 PM approximately seventeen (17) hours later. Further review of the Nurse's Notes, dated [DATE] at 6:24 PM, revealed the resident was noted to have a fixed facial expression. Cardiopulmonary resuscitation(CPR) was initiated and continued until Emergency Medical Services (EMS) arrived. Resuscitation was unsuccessful and the resident expired. Interview conducted with the Administrator, on [DATE] at 3:20 PM, revealed the oncoming licensed staff failed to obtain the stat Solu [MEDICATION NAME] which was in the EDK box and administer the medication. 3. Record review revealed the facility admitted Resident #12 on [DATE] with a [DIAGNOSES REDACTED]. According to a Nurse's Note, dated [DATE] at 7:27 PM, Resident #12 had a [MEDICAL CONDITION] at 11:45 AM (same date). Review of a Nurses Note, dated [DATE] at 6:53 AM, revealed a new order was received from the APRN to transport the resident to the emergency room for evaluation and treatment. The resident was transported by Emergency Medical Services (EMS) at 6:45 PM. Resident #12 was admitted to the hospital. Review of a Nurse's Note, dated [DATE] at 5:38 PM, revealed Resident #12 was readmitted to the facility with readmission orders [REDACTED]. Review of the [DATE] MAR revealed the order was handwritten on the MAR as [MEDICATION NAME] (levetracetam) 500 mg by mouth twice daily and to receive the first dose at 9:00 PM on [DATE]. However, further review revealed there was no documentation on the MAR that the [MEDICATION NAME] was administered twice daily per the physicians order after the resident's readmission to the facility on [DATE] through [DATE] (a total of seven (7) doses) and no documentation as to why the medication was not administered according to the physician's order or if the pharmacy was notified. Further review of the Nurse's Notes revealed on [DATE], the resident experienced another [MEDICAL CONDITION] and was transported back to the emergency room and was admitted again. Interview with the Administrator, on [DATE] at 10:30 AM, revealed after reviewing the MAR that it appeared the [MEDICATION NAME] wasn't given. Review of the admission orders [REDACTED]. Interview with the Advanced Practical Registered Nurse (APRN), on [DATE] at 1:26 PM, revealed on [DATE] the discharge medications were written by the APRN for [MEDICATION NAME] 1000 mg PO twice a day. Interview with the Director of Nursing, on [DATE] at 1:45 PM, revealed the [MEDICATION NAME] dosage given [DATE] through [DATE] was incorrect. The MAR was printed to read [MEDICATION NAME] 500 mg by mouth twice a day instead of [MEDICATION NAME] 1000 mg by mouth twice daily. 4. Record review revealed the facility admitted Resident #15 on [DATE] with a [DIAGNOSES REDACTED].#15's cognition as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of the [DATE] Physician Orders revealed an order for [REDACTED]. However, review of the [DATE] MAR revealed the resident did not receive his/her [MEDICATION NAME] every three (3) days as ordered on [DATE], [DATE] and [DATE] which resulted in the resident not having a pain patch in place to control his/her pain for a total of eight (8) days. Interview with Resident #15, on [DATE] at 11:30 AM, revealed he/she was currently hurting "bad". Assessment at the time, by the Assistance Director of Nursing revealed there was no [MEDICATION NAME] in place. Resident #15 was unaware he/she did not have a patch in place. The resident stated the patch helped as he/she always had pain. Interview with LPN #3, on [DATE] at 3:00 PM, revealed Resident # 15 did not have the prescribed [MEDICATION NAME]es available in the medication cart drawer on [DATE] and another time at the beginning of the month. She stated she called the pharmacy and was told the [MEDICATION NAME] was not covered by the resident's insurance but [MEDICATION NAME] was covered. LPN #3 stated she called the ARNP, who said the resident had been on the [MEDICATION NAME] for some time and she wanted him/her to have the [MEDICATION NAME]. LPN #3 stated Resident #15 had "Hit me at the door complaining of pain and had never complained of pain like that before and that's how I knew it was missed." She stated, "the pharmacy will not send a medication if it's not covered by insurance and the residents go a day or two without". 5. Record review revealed the facility admitted Resident #14 on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated [DATE], revealed the facility assessed Resident #14 as cognitively intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Review of the [DATE] Physician's Order, revealed an order for [REDACTED]. However, review of the [DATE] MAR revealed the resident did not receive a total of fourteen (14) doses of [MEDICATION NAME] (enzyme) 5000 units on [DATE], [DATE], [DATE] and [DATE] per the physician's orders. Interview with Resident #14, on [DATE] at 2:25 PM, revealed he/she had not received the medication and he/she did not know why as he/she had received this medication for years. The resident stated he/she was told that the medical card would not pay for it. Interview with the DON, on [DATE] at 3:35 PM revealed she was currently investigating the situation and he/she had authorized the pharmacy to fill the medication and bill it to the facility. 6. Record review revealed the facility admitted Resident #13 on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's Order, dated [DATE], revealed an order to administer [MEDICATION NAME] (antianxiety agent) 5 mg per PEG tube twice daily routine. Review of the [DATE] MAR revealed staff initials were circled on the MAR for [DATE] through [DATE] which indicated the medication was not given, with no entry for the 9:00 PM dose on [DATE]. The 9:00 AM dose on [DATE] had an initialed circle on the MAR. However, review of the back of the MAR with LPN #2, revealed the pharmacy was called on [DATE] at 9 AM to inquire about the medication and was told it would be in that night but there was no documentation indicating the pharmacy had been called prior to this or documentation as to why the medication was not given. Review of the [DATE] MAR revealed the medication was given on [DATE] at 9:00 PM. 7. Record review revealed the facility admitted Resident #16 on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated [DATE] revealed the facility assessed Resident #16 as cognitively intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the [DATE] Physician's Orders revealed orders for [MEDICATION NAME] (diuretic) 30 mg daily, [MEDICATION NAME] (for Gout) 50 mg daily, Aspirin ([MEDICATION NAME]) 81 mg daily, [MEDICATION NAME] (anticonvulsant) 400 mg by mouth three (3) times daily, K-Dur (electrolyte supplement) 40 milliequivilant three (3) times daily, [MEDICATION NAME] (antibiotic) 300 mg three (3) times daily for 10 days (to end on [DATE]), [MEDICATION NAME] (antibiotic) one (1) Gram twice daily for seven (7) days (with last dose on [DATE]) and [MEDICATION NAME] ([MEDICATION NAME]) ,[DATE] mg every eight (8) hours routine. Review of the [DATE] MAR revealed the boxes were blank and there was no documentation to indicate if the medication was given or not on the MAR for these medications on these dates: [MEDICATION NAME] 30 mg on [DATE], [DATE] and [DATE], [MEDICATION NAME] 50 mg on [DATE] and [DATE], Aspirin 81 mg on [DATE] and [DATE], [MEDICATION NAME] 400 mg on [DATE], [DATE] and [DATE], K-Dur 40 meq on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], [MEDICATION NAME] 300 mg on [DATE] and [DATE], [MEDICATION NAME] on [DATE] and [MEDICATION NAME] on [DATE], [DATE] and [DATE]. Interview with Resident #16, on [DATE] at 2:23 PM, revealed the resident reported the presence of pain while not receiving his/her medications as ordered. Interview with the DON, on [DATE] at 1:10 PM, revealed if a medication or treatment wasn't documented, it wasn't done. 8. Observation of a medication pass performed by Licensed Practical Nurse (LPN) #3, on [DATE] at 8:40 AM, revealed [MEDICATION NAME] (blood pressure medication) 10 mg was not administered to Resident #18 as ordered because the medication was not available in the medication cart. Review of Resident #18's Physician's Orders, dated ,[DATE], revealed [MEDICATION NAME] 10 mg Tablet, give one tablet by mouth daily. Review of the [DATE] MAR revealed [MEDICATION NAME] 10 mg on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (total of ten doses) was initial and circled. There was no documentation on the back of the MAR to indicate the rationale for the medication not being administered or if the pharmacy was notified. Additionally, Resident #18 did not receive Pantoprazole 20 mg eleven (11) times per the [DATE] MAR. The MAR revealed initials circled indicating not received on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The back of the MAR revealed six (6) days documentation for Pantoprazole not available on [DATE]th, 23rd, 24th, 25th, 26th and 27th. The five (5) remaining missed doses had no documentation to indicate the reason the medication was not administered. There was no documentation indicating if pharmacy was notified the medication was not available for administration. Interview conducted with LPN #3, on [DATE] at 9:30 AM and 10:25 AM, revealed she was not aware the resident was out of this medication until she was doing the medication pass. She stated she would check the Emergency Drug Kit (EDK) box to see if it would be in there to give, then call the pharmacy to see what the issue was. LPN #3 revealed after checking with the Pharmacy she was informed the last time [MEDICATION NAME] was delivered was on [DATE]. 9. Record review revealed the facility admitted Resident #3 on [DATE] with a [DIAGNOSES REDACTED]. However, review of the [DATE] MAR revealed this medication was initialed and circled from [DATE] through [DATE] (seven (7) doses) which indicated the medication was not given and no documentation on the back of the MAR to indicate why it was not given and if the pharmacy had been notified. 10. Record review revealed the facility admitted Resident #2, on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #2's cognition as cognitively intact with a BIMS score of fifteen (15) indicating the resident was interviewable. Review of the Physician's Order, dated [DATE], revealed an order for [REDACTED]. However, a review of the [DATE] Medication Administration Record (MAR) revealed the medication was not initialed/documented as given on [DATE] through [DATE] and there was no documentation indicating the pharmacy was notified. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:15 AM, verified the medication was not available for administration and that it was not available for administration the last time she passed medications a few days ago. Interview with Resident #2, on [DATE] at 4:00 PM, revealed he/she had not received the medication. 11. Record review revealed the facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. However, review of the [DATE] Treatment Administration Record (TAR) revealed no documented evidence the treatments were performed on the 6a-6p shift on [DATE] through [DATE]. Interview with LPN #1, on [DATE] at 3:25 PM, revealed the order for the cleansing of the wound drainage site was not on the original TAR and she did not do it. He/she reported that the TAR was corrected the following Monday morning ([DATE]). Post Survey interview conducted on [DATE] at 3:35 PM with LPN #4 revealed nurses should follow the six (6) rights of medication administration related to right resident, right medication, right time, right dose, right route, and right to receive. The LPN stated when they identify a medication is getting low they have to peel off the sticker from the label and send it to the pharmacy. The LPN revealed the medication should come in that night's tote unless there were insurance or prescription issues and then the pharmacy would fax a paper stating the medication could not be delivered. The LPN stated if a medication was not available for administration the pharmacy would be called and the Unit Manager would be notified. She stated she would document by initialing the MAR and circling her initials and write the reason not given on the back of the MAR. The LPN stated the way she would find out if a medication was in the EDK box was by getting the list of medications that was in the box and see if it was on the list. Post Survey interview conducted on [DATE] at 3:45 PM with LPN #3 revealed nurses should follow the eight (8) rights of medication administration related to right resident, right medication, right time, right dose, right route, right documentation, right to refuse and right to receive. The LPN stated when they identify a medication is getting low, they remove the sticker on the box and place it on a fax sheet and fax to the pharmacy. The LPN revealed if a medication was not available to administer the pharmacy would be called and the Physician would be notified. She stated she would go on the computer and document in the Nurse's Notes which medication were not given and would initial and circle her initials on the MAR. The LPN stated she would look at the list kept in the EDK box to identify if a medication was in the box. Interview with the DON, on [DATE] at 1:10 PM, revealed if medications were not available for administration for a resident, the pharmacy should be called. She stated medications could be ordered STAT and the pharmacy could send them from the back up pharmacy as needed. The DON further reported that if a medication or treatment wasn't documented, it wasn't done. A Post Survey interview with the DON, on [DATE] at 9:20 AM, revealed the nurses should have initialed and circled the box on the MAR if the medication was not available for administration and should have documented on the back of the MAR why the medication was not given. In addition, she stated the nurses should have notified the pharmacy the medication was not available for administration and documented the pharmacy was notified on the back of the MAR. The DON stated some of the residents' medications were not available due to the physician's Medicaid number not being renewed but others were because the nurses had failed to order the medication. Interview with the Administrator, on [DATE] at 3:20 PM, revealed the facility had been having a problem with some of the resident's medications not being delivered from the pharmacy due to a Physician needing to update his provider number. She stated the protocol was for the pharmacy to continue to send the medications until the problem was resolved and the facility was currently working with the pharmacy on that. However, when staff was unable to carry out a physician's order, he/she would have expected the staff to report to the nurse in charge, and stated staff should have called the pharmacy and checked the EDK box to ensure medications were available for administration. A Post Survey interview with the Administrator, on [DATE] at 9:45 AM, revealed the staff should have documented on the MAR why a medication was not given and if the medication was not available for administration the staff should have documented this on the back of the MAR and also documented that pharmacy was made aware. *The facility implemented the following actions to remove the Immediate Jeopardy: On [DATE], the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's Order for Residents #3, #10, #11, #12, #13, #14, #15, #16 and #17. On [DATE], the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician Orders for the previous thirty (30) days to assure all orders were correct on the MAR. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On [DATE], the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On [DATE], the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after [DATE] without having had this re-education and competency test. On [DATE], two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of [DATE], the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on [DATE] to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On [DATE] at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to ,[DATE] days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On [DATE] at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on [DATE] regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation rega

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to provide pharmaceutical services to meet the needs of one (1) of seven (7) sampled residents (Resident #15); and, for one (1) unsampled resident (Resident F) related to the unavailability of medications for administration. Resident #15 was not administered two (2) doses of Lyrica (medication for nerve pain) and one (1) dose of Klonopin (medication for anxiety); and Unsampled Resident F had a physician's orders [REDACTED]. The findings include: Review of a facility protocol titled, "Medication Availability Protocol" not dated, revealed the physician's orders [REDACTED]. If at any time staff was unable to follow the physician's orders [REDACTED]. Further review revealed the policy for maintaining medications included obtaining the medication from the Emergency Drug Kit (EDK) or notifying the after-hours pharmacy and request for medications to be sent stat (immediately). Additionally, the protocol stated any missed dose of medication excluding refusals required an incident report for a medication error and the physician, family, and Director of Nursing (DON) should be notified. 1. Record review revealed the facility readmitted Resident #15 on 08/14/14 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. However, review of the August 2014 Medication Administration Record (MAR), revealed Lyrica 50 mg was not administered on 08/14/14 at 9:00 PM and on 08/15/14 at 9:00 AM; and, Klonopin 0.5 mg was not administered on 08/14/14 at 9:00 PM. Review of the Medication Notes, dated 08/14/14 at 9:00 PM, revealed Lyrica 50 mg, and Klonopin 0.5 mg were unavailable, and the pharmacy and physician were notified. On 08/15/14 at 9:00 AM, it was documented Lyrica 50 mg was unavailable; however, there was no documentation that the physician or the pharmacy was notified per the facility's policy and procedures. Interview with the Director of Nursing, on 09/06/14 at 11:15 AM and at 4:15 PM, revealed Resident #15 had returned from a psychiatric hospitalization with new admission orders [REDACTED]. She further stated she was notified of the unavailable medications however, there was no documentation the staff followed protocol to obtain the unavailable medications. Interview with the Pharmacy Registered Nurse/Account Executive, on 09/06/14 at 2:55 PM, revealed the pharmacy could not fill an order for [REDACTED]. 2. Record review revealed the facility admitted Unsampled Resident F on 08/12/14. Review of the Admission physician's orders [REDACTED]. Observation during a MAR to medication cart audit, on 09/05/14 at 5:00 PM, revealed Unsampled Resident F's September 2014 MAR revealed an order for [REDACTED]. Further observation of the medication cart revealed the Norco was not available on the medication cart. Interview with the Pharmacy Registered Nurse/Account Executive, on 09/06/14 at 2:55 PM, revealed the pharmacy had received the new admission orders [REDACTED]. Further interview revealed the pharmacy faxed a request for the signed copy of the medication order on 08/12/14; however, they never received a response from the facility and therefore did not dispense the medication. Further interview revealed he was not aware of any system in place to follow up on the faxed request sent to the facility. Interview with the DON, on 09/06/14 at 4:15 PM, revealed she was not aware of the issue of not having the medication available. Interview with the Administrator, on 09/06/14 at 4:30 PM, revealed there were audits being performed by the pharmacy to ensure the medications were available for each resident according to their physician's orders [REDACTED]. He further stated, in addition to the pharmacy audits, audits were being performed by the Nursing Department to ensure accuracy of the MAR and physician's orders [REDACTED].

Based on interview, record review, and review of the facility's Quality Assurance Policy, it was determined the Quality Assessment and Assurance Committee failed to identify, develop and implement appropriate plans of action to correct quality deficiencies related to pharmacy services. The facility failed to ensure medications were available to be administered, per physician's orders [REDACTED].#3, #10, #11, #12, #13, #14, #15 and #17) . Resident #10 did not receive a dose of Potassium on [DATE] as ordered by the physician and did not receive the Potassium until [DATE]. Resident #11 did not receive a "stat" dose of Solu-Medro (steroid) intramuscular (IM), [MEDICATION NAME] (antibiotic) Intravenous (IV) and [MEDICATION NAME] ordered on [DATE], until [DATE]. Resident #12, who had a [MEDICAL CONDITION] disorder did not receive six (6) doses of [MEDICATION NAME] [MEDICATION]) and experienced [MEDICAL CONDITION] activity requiring hospitalization . The order was changed on [DATE], from 500 mg to 1000 mg twice a day, the resident received only 500 mg for a total of thirty five (35) incorrect doses. Resident #14 did not receive a total of fourteen (14) doses of [MEDICATION NAME] 5000 Units from [DATE] through [DATE] (for seven days). Resident #15 who had chronic pain, did not receive his/her [MEDICATION NAME]es as prescribed, on [DATE], [DATE], and [DATE]. Resident #3 did not receive seven (7) doses of [MEDICATION NAME] (blood pressure medication). Resident #13 did not receive [MEDICATION NAME] (anti-anxiety medication) for a total of six (6) doses. In addition, Licensed Practical Nurse (LPN) #1 was observed to draw up seven (7) units of [MEDICATION NAME] regular insulin instead of the five (5) units as per the physician's orders [REDACTED].#17. The Administrator become aware beginning on [DATE] that there was a problem with residents receiving medications as prescribed, as the medications were not available and/or not administered as ordered. Even though the facility was aware of these concerns there was no documented evidence the facility's Quality Assurance Committee identified and addressed these concerns to correct this quality deficiency to ensure medications were available. Refer to F333. The QAA committee's failure to identify, develop and implement appropriate plans of action to correct deficiencies related to pharmacy services and medication errors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy and SQC was identified at 483.25 Quality of Care on [DATE] and determined to exist on [DATE]. The findings include: Review of the undated Quality Assurance Policy revealed the purpose was to ensure an Interdisciplinary approach to all residents' needs and to provide the highest level of care possible all the while keeping the IDT, physician and responsible party informed of their condition changes and interventions implemented as they occur and when necessary. The Interdisciplinary Team will meet at least weekly and consist of at minimum the Administrator, Director of Nursing or Nursing Representative, Social Services, Therapy, Dietary and Activities. Resident #10 did not receive a dose of Potassium on [DATE] as ordered by the physician and did not receive the Potassium until [DATE]. Resident #11 did not receive Solu-Medro (steroid) intramuscular (IM), [MEDICATION NAME] (antibiotic) Intravenous (IV) and [MEDICATION NAME] until [DATE], although the order was received as a "stat" order on [DATE]. Resident #12, who had a [MEDICAL CONDITION] disorder and was being treated with [MEDICATION NAME] [MEDICATION]) did not receive six (6) doses and experienced [MEDICAL CONDITION] activity requiring hospitalization . Additionally, after returning to the facility on [DATE], with a physician's orders [REDACTED]. Resident #14 did not receive a total of fourteen (14) doses of [MEDICATION NAME] 5000 Units from [DATE] through [DATE] (for seven days). Resident #15 who had a [DIAGNOSES REDACTED]. Resident #3 did not receive seven (7) doses of [MEDICATION NAME] (blood pressure medication). Resident #13 did not receive [MEDICATION NAME] (anti-anxiety medication) for a total of six (6) doses. Additionally, during a medication pass observation, Licensed Practical Nurse (LPN) #1 was observed to draw up seven (7) units of [MEDICATION NAME] regular insulin instead of the five (5) units as per the physician's orders [REDACTED].#17. The LPN was about to administer the seven units of insulin but another LPN (#6) who was shadowing LPN #1 pointed out the resident should only receive five (5) units. (Refer to F333). An interview, on [DATE] at 5:30 PM, with LPN #4, revealed she circled initials on medications that were unavailable for administration on the MAR and medications had not been arriving from the Pharmacy on a larger scale than normal most of [DATE]. Interview with LPN #3, on [DATE] at 3:00 PM, revealed medications had not been available on various occasions and nurses had to call the Pharmacy and ask why. She stated "At least daily, there is a medication that is not covered". She additionally stated the Pharmacy will not send a medication if it is not covered and residents go a day or two without. Interview, on [DATE] at 11:15 AM, with Licensed Practical Nurse (LPN) #1 revealed medications for Resident #14 were not available at this time and stated the medications were not available the last time she administered medications on this hall. She was not aware Resident #14 had not received a prescribed medication in the past few days until this date ([DATE]). She stated the Pharmacy had informed her the Physician's Medicaid "something" had expired and that was why the Pharmacy did not send the medication. She also stated, "I'm not sure why they are not filling that medication ([MEDICATION NAME])" but they fill the other medications. An interview with the Advanced Practice Registered Nurse (APRN), on [DATE] at 1:30 PM, revealed she was only aware of Resident #14 not receiving medications as ordered due to the Pharmacy not delivering them and said there was a problem with Medicaid and she had been "kicked out of the system as well as the Physician". Interview with the Administrator, on [DATE] at 4:10 PM, revealed problems with medications being unavailable for administration was an issue related to one of the facility's Physician's need to update his/her provider number for Medicaid as it was not showing active in the system. The Administrator stated the latter part of the previous week (week of [DATE]) the facility was made aware and implemented weekly Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviews. She further stated there was no policy to address reviewing the MARs or TARs. A QA meeting was not held until [DATE]. Post Survey interviews with the Administrator, on [DATE] at 9:45 AM, 2:55 PM and 5:00 PM, revealed the MAR and TAR reviews were implemented on [DATE] but there was nothing put in place to ensure the MAR and TAR reviews were being conducted to ensure the facility would identify when medications were not available for administration and administered per physician's orders [REDACTED]. She stated at first they thought the medication problem was only related to new admissions and readmissions, then they thought it was due to lack of documentation and then the physician's Medicaid provider number issue was identified. She revealed they took steps to address each of these concerns as identified. She was unable to provide an explanation as to why medications were still unavailable for administration after the issues were identified. *The facility implemented the following actions to remove the Immediate Jeopardy: On [DATE], the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's orders [REDACTED].#10, #11, #12, #13, #14, #15, #16 and #17. On [DATE], the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician order [REDACTED]. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On [DATE], the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On [DATE], the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after [DATE] without having had this re-education and competency test. On [DATE], two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of [DATE], the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on [DATE] to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On [DATE] at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to ,[DATE] days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On [DATE] at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on [DATE] regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On [DATE] at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On [DATE] at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On [DATE] at 11 :46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On [DATE] at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On [DATE] at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On [DATE] at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On [DATE] at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On [DATE] at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On [DATE] at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On [DATE] at 2:40 PM, the DON verified through interview that she began education with licensed staff on [DATE] regarding medication administration and availability. The staff was required to complete a post test. On [DATE] at 2:50 PM, RN #3 verified through interview that he/she had received recent training on medication availability and administration. Reports that medication availability was covered to include checking the EDK box, calling the pharmacy and if unable to obtain the medication in a timely manner, the physician should be notified. RN #3 stated that medication availability was 100% better. If a medication supply is getting low, the sticker should be pulled and faxed to pharmacy. Medications were usually reordered when a three (3) day supply is left. Staff is to notify the physician if there are problems obtaining a medication or if the resident refuses a medication. RN #3 also verified the receipt of education regarding care plans. Staff should always follow the care plan and if unable should notify the physician as well as the DON. Care plans were updated by a RN; and, SRNA's care plans were updated by the RN or the DON. SRNAs use the Accunurse system to access information regarding a resident's plan of care. If a SRNA is unable to follow the care plan for a resident, the Charge Nurse or administration should be notified. On [DATE] at 3:08 PM, LPN #5 verified through interview that he/she had received recent education on medication availability and administration. A post test was completed after receiving inservice training. If a medication is not available, the EDK box should be checked and if the medication is not available there, the pharmacy should be called to get the medication STAT and the physician should be called for additional orders. Reordering resident medications should be done when there is a three (3) day supply of the medication left. The sticker should be pulled, placed on the reorder form and faxed to the pharmacy. LPN #5 revealed that medication availability has improved. The LPN verified that he/she has received recent education regarding care plans. If staff is unable to follow the plan of care for a resident, the Charge Nurse should be notified and will alert the DON and the physician. The computer or the Accunurse system can be utilized to view the resident's plan of care. On [DATE] at 3:34 PM, the pharmacy representative verified through interview that he and Certified Pharmacy Technicians completed a MAR to medication cart audits for all residents on [DATE] and [DATE]. On [DATE] at 4:20 PM, an interview with the DON and the Administrator, revealed omissions on the [DATE] MAR for Resident #15 on [DATE] at 3:00 PM of a dose of [MEDICATION NAME] and a 2:00 PM dose of [MEDICATION NAME] indicated the medications were not administered by LPN #1. It was revealed that LPN #1 was terminated related to the medication errors. On [DATE] at 5:00 AM, a dose of [MEDICATION NAME] was not documented as given by RN #4 and disciplinary action was pending related to the omission on the MAR. On [DATE] at 4:52 PM, the DON and the Administrator were interviewed regarding omissions on the [DATE] MAR for Resident #18. Review of the [DATE] MAR revealed no documentation for a 7:00 AM dose of [MEDICATION NAME] on [DATE] and 5:00 PM doses of [MEDICATION NAME] on [DATE] and [DATE]. Interview on [DATE] at 5:15 PM with LPN #3 revealed that he/she had given the [MEDICATION NAME] to Resident #18 on [DATE] but failed to document it on the MAR. The LPN stated she had signed a disciplinary action five (5) minutes prior to the interview. Interview on [DATE] at 5:24 PM, with LPN #4 revealed that he/she had given the 5:00 PM [MEDICATION NAME] doses to Resident #18 on [DATE] and [DATE] but failed to document the administration on the MAR. Further interview revealed the LPN received disciplinary action thirty (30) minutes prior to the interview. Interview with the DON on [DATE] at 5:48 PM, revealed that training and education were provided to staff as a part of a disciplinary action. Interview with the Administrator, on [DATE] at 5:50 PM, revealed that an additional, 3rd, MAR check was added on [DATE] to include staff at shift change checking MARs for omissions. Interview with the Administrator, on [DATE] at 9:15 AM, revealed that an additional, 3rd MAR check was initiated on [DATE]. The Medical Director was notified and participated in a QA meeting/conference call regarding the plan. Interview with the Administrator, on [DATE] at 10:28 AM, revealed that LPN #4 had not worked and had been out of town and that disciplinary action was provided upon the first day of her return to work. Interview with the Administrator, DON and Regional RN, on [DATE] at 10:50 AM, revealed the medications for Resident #18 were available on the cart for administration. Staff interviews reveal that the medications were administered and available on [DATE], [DATE] and [DATE] and disciplinary action was administered according to the AOC. The number of pills available on the medication cart on [DATE] appeared to be adequate based on the date of delivery.

Based on interview, record review and review of the facility's Quality Assurance Policy, it was determined the facility failed to monitor its plans of action to correct identified quality deficiencies. The facility failed to identify, during their audits, that medications were not available for one (1) of seven sampled residents (Resident #15) and for one (1) unsampled resident (Resident F). The findings include: Review of the facility's policy and procedure titled, "Quality Assurance Policy", last revised 01/11, revealed the Administrator's purpose was to ensure an interdisciplinary approach to all residents' needs and to provide the highest level of care possible all the while keeping the Interdisciplinary Team (IDT), physician and responsible party informed of their condition changes and interventions implemented as they occur and when necessary. The Interdisciplinary Team will meet at least weekly and consist of at minimum the Administrator, Director of Nursing or Nursing Representative, Social Services, Therapy, Dietary and Activities. Review of the facility's Plan of Correction for the survey dated 06/13/14 with an alleged compliance date of 07/11/14, revealed medication administration observations would be conducted three (3) times per week to assure medications were administered correctly were available. The results of these audits would be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review at least monthly for three (3) months. In addition, the Plan of Correction stated the Pharmacy would audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two (2) weeks for eight (8) weeks beginning on 06/09/14. Further review revealed the DON, ADON, Minimum Data Set (MDS) Nurse or the Unit Managers will complete an audit of all MARs to ensure professional standards of practice for clinical record documentation were followed five (5) times per week for twelve (12) weeks. The results of the audits would be forwarded to the facility QAPI committee for review. 1. Record review revealed Resident #15 did not receive two (2) doses of [MEDICATION NAME] (nerve medication) on 08/14/14 and 08/15/14 and one (1) dose of Klonopin (nerve medication) on 08/14/14 as ordered by the physician due to the failure of the facility to send the appropriate documentation to the pharmacy to ensure medication was available for administration. 2. Record review revealed Usampled Resident F had a physician's orders [REDACTED]. However, the facility failed to send the appropriate documentation to the pharmacy to ensure the medication was available for administration. Interview with the Director of Nursing (DON), on 09/06/14 at 4:15 PM, revealed the audits were completed by the pharmacy to compare the MAR indicated [REDACTED]. In addition she stated that she and other staff completed the audits of medication administration observations to ensure medications were administered correctly and ordered medications were available which was done three (3) times per week; however, they failed to identify the medication was not available. Interview with the Administrator, on 09/06/14 at 4:30 PM, revealed the audits were in place and the facility should have identified the errors.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to maintain clinical records that were complete and accurately documented for ten (10) of seventeen sampled residents (Residents #1, #2, #3, #10, #11, #12, #13, #14, #15, #16) and one (1) unsampled resident (Resident A), related to incomplete documentation of medication administration, treatments, and services provided. The facility failed to document in the clinical record when medications were not given, why and if the pharmacy was notified for Resident #2, #3, #10 #11, #12, #13, #14, #15, #16 and Resident A. The facility's failure to maintain clinical record that were complete and accurately documented caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on 06/02/14 and determined to exist on 05/05/14. The facility was notified of the Immediate Jeopardy on 06/02/14. The findings include: Review of the facility's policy and procedure titled, "Medication Shortages/Unavailable Medications" last revised 01/01/13, revealed actions to take upon discovery that the facility has an inadequate supply of medication to administer to a resident included staff taking immediate action to obtain the medication. When a missed dose is unavoidable, the nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and in the Nurse's Notes, per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy's response upon notification and the action(s) taken. 1. Record review revealed the facility admitted Resident #10 on 05/16/14 with [DIAGNOSES REDACTED]. On 05/29/14 at 9:40 AM, Licensed Practical Nurse (LPN) #3 received an order from the physician to medicate the resident with Potassium 40 meq now. Interview with LPN #3 on 05/31/14 at 3:00 PM, revealed that she forgot to put the medication order on the MAR and did not administer the Potassium as ordered. The missed Potassium dose was administered on 05/30/14 at 9:00 AM by LPN #4 after the ADON clarified the order. A repeat Potassium level was obtained on 05/30/14 at 1:45 PM and the result was 2.4 mmol/L. The result was phoned to the Physician's Assistant at 6:09 PM by the lab staff. An order was received at 8:30 PM to send the resident to the emergency room for evaluation. The resident was evaluated in the Emergency Department on 05/30/14 at 8:59 PM and subsequently admitted into the hospital with a [DIAGNOSES REDACTED]. The facility failed to ensure the clinical record was complete as the order for the resident's Potassium was not documented on the MAR. Interview conducted with LPN #3, on 05/31/14 at 3:00 PM, revealed on 05/29/14, she forgot to document the medication order on Resident #10's MAR and did not administer the Potassium as ordered. 2. Record review revealed the facility admitted Resident #1 on 02/13/14 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident with a Brief Interview for Mental Status (BIMS) of fifteen (15) indicating the resident was interviewable. The Comprehensive Care Plan was not revised to include the transfer needs of the resident. The resident was transferred using a mechanical lift on 03/30/14 by one (1) staff member and received an injury resulting in a fractured right tibia and fibula. The resident was not care planned for the use of a mechanical lift during transfers. The facility failed to document the incident on 03/30/14, or the subsequent event details in the medical record. 3. Record review revealed the facility admitted Resident #2 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], revealed the resident to have a BIMS score of fifteen (15). On 05/16/14, the Advanced Practice Registered Nurse (APRN) ordered [MEDICATION NAME] 100 mg by mouth every day for five (5) days for a yeast rash. The shipment detail from the pharmacy revealed the medication was delivered on 05/19/14 at 11:57 PM. An interview with the resident revealed she did not receive the medication. Review of the May 2014 MAR revealed the [MEDICATION NAME] was to be administered at 7:00 AM on 05/17/14 through 05/22/14. Further review of the MAR revealed initials with circles on those dates indicating the medication was not given. The facility failed to ensure the medical record was complete and accurate as there was no documentation on the back of the MAR to indicate the reason the medication was not administered, that pharmacy was notification and their response, as per the policy. 4. Record review revealed the facility admitted Resident #3 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the MAR revealed the resident did not receive [MEDICATION NAME] (blood pressure medication) 10 mg daily from 05/23/14 through 05/29/14. The facility failed to ensure the medical record was complete and accurate as there was no documented evidence in the medical record stating the medication was not administered or why it wasn't given. 5. Record review revealed the facility admitted Resident #11 on 07/01/12 with [DIAGNOSES REDACTED]. On 05/21/14 at 10:57 PM, LPN #5 assessed the resident and noted the resident was experiencing labored breathing. The APRN was notified on 05/21/14 at 11:30 PM and orders received to medicate the resident with Solu-[MEDICATION NAME] 40 mg intramuscularly (IM), [MEDICATION NAME] 500 mg IV every 24 hours, [MEDICATION NAME] 40 mg by mouth times two (2) doses, [MEDICATION NAME] every 4 hours, check vital signs every 4 hours, a chest radiograph (x-ray) and a complete blood count (CBC) stat. The resident received the Solu-[MEDICATION NAME] 40 mg IM on 05/22/14 at 5:49 PM (the next day) after taken from the emergency drug kit (EDK) by LPN #1. The facility failed to ensure the medical record was complete and accurate as they failed to document on the resident's MAR that the medications were not given. LPN #5 failed to document on the back of the resident's MAR, as per the policy, the reason the medications were not administered and response of the pharmacy when notified. 6. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the hospital on [DATE] at 11:45 AM, after experiencing [MEDICAL CONDITION] activity. On 05/05/14 Resident #12 returned to the facility with a continued order for [MEDICATION NAME] (anti-convulsant) 500 mg twice daily. Review of the May 2014 MAR revealed no documented evidence the medication was administered or not administered from the time of readmission on 05/05/14 until 05/08/14 (six doses). 7. Record review revealed the facility admitted Resident #13 on 07/01/14 with [DIAGNOSES REDACTED]. The Annual MDS assessment dated [DATE], revealed the resident to have a BIMS score of six (6). The Comprehensive Care Plan, May 2014, related to impulse control lists as an intervention to give medications as ordered. On 05/24/14 an order was received from the APRN for [MEDICATION NAME] 5 mg per PEG tube twice daily routine. The medication was unavailable for administration until 05/27/14 at 9:00 PM. There was no evidence the facility policy was followed related to documenting why a medication was not administered. 8. Record review revealed the facility admitted Resident #14 on 10/11/13, with [DIAGNOSES REDACTED]. Review of the May 2014 MAR revealed the resident did not receive a total of fourteen (14) doses of [MEDICATION NAME] 5000 units on 05/19/14, 05/21/14, 05/22/14 and 05/28/14. The medication was ordered to be taken at meals and before bedtime. An interview with the resident on 05/28/14 at 2:25 PM revealed he/she has been missing the medication but doesn't understand why as he/she has been on it for years. Review of the MAR revealed no documented evidence why the medication was not given, as ordered on [DATE], 05/23/14 and 05/28/14 or if pharmacy was notified or their response, as per the facility policy. 9. Record review revealed the facility admitted Resident #15 on 07/03/12, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, revealed no care plan for chronic pain. A review of the May 2014 Physician orders [REDACTED]. A review of the May 2014 MAR revealed the resident did not receive his/her [MEDICATION NAME] on 05/5/14, 05/14/14 and 05/26/14. The facility failed to ensure the medical record was complete and accurate as there was no documentation on the back of the MAR to indicate why the medication was not given, if the pharmacy had been notified and their response. 10. Record review revealed the facility admitted Resident #16 on 09/19/13, with [DIAGNOSES REDACTED]. Review of May 2014 physician's orders [REDACTED]./14) and [MEDICATION NAME] 10-325 mg every eight (8) hours routine. Review of the May 2014 MAR revealed there was no documentation the medications were given or not give on the MAR for these medications on these dates: [MEDICATION NAME] 30 mg on 05/18/14, 05/25/14 and 05/31/14; [MEDICATION NAME] 50 mg on 05/14/14 and 05/26/14; Aspirin 81 mg on 05/11/14 and 05/20/14; [MEDICATION NAME] 400 mg on 05/17/14, 05/20/14 and 05/31/14; K-Dur 40 meq on 05/01/14, 05/06/14, 05/08/14, 05/09/14, 05/13/14, 05/19/14, 05/20/14, 05/27/14 and 05/31/14; [MEDICATION NAME] 300 mg on 05/02/14 and 05/08/14; [MEDICATION NAME] on 05/20/14; and, [MEDICATION NAME] on 05/18/14, 05/20/14 and 05/31/14. 11. Observation during a medication pass, on 05/29/14 at 9:20 AM, revealed Resident A did not receive [MEDICATION NAME] 10 mg as ordered, as it was not available. Review of the May 2014 MAR revealed the resident did not receive [MEDICATION NAME] 10 mg on 05/15/14, 05/16/14, 05/19/14, 05/23/14, 05/24/14, 05/25/14, 05/26/14, 05/27/14, 05/28/14, and 05/29/14 (total of ten doses). There was no documentation on the back of the MAR to indicate the rationale for the medication not being administered. Additionally, Resident #18 did not receive Pantoprazole 20 mg eleven (11) times according to the May 2014 MAR. The MAR revealed initials circled indicating not received on 05/12/14, 05/13/14, 05/15/14, 05/16/14, 05/19/14, 05/23/14, 05/24/14, 05/25/14, 05/26/14, 05/27/14, and 05/28/14. The back of the MAR revealed six (6) days documentation for Pantoprazole unavailable on May 13th, 23rd, 24th, 25th, 26th, and 27th. The five (5) remaining missed doses had no documentation to indicate the reason the medication was not administered. Interview with the Assistant Director of Nurses (ADON), on 05/30/14 at 10:15 AM, revealed if a medication was not administered, a circled initial was to be placed on the MAR indicating it was not given and the reason also documented. Interview with the Director of Nursing (DON) and the Administrator, on 05/29/14 at 1:10 PM, revealed if medications were not available for administration for a resident, the pharmacy should be called. The nurse should circle the initial and document on the back of the MAR or Nurse's Notes the reason why the medication was not given and would not be accurate if not correctly documented. *The facility implemented the following actions to remove the Immediate Jeopardy: On 06/04/14, the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's orders [REDACTED].#10, #11, #12, #13, #14, #15, #16 and #17. On 05/31/14, the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician order [REDACTED]. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On 06/01/14, the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On 06/01/14, the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after 06/04/14 without having had this re-education and competency test. On 06/02/14, two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of 06/09/14, the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on 06/03/14 to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On 06/12/14 at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to 3-5 days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On 06/12/14 at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on 06/12/14 regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On 06/12/14 at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On 06/12/14 at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On 06/12/14 at 11:46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On 06/12/14 at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On 06/12/14 at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On 06/12/14 at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On 06/12/14 at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On 06/12/14 at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On 06/12/14 at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On 06/12/14 at 2:40 PM, the DON verified through interview that she began education with licensed staff on 06/01/14 regarding medication administration and availability. The staff was required to complete a post test. On 06/12/14 at 2:50 PM, RN #3 verified through interview that he/she had received recent training on medication availability and administration. Reports that medication availability was covered to include checking the EDK box, calling the pharmacy and if unable to obtain the medication in a timely manner, the physician should be notified. RN #3 stated that medication availability was 100% better. If a medication supply is getting low, the sticker should be pulled and faxed to pharmacy. Medications were usually reordered when a three (3) day supply is left. Staff is to notify the physician if there are problems obtaining a medication or if the resident refuses a medication. RN #3 also verified the receipt of education regarding care plans. Staff should always follow the care plan and if unable should notify the physician as well as the DON. Care plans were updated by a RN; and, SRNA's care plans were updated by the RN or the DON. SRNAs use the Accunurse system to access information regarding a resident's plan of care. If a SRNA is unable to follow the care plan for a resident, the Charge Nurse or administration should be notified. On 06/12/14 at 3:08 PM, LPN #5 verified through interview that he/she had received recent education on medication availability and administration. A post test was completed after receiving inservice training. If a medication is not available, the EDK box should be checked and if the medication is not available there, the pharmacy should be called to get the medication STAT and the physician should be called for additional orders. Reordering resident medications should be done when there is a three (3) day supply of the medication left. The sticker should be pulled, placed on the reorder form and faxed to the pharmacy. LPN #5 revealed that medication availability has improved. The LPN verified that he/she has received recent education regarding care plans. If staff is unable to follow the plan of care for a resident, the Charge Nurse should be notified and will alert the DON and the physician. The computer or the Accunurse system can be utilized to view the resident's plan of care. On 06/12/14 at 3:34 PM, the pharmacy representative verified through interview that he and Certified Pharmacy Technicians completed a MAR to medication cart audits for all residents on 06/02/14 and 06/09/14. On 06/12/14 at 4:20 PM, an interview with the DON and the Administrator, revealed omissions on the June 2014 MAR for Resident #15 on 06/05/14 at 3:00 PM of a dose of [MEDICATION NAME] and a 2:00 PM dose of [MEDICATION NAME] indicated the medications were not administered by LPN #1. It was revealed that LPN #1 was terminated related to the medication errors. On 06/11/14 at 5:00 AM, a dose of [MEDICATION NAME] was not documented as given by RN #4 and disciplinary action was pending related to the omission on the MAR. On 06/12/14 at 4:52 PM, the DON and the Administrator were interviewed regarding omissions on the June 2014 MAR for Resident #18. Review of the June 2014 MAR revealed no documentation for a 7:00 AM dose of [MEDICATION NAME] on 06/09/14 and 5:00 PM doses of [MEDICATION NAME] on 06/07/14 and 06/08/14. Interview on 06/12/14 at 5:15 PM with LPN #3 revealed that he/she had given the [MEDICATION NAME] to Resident #18 on 06/09/14 but failed to document it on the MAR. The LPN stated she had signed a disciplinary action five (5) minutes prior to the interview. Interview on 06/12/14 at 5:24 PM with LPN #4 revealed that he/she had given the 5:00 PM [MEDICATION NAME] doses to Resident #18 on 06/07/14 and 06/08/14 but failed to document the administration on the MAR. Further interview revealed the LPN received disciplinary action thirty (30) minutes prior to the interview. Interview with the DON on 06/12/14 at 5:48 PM, revealed that training and education were provided to staff as a part of a disciplinary action. Interview with the Administrator, on 06/12/14 at 5:50 PM, revealed that an additional, 3rd MAR check was added on 06/12/14 to include staff at shift change checking MARs for omissions. Interview with the Administrator, on 06/13/14 at 9:15 AM, revealed that an additional, 3rd MAR check was initiated on 06/12/14. The Medical Director was notified and participated in a QA meeting/conference call regarding the plan. Interview with the Administrator, on 06/13/14 at 10:28 AM, revealed that LPN #4 had not worked and had been out of town and that disciplinary action was provided upon the first day of her return to work. Interview with the Administrator, DON and Regional RN, on 06/13/14 at 10:50 AM, revealed the medications for Resident #18 were available on the cart for administration. Staff interviews reveal that the medications were administered and available on 06/07/14, 06/08/14 and 06/09/14 and disciplinary action was administered according to the AOC. The number of pills available on the medication cart on 06/13/14 appeared to be adequate based on the date of delivery.

Based on interview, record review, review of the Administrator Position Description, and review of the facility's policy/procedure, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being for residents residing in the facility. The facility failed to provide pharmaceutical services which ensured the availability and timely administration of drugs and biologicals to meet the needs of each resident that included some issues with the Physician's Medicaid provider number for billing and some administration errors. The facility failed to have an effective system in place to ensure medications were available and/or administered according to physician orders. The facility's census on 05/21/14 was forty one (41) residents, and nine (9) of those residents were affected by medications not administered and/or available to meet their needs. The facility's failure to ensure the facility was administered in a manner that enabled it to provide pharmalogical services to ensure medications were available for administration caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on 06/02/14 and determined to exist on 05/05/14. The facility was notified of the Immediate Jeopardy on 06/02/14. The findings include: Review of the Position Description for Administrator (no date) revealed the purpose was to direct the day to day functions of the facility in accordance with current Federal, State and Local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. Essential Functions of the Position included: Ensure excellent care for residents is maintained by overseeing and monitoring patient care services delivered. Review of the facility's policy and procedure titled, "Medication Shortages/Unavailable Medications", last revised 01/01/13, revealed actions to take upon discovery that the facility has an inadequate supply of a medication to administer to a resident included staff taking immediate action to obtain the medication. "When a missed dose is unavoidable, the nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and in the Nurse's Notes, per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy's response upon notification and the actions(s) taken." Record review revealed Resident #13 was to receive [MEDICATION NAME] (anti-anxiety) five (5) mg twice daily. However, review of the May 2014 MAR revealed, on 05/24/14 at 9:00 PM through 05/27/14 at 9:00 AM (a total of six doses), staff had not initialed or circled the the medication was administered. Interview with the Administrator, on 05/30/14 at 4:00 PM, and 06/02/14 at 5:20 PM, revealed there was a problem with one of the Physicians needing to update his provider number for Medicaid because it was not showing up as active in the system. The protocol was for the pharmacy to continue to send the medications until the problem was resolved and she was currently working on the problem. She additionally revealed the Director of Nursing (DON) was responsible to ensure medications were administered as prescribed but she was ultimately responsible to monitor the DON for ensuring facility practice compliance. Further interview with the Administrator, during a Post Survey Interview, on 07/02/14 at 2:55 PM and 5:00 PM revealed she was made aware on 05/19/14, (the survey was initiated on 05/21/14, after the Administrator had been made aware of residents not receiving medications) some resident's were not receiving medications from the pharmacy because the physician's Medicaid provider number needed to be updated. She stated the pharmacy had been sending the faxes informing the facility of this to the nurse's station fax number and Administrative staff had not been made aware of the problem. She stated she contacted the pharmacy and was having the pharmacy send a three (3) day supply of medications and on 05/29/14 she changed it to a seven (7) day supply of medication. She stated on 05/16/14, the facility had initiated weekly MAR and TAR reviews due to identifying documentation problems on the MARs; however, there was nothing in place to monitor to ensure the MAR and TAR reviews were being conducted to identify if medications were available for administration or were being administered as ordered. The facility's failure to have an effective action in place after 05/16/14, (the Administrator was aware there was a problem on 05/16/14) to ensure medications were available for administration and administered as ordered caused the facility to continue to fail to ensure medications were available and administered as ordered, as noted above. Post Survey interviews with the Administrator, on 07/02/14 at 9:45 AM, 2:55 PM and 5:00 PM, revealed the MAR and TAR reviews were implemented on 05/16/14, but there was nothing put in place to ensure the MAR and TAR reviews were being conducted to ensure the facility would identify when medications were not available for administration and administered per physician's orders [REDACTED]. She stated at first they thought the medication problem was only related to new admissions and readmissions, then they thought it was due to lack of documentation and then the physician's Medicaid provider number issue was identified. She revealed they took steps to address each of these concerns as identified. The Administrator was unable to provide an explanation as to why medications were still unavailable for administration after the issues were identified. Post Survey Interview with the Director of Nursing, on 07/15/14 at 1:20 PM, revealed the MAR/TAR reviews were conducted on 05/22/14 and 05/23/14 due to the initiation of a complaint survey at the facility and those reviews were not documented. She stated a QA meeting was not conducted until 05/27/14 after the complaint survey was initiated. Post Survey interview with the Medical Director, conducted on 7/15/14 at 2:50 PM, revealed he could not say the exact date he was aware of there being a problem with his provider number which had not been updated in the Medicaid system. Although a review of a letter dated 06/02/14 from the facility's pharmacy provider, which was addressed to the facility, stated "unable to bill Medicaid for claims written by physician starting the beginning of May due to a license issue with Kentucky Medicaid." *The facility implemented the following actions to remove the Immediate Jeopardy: On 06/04/14, the physician was notified by the Director of Nursing (DON) of medications not administered according to physician's orders [REDACTED].#10, #11, #12, #13, #14, #15, #16 and #17. On 05/31/14, the DON and a consulting DON and the Regional Nurse Consultant (RNC) audited Physician order [REDACTED]. Any discrepancy was clarified with the physician and written correctly on the Physician Orders. On 06/01/14, the RNC re-educated the DON on "Medication Availability" protocol, which states the procedure to follow for physician notification when medications are not available to be administered as per the physicians order, and post test completed. On 06/01/14, the DON began education with Licensed Nurses on "Medication Availability" and post test titled "Medication Availability" which states the procedure to follow for physician notification when medications are not available to be administered per physician order. This training will be completed with all licensed nurses by the DON. The DON will educate and validate competency with the Assistant Director of Nursing (ADON), MDS Nurse or Unit Manager and the licensed nurses. No licensed nurse will work after 06/04/14 without having had this re-education and competency test. On 06/02/14, two representatives from the Pharmacy completed a Medication Administration Record (MAR) to medication cart audit for all current residents to ensure all medications were available for administration per physician order. Any medication identified as not available and not in the emergency drug kit was sent stat to the pharmacy for immediate delivery. Beginning the week of 06/09/14, the Pharmacy will audit all current residents' MARs and compare to the medication available in the medication cart for each resident one (1) time per week for four (4) weeks then every two weeks for eight (8) weeks to assure all medications are available. Any deficiency identified will be corrected immediately. The results of this audit will be forwarded to the facility's Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation weekly until the Jeopardy is removed and then monthly for at least three (3) months. If at any time concerns are identified, the QAPI Committee will convene to review and make further recommendations as needed. The QAPI Committee will consist of at a minimum; the Administrator, DON, ADON, Social Services Director, Dietary Services Manager and Business Office Manager with the Medical Director attending at least quarterly. An Ad-Hoc Quality Assurance meeting (QAPI) was held on 06/03/14 to review the alleged deficient practice and plan of removal with the Medical Director, Administrator, Director of Nursing, MDS Nurse, Social Service Director, Housekeeping Supervisor, Director of Rehabilitation, Dietary Manager, Maintenance Director, and Admissions Coordinator with no further recommendations made. The State Survey Agency validated the corrective actions taken by the facility as follows: On 06/12/14 at 10:40 AM, LPN #4 verified through interview he/she had received recent inservice training on medication availability. If a medication is not in the medication cart drawer, the emergency drug kit (EDK) should be checked to see if the medication is available there. If unavailable, the pharmacy should be called and the medication will be delivered anywhere from one-four hours for a "STAT" order. When there are new medication orders for a resident, the medications are entered in the computer and then a copy of the order is faxed to the pharmacy as well as a follow-up phone call to the pharmacy. If a medication is unavailable the physician is notified. Normal pharmacy delivery is made on the night shift. The MAR checks are done at the end of shift for the opposite hallway. The DON has also been completing MAR checks to make sure that medications are not missed. For medication STAT orders, staff are to look in the EDK, STAT from the pharmacy or if an urgent need the resident would be sent out to the hospital. The LPN stated medications have been available recently for administration. When a medication supply for a resident gets down to 3-5 days, the sticker is pulled and a fax is sent to the pharmacy. If there is an insurance issue, the pharmacy will send medication for the resident then will work to resolve the issue. LPN #4 verified he/she was provided recent education regarding Care Plans. If staff is unable to follow the resident's care plan, the physician should be notified as well as the DON. On 06/12/14 at 10:54 AM, RN #2 verified through interview he/she has been educated regarding medication administration and availability. If a medication is not available on the medication cart, the EDK should be checked, the pharmacy should be called and the physician notified of any issues. RN #2 revealed through interview he/she was still in orientation and was to receive education on 06/12/14 regarding medication orders for a newly admitted resident. She verified there was a list of medications available in the EDK box for staff reference. RN #2 verified through interview that he/she has received education while in orientation regarding Care Plans. A computer based education program was provided in reference to care plans and the Accunurse system. Further interview revealed care plans were changed by the RN for new orders or changes in care. The DON and Charge Nurse are notified of any changes in the care plan. RN #2 verified no problems with medication availability since he/she started working at the facility two (2) days ago. On 06/12/14 at 11:02 AM, LPN #9 (MDS Nurse) verified through interview that she had received inservice training regarding medication availability. If a medication is not available, the EDK should be checked and the pharmacy should be called. The physician should be notified if a medication cannot be given at the ordered time. She stated she was unaware of any recent issues with medication availability. The process to reorder medications is to pull the sticker and fax it to the pharmacy to get the medication delivered. An order has to be received at the pharmacy by 5:30 PM in order to receive the medication on the routine evening delivery. Medication orders for new residents should be faxed to the pharmacy to assure medication delivery. LPN #9 verified through interview he/she has received inservice training regarding care plans to include that care plans are to be followed and if the care plan cannot be followed the DON and the physician should be notified. It was reported that nurses update care plans and if a change is made with the MDS assessment, revisions are made at that time by the MDS nurse. On 06/12/14 at 11:15 AM, LPN #3 verified through interview that he/she had received recent education regarding medication availability and care plans. If there is a new resident admission, the pharmacy should be called to get the medications. The EDK should be checked to see if the medication is available in the box. If there is a problem getting a medication, the physician should be notified. LPN #3 denied any recent problems with medication availability. To reorder medications, the sticker should be pulled and faxed to the pharmacy. As a routine, staff should be checking to make sure that medications are available. LPN #3 reported that staff need to take the initiative to get medications before the resident runs out. The LPN stated the pharmacy is good about getting STAT medications to the facility. Staff should make sure that they notify the physician for any new orders or changes related to medications. LPN #3 verified that he/she has received education regarding care plans. He/she reports that staff need to go by the care plan and if something is unavailable, the Charge Nurse should be made aware. If there is an intervention on the care plan that cannot be followed, staff need to call the DON and the physician. LPN #3 revealed that care plan revisions were completed by the RN. On 06/12/14 at 11:46 AM, SRNA #2 verified through interview that he/she has received recent education regarding Care Plans. Staff are to access the Accunurse system to check care plans and any updates. He/she also reports the receipt of daily written care plans for the residents. If a problem with a care plan is identified or cannot be carried out, the SRNA would notify the charge nurse. The SRNA care plan is updated by the DON. On 06/12/14 at 12:00 PM, SRNA #3 verified through interview that he/she has received recent education regarding Care Plans. Inservice training was also provided regarding the Accunurse system and how to retrieve the plan of care for a resident. He/she revealed the Accunurse system alerts staff when a resident's plan of care has changed. The DON updates the care plan as needed. Staff was required to complete a quiz regarding education material. If staff is unable to follow a plan of care, the SRNA should notify the Charge Nurse. On 06/12/14 at 12:03 PM, SRNA #4 verified through interview that he/she has received recent education regarding Care Plans. If a care plan changes in the Accunurse system, staff will be alerted regarding the change. Staff also received a copy of the resident's plan of care. If the SRNA is unsure about the plan of care, he/she should notify the Charge Nurse. If the care plan cannot be followed, the SRNA should contact the Charge Nurse. SRNA was required to complete a post test on the covered inservice material. On 06/12/14 at 12:06 PM, SRNA #5 verified through interview that he/she had received recent education regarding care plans and completed a post test. Further interview revealed the education provided covered the Accunurse System and how to review the care plan. Staff were to notify the Charge Nurse if the plan of care could not be followed. Staff should follow the chain of command for reporting if the issue was not resolved. On 06/12/14 at 12:09 PM, SRNA #6 verified through interview that he/she had received recent education regarding care plans. Staff were to check the Accunurse system headset for any change in the plan of care for the resident. Staff are also alerted of changes to the plan of care through the headset. It is reported that staff also receive a written copy of the care plan. If staff is unable to provide resident care as outlined in the plan of care, the Charge Nurse should be notified. On 06/12/14 at 12:30 PM, SRNA #7 verified through interview that he/she had received recent education regarding care plans and the Accunurse system. Staff should use the Accunurse system to review required care needs for a resident. If there was a concern providing care for the resident, the Charge Nurse should be notified. Staff received a copy of interventions for each resident daily. A post test was completed. On 06/12/14 at 1:37 PM, SRNA #8 verified through interview that he/she received recent education regarding care plans. If staff is unable to follow the plan of care, the Charge Nurse should be notified immediately. Access to the resident's plan of care is through the Accunurse system and staff received printed information. The Accunurse system will alert staff to any changes in a resident's plan of care. SRNA #8 also verified that he/she completed a post test after inservice training. On 06/12/14 at 2:40 PM, the DON verified through interview that she began education with licensed staff on 06/01/14 regarding medication administration and availability. The staff was required to complete a post test. On 06/12/14 at 2:50 PM, RN #3 verified through interview that he/she had received recent training on medication availability and administration. Reports that medication availability was covered to include checking the EDK box, calling the pharmacy and if unable to obtain the medication in a timely manner, the physician should be notified. RN #3 stated that medication availability was 100% better. If a medication supply is getting low, the sticker should be pulled and faxed to pharmacy. Medications were usually reordered when a three (3) day supply is left. Staff is to notify the physician if there are problems obtaining a medication or if the resident refuses a medication. RN #3 also verified the receipt of education regarding care plans. Staff should always follow the care plan and if unable should notify the physician as well as the DON. Care plans were updated by a RN; and, SRNA's care plans were updated by the RN or the DON. SRNAs use the Accunurse system to access information regarding a resident's plan of care. If a SRNA is unable to follow the care plan for a resident, the Charge Nurse or administration should be notified. On 06/12/14 at 3:08 PM, LPN #5 verified through interview that he/she had received recent education on medication availability and administration. A post test was completed after receiving inservice training. If a medication is not available, the EDK box should be checked and if the medication is not available there, the pharmacy should be called to get the medication STAT and the physician should be called for additional orders. Reordering resident medications should be done when there is a three (3) day supply of the medication left. The sticker should be pulled, placed on the reorder form and faxed to the pharmacy. LPN #5 revealed that medication availability has improved. The LPN verified that he/she has received recent education regarding care plans. If staff is unable to follow the plan of care for a resident, the Charge Nurse should be notified and will alert the DON and the physician. The computer or the Accunurse system can be utilized to view the resident's plan of care. On 06/12/14 at 3:34 PM, the pharmacy representative verified through interview that he and Certified Pharmacy Technicians completed a MAR to medication cart audits for all residents on 06/02/14 and 06/09/14. On 06/12/14 at 4:20 PM, an interview with the DON and the Administrator, revealed omissions on the June 2014 MAR for Resident #15 on 06/05/14 at 3:00 PM of a dose of [MEDICATION NAME] and a 2:00 PM dose of [MEDICATION NAME] indicated the medications were not administered by LPN #1. It was revealed that LPN #1 was terminated related to the medication errors. On 06/11/14 at 5:00 AM, a dose of [MEDICATION NAME] was not documented as given by RN #4 and disciplinary action was pending related to the omission on the MAR. On 06/12/14 at 4:52 PM, the DON and the Administrator were interviewed regarding omissions on the June 2014 MAR for Resident #18. Review of the June 2014 MAR revealed no documentation for a 7:00 AM dose of [MEDICATION NAME] on 06/09/14 and 5:00 PM doses of [MEDICATION NAME] on 06/07/14 and 06/08/14. Interview on 06/12/14 at 5:15 PM with LPN #3 revealed that he/she had given the [MEDICATION NAME] to Resident #18 on 06/09/14 but failed to document it on the MAR. The LPN stated she had signed a disciplinary action five (5) minutes prior to the interview. Interview on 06/12/14 at 5:24 PM with LPN #4 revealed that he/she had given the 5:00 PM [MEDICATION NAME] doses to Resident #18 on 06/07/14 and 06/08/14 but failed to document the administration on the MAR. Further interview revealed the LPN received disciplinary action thirty (30) minutes prior to the interview. Interview with the DON on 06/12/14 at 5:48 PM, revealed that training and education were provided to staff as a part of a disciplinary action. Interview with the Administrator, on 06/12/14 at 5:50 PM, revealed that an additional, 3rd, MAR check was added on 06/12/14 to include staff at shift change checking MARs for omissions. Interview with the Administrator, on 06/13/14 at 9:15 AM, revealed that an additional, 3rd MAR check was initiated on 06/12/14. The Medical Director was notified and participated in a QA meeting/conference call regarding the plan. Interview with the Administrator, on 06/13/14 at 10:28 AM, revealed that LPN #4 had not worked and had been out of town and that disciplinary action was provided upon the first day of her return to work. Interview with the Administrator, DON and Regional RN, on 06/13/14 at 10:50 AM, revealed the medications for Resident #18 were available on the cart for administration. Staff interviews reveal that the medications were administered and available on 06/07/14, 06/08/14 and 06/09/14 and disciplinary action was administered according to the AOC. The number of pills available on the medication cart on 06/13/14 appeared to be adequate based on the date of delivery.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of seventeen (17) sampled residents (Resident #1) was provided adequate supervision to prevent accidents during a transfer with a mechanical lift. On 03/30/14, State Registered Nurse Aide (SRNA) transferred Resident #1 with a mechanical lift without assistance, as per facility policy and the resident's right foot became stuck between the (2) two metal bars on the lift. The SRNA failed to report the incident. On 04/03/14, the resident complained of pain to the right foot and an x-ray was ordered. The resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy titled Safe Handling and Movement Policy, last revised 10/31/13, revealed all patient transfers with mechanical lifts will be done with a minimum of two (2) persons or as specified in the patient's plan of care. Additionally, the policy revealed that injuries from patient handling and movement should be reported. Record review revealed the facility admitted Resident #1 on 02/13/14, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 02/20/14, revealed the facility assessed Resident #1 as cognitively intact with a score of fifteen (15) which indicated the resident was interviewable. Further review revealed the facility assessed the resident to require the extensive assistance of two (2) staff for transfers. Further record review revealed no documented evidence of an assessment for the use of a mechanical lift for Resident #1. Review of the Comprehensive Care Plan for Activities of Daily Living (ADL), dated 04/24/14, revealed Resident #1's level of physical functioning required for transfers to be a one person assist and there was no intervention for staff to use a mechanical lift for transfers. Review of the facility's Final Report of the investigation, dated 04/10/14, revealed the resident was transferred by State Registered Nurse Assistant (SRNA) #1 using a mechanical lift without assistance. While being transferred, the resident's right foot became tangled and due to the resident's [DIAGNOSES REDACTED], the resident was unable to feel pain to his/her leg. The resident's family member was present and witnessed and assisted the SRNA to untangle the resident's leg. The incident was not reported by the SRNA. An x-ray of the resident's right foot was ordered on [DATE] and completed on 04/04/14 by the mobile x-ray service. Following the investigation, it was determined the SRNA did not follow the resident's plan of care and did not have assistance with operating a mechanical lift, as required by facility policy. The SRNA was terminated on 04/16/14. Review of the Radiology Report, dated 04/04/14, revealed the resident had nondisplaced fractures of the right distal tibia and fibula. The physician was notified of the result on 04/04/14 at 3:00 PM by Licensed Practical Nurse #7. Orders were received to make an orthopedic appointment which was scheduled for 04/10/14 at 1:00 PM. An order was received from the physician on 04/04/14 at 8:30 PM to send the resident to the emergency room for evaluation of the fractured tibia/fibula. An x-ray of the right lower leg done on 04/04/14 at 10:30 PM revealed a radiologist interpretation of diffuse severe osteopenia with oblique comminuted, minimally displaced fractures involving the distal tibia and fibula. Interview with Resident #1, on 05/21/14 at 9:00 AM, revealed he/she was transferred by a mechanical lift resulting in a leg fracture and deformity to the resident's leg. Further interview revealed the resident had no sensation so he/she could not feel any pain. He/she stated while being transferred, his/her leg got caught. The resident stated he/she should have been transferred using two (2) staff. A telephone interview with the family member, on 05/22/14 at 10:22 AM, revealed on Sunday, 03/30/14, he was at the facility to take the resident out for a while. He stated the staff person picked the resident up with the lift and caught the resident's leg between the two (2) steel pieces. He revealed the staff person had to raise the lift to get the resident's foot out. He stated the staff person was working alone and he was not sure if the staff normally used a lift with the resident. Further interview revealed there was no obvious injury and he didn't know the resident was hurt. He stated he was not sure if the staff person reported the incident. A telephone interview with Licensed Practical Nurse (LPN) #7, on 05/22/14 at 3:51 PM, revealed she was made aware the resident was reporting pain; however, record review revealed there was no documented evidence of the resident's complaints of pain. The physician was notified on 04/03/14 at 5:13 PM and an order received for an x-ray of the right foot. Interview with the Director of Nursing, on 05/23/14 at 10:46 AM, revealed the facility did conduct assessments of staff to ensure they were competent with the use of the lift. Further interview revealed the Interdisciplinary Team (IDT) determined which lift was to be used for which resident. Interview with the Administrator, on 05/21/14 at 11:10 AM, revealed Resident #1 sustained an injury to the right lower leg while being transferred by SRNA #1 using a mechanical lift. The Administrator revealed the resident was not care planned for the use of a lift.

Based on observation, interview, and record review it was determined the facility failed to revise the care plan for one (1) of four (4) sampled residents (Resident #1). Resident #1 was readmitted to the facility on [DATE] with orders to apply protective heelboots and the facility failed to revise the care plan to include the protective boots. Resident #1 developed Stage II pressure sores to the lateral aspect of the left and right foot. (Refer to F314) The findings include: Interview with the Director of Nursing (DON), on 12/10/13 at 4:02 PM, revealed the facility did not have a policy/procedure that addressed the revision of care plans. Record review revealed the facility admitted Resident #1 on 07/01/12 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/12/13, revealed the facility assessed Resident #1's cognition as moderately impaired and he/she required extensive assistance with activities of daily living. Review of a Physician Order, dated 11/25/13, revealed staff should apply protective boots every shift. Review of Resident #1's Comprehensive Care Plan for impaired skin integrity, initiated on 03/28/13, and the Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Plan of Care, dated 12/09/13, revealed the care plans were not revised to include the intervention to apply protective boots every shift. Further review of Resident #1's potential for impaired skin integrity care plan, initiated on 03/28/13, revealed the care plan was not revised to include the Stage II area to the lateral aspect of the left foot or the right foot. Observations on 12/09/13 at 1:22 PM and on 12/10/13 at 9:28 AM and 10:20 AM revealed Resident #1 was in bed and there were no protective boots on his/her feet. Further observation on 12/10/13 at 3:20 PM with the DON revealed Resident #1 was in bed with no protective boots on his/her feet. Interviews with CNA #7, CNA #8, and CNA #9, on 12/13/13 at 2:00 PM, 2:23 PM and 2:30 PM, respectively, revealed they were not aware Resident #1 was supposed to wear protective boots. The CNAs stated if the resident was supposed to wear protective boots it should be on the CNA care plan. Interview with Licensed Practical Nurse (LPN) #1 and LPN #3, on 12/12/13 at 10:40 AM, and on 12/13/13 at 2:55 PM and 3:28 PM, respectively, revealed the protective boots should be on the CNA care plan so the CNAs know what care to provide for the resident. Interview with LPN #4, on 12/13/13 at 3:36 PM, revealed the physician orders [REDACTED]. LPN #4 revealed if the physician order [REDACTED]. Interview with the DON, on 12/12/13 at 10:50 AM and 11:00 AM and on 12/13/13 at 8:58 AM and 2:55 PM, revealed the purpose of the protective boot was to offload or to provide a pressure reducing surface to protect the skin integrity. The DON stated she expected the physician orders [REDACTED]. She stated the whole Interdisciplinary Team (IDT) was responsible for updating the care plan. Review of Resident #1's Wound Assessment Report for left side of left foot, dated 12/10/13, revealed the facility identified a Stage II pressure sore with a scant amount of sanguineous drainage and measured 1.30 centimeters (cm.) x 1.30 cm. x 0.40 cm. Review of Resident #1's Wound Assessment Report for the right side of right foot, dated 12/10/13 revealed the facility identified a Stage II pressure sore with a small amount of sanguineous drainage and measured 1.00 cm. x 1.00 cm. x 0.40 cm. on 12/10/13.

Based on observation, interview, and record review it was determined the facility failed to provide care in accordance with each resident's written plan of care for one (1) of four (4) sampled residents (Resident #2). Resident #2 was care planned to wear heelboots every day however, observations revealed Resident #2 had no heelboots on. The facility identified an "open blister" to the tip of the resident's right great toe on 12/11/13. (Refer to F314) The findings include: Interview with the Director of Nursing (DON), on 12/10/13 at 4:02 PM, revealed the facility did not have a policy/procedure that addressed care plans. Record review revealed the facility admitted Resident #2 on 04/08/13 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment, dated 09/19/13, revealed the facility assessed Resident #2's cognition as severely impaired and he/she required extensive assistance with activities of daily living. Review of the Comprehensive Care Plan for impaired skin integrity, initiated on 04/09/13, and the Certified Nurse Aide (CNA) Activities of Daily Living (ADL) Plan of Care, dated 08/21/13, revealed an intervention for Resident #2 to wear bilateral heel float boots. Observations on 12/09/13 at 1:43 PM and on 12/10/13 at 9:07 AM and 10:05 AM, revealed Resident #2 was in bed and did not have bilateral heel float boots on his/her feet. Further observation, on 12/10/13 at 3:20 PM with the DON, revealed Resident #2 was in bed and did not have bilateral heel float boots on his/her feet. Interview with CNA #7, on 12/13/13 at 2:00 PM, revealed Resident #2's boots used to be put on by therapy. However, this was no indicated on the CNA ADL Plan of Care. Interview with CNA #8, on 12/13/13 at 2:23 PM, revealed Resident #2 did not need the heel floats or protective boots while in bed; even though bilateral heel float boots was listed on Resident #2's CNA ADL Plan of Care. Interview with CNA #9, on 12/13/13 at 2:30 PM, revealed the CNAs were supposed to put the boots on the resident. The CNA stated Resident #2's CNA ADL Plan of Care revealed he/she was care planned for heel float boots. However, the heel boots were not applied. Interview with Licensed Practical Nurse (LPN) #1, on 12/12/13 at 10:40 AM and on 12/13/13 at 2:55 PM, revealed the CNAs were responsible for placing the heel float boots on the residents. Interview with the DON, on 12/12/13 at 11:00 AM, revealed the whole Interdisciplinary Team (IDT) was responsible for updating the care plan, and she expected the staff to follow the care plan. Review of the Wound Healing Progress Report, (no date), revealed the facility identified an open blister to the tip of the right great toe on 12/11/13 measuring 2.20 cm. x 2.20 cm.

Based on observation, interview, record review, and facility policy/procedure review it was determined the facility failed to ensure a resident who enters the facility without pressure sores does not develop pressure sores for two (2) of four sampled residents (Resident #1 and Resident #2). Resident #1 was readmitted to the facility on [DATE] with orders to apply protective boots to his/her feet. The facility failed to revise the care plan to include the protective boots. Observations on 12/09/13 and 12/10/13 revealed there were no protective boots on Resident #1. Interviews with the Certified Nurse Aides (CNAs) revealed they were not aware the resident was supposed to wear protective boots. Interview with the Licensed Practical Nurse (LPN) #1 revealed she identified a Stage II pressure sore to the resident's lateral aspect of the left foot on 12/09/13 and the lateral aspect of the right foot on 12/10/13. However, the LPN failed to measure the resident's wounds when the wounds were identified. (Refer to F280) Resident #2 was care planned for bilateral heel float boots. Observations on 12/09/13 and 12/10/13 revealed Resident #2's heel float boots were not applied. The facility identified Resident #2 had an "opened blister" on the tip of the right great toe on 12/11/13. (Refer to F282) The findings include: Review of the facility's policy titled, "Skin System Policy", (no date), revealed all residents would be assessed on admission, with each change in condition, and quarterly. Skin assessments would be completed weekly. Staging and measuring would be done exclusively by the skin Management Nurse assigned to that resident to maintain continuity in documentation of progression. On admission and when observed skin was compromised, the Nurse finding the problem would initiate a treatment using formulary product if possible and physician approval. Physician and Family must be notified at time of discovery and notification must be documented in medical record. 1. Record review revealed the facility admitted Resident #1 on 07/01/12 with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment, dated 11/12/13, revealed the facility assessed Resident #1's cognition as moderately impaired and he/she required extensive assistance with activities of daily living. Additionally, the resident was assessed at risk of developing pressure ulcers. Review of the Nursing Notes revealed Resident #1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident #1's Admission Skin Assessment, dated 11/25/13 at 12:00 noon, revealed there were no wounds identified to the lateral aspect of the left or right foot of the resident. Review of a Physician Order, dated 11/25/13, revealed staff should apply protective boots every shift. However, review of Resident #1's Comprehensive Care Plan for impaired skin integrity, initiated on 03/28/13, and the CNA Activities of Daily Living (ADL) Plan of Care, dated 12/09/13, revealed the care plans were not revised to include the intervention to apply protective boots every shift. Review of Resident #1's December 2013 Treatment Administration Record (TAR) revealed to apply protective boots every shift with a start date of 11/25/13 and the TAR was initialed indicating the protective boots were applied. However, observations on 12/09/13 at 1:22 PM and on 12/10/13 at 9:28 AM, 10:20 AM, and 3:20 PM revealed Resident #1 was in bed and there were no protective boots on his/her feet. Interviews with CNA #7, CNA #8, and CNA #9, on 12/13/13 at 2:00 PM, 2:23 PM, 2:30 PM and 2:45 PM, respectively, revealed they were not aware Resident #1 was supposed to wear protective boots. The CNAs stated if the resident was supposed to wear protective boots it should be on the CNA care plan. CNA #7 stated Resident #1 never had any foot protectors. Observation, on 12/10/13 at 9:28 AM of a skin assessment and wound treatment by LPN #1 for Resident #1, revealed [MEDICATION NAME] foam with Kerlix dressing , (not dated or initialed), were pulled off of a wound on the left lateral aspect of the left foot, and the LPN redressed the wound. LPN #1 examined the right foot and found an area on the lateral aspect of the right foot and dressed it with [MEDICATION NAME] foam and kerlix dressing without measuring either area or notifying the physician for treatment. LPN #1 stated she had identified the wound on the lateral aspect of the resident's left foot on 12/09/13. Further record review revealed there was no evidence the physician and family were notified of the wound to the left lateral aspect of the left foot on 12/09/13. Interview with Resident #1's Physician, on 12/11/13 at 3:30 PM, revealed he expected to be notified of a new wound immediately and felt this was a rule for all nursing facilities. Further interview with LPN #1, on 12/10/13 at 9:28 AM and 12:24 PM, revealed she did not notify the physician or family about the wound on 12/09/13 because she had an emergency and was called away so she treated the wound according to the wound care guidelines. LPN #1 further revealed there was no order for the foam dressing applied to the lateral aspect of the left foot wound on 12/09/13 and 12/10/13 and no order for the dressing applied to the lateral aspect of the right foot on 12/10/13. She stated she should have notified the physician when she identified the wound on 12/09/13. The LPN further stated she should have measured the areas when she identified them so the wounds could be tracked to determine if they were healing or not. LPN #1 revealed the protocol for wounds was to do a skin assessment and if an open area was found to measure it and clean it, notify the health care provider, write order and put the order on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of Resident #1's Wound Assessment Report for left side of left foot, dated 12/10/13, revealed the wound was identified on 12/10/13, instead of 12/09/13, assessed as a Stage II with a scant amount of sanguineous drainage and measured 1.30 centimeters (cm.) x 1.30 cm. x 0.40 cm. The physician and family were notified on 12/10/13. Review of Resident #1's Wound Assessment Report for the right side of right foot, revealed the wound was identified on 12/10/13, assessed as a Stage II with small amount of sanguineous drainage and measured 1.00 cm. x 1.00 cm. x 0.40 cm. Further review of Resident #1's potential for impaired skin integrity care plan, initiated on 03/28/13, revealed the care plan was not revised to include the Stage II area to the lateral aspect of the left foot or the right foot. Interviews with LPN #1, LPN #3, and LPN #4, on 12/12/13 at 10:40 AM and on 12/13/13 at 2:55 PM, 3:28 PM and 3:36 PM respectively, revealed the protective boots should be on the CNA care plan so the CNAs know what care to provide for the resident. LPN #4 revealed if the physician order [REDACTED]. Interview with the Director of Nursing (DON), on 12/10/13 at 3:00 PM and 4:02 PM, on 12/12/13 at 10:50 AM and 11:00 AM and on 12/13/13 at 8:58 AM and 2:55 PM, revealed the purpose of the protective boot was to offload or to provide a pressure reducing surface to protect skin integrity. The DON stated she expected the physician orders [REDACTED]. The DON revealed when licensed staff identify a wound she expected the staff to notify the physician. She stated if an open area was identified it should be measured, a treatment put in place specific to wound, and the wound should be documented on the wound healing progress sheet. 2. Record review revealed the facility admitted Resident #2 on 04/08/13 with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment, dated 09/19/13, revealed the facility assessed Resident #2's cognition as severely impaired and he/she required extensive assistance with activities of daily living. Review of Resident #2's Skin Assessment, dated 10/01/13, revealed there was no open wound to right great toe on admission. Review of the Comprehensive Care Plan for impaired skin integrity, initiated on 04/09/13, and the CNA ADL Plan of Care, dated 08/21/13, revealed an intervention for Resident #2 to wear bilateral heel float boots. Observations on 12/09/13 at 1:43 PM and on 12/10/13 at 9:07 AM, 10:05 AM, and 3:20 PM, revealed Resident #2 was in bed and did not have bilateral heel float boots on his/her feet. Review of Resident #2's December 2013 TAR revealed to place heel float boot to both feet and encourage and monitor placement every shift to promote skin integrity. The TAR was initialed on 12/09/13 on day shift indicating the heel float boots were in place. Observation on 12/10/13 at 10:05 AM of skin assessment by LPN #1 for Resident #2 revealed the resident refused to allow the LPN to conduct the assessment. Review of the Wound Healing Progress Report, (no date), revealed the facility identified an open blister to the tip of the right great toe on 12/11/13 measuring 2.20 cm. x 2.20 cm. Interview with CNA #9, on 12/13/13 at 2:30 PM, revealed the CNAs were supposed to put the boots on the resident. The CNA stated Resident #2's CNA ADL Plan of Care revealed he/she was care planned for heel float boots. Interview with LPN #1, on 12/12/13 at 10:40 AM and on 12/13/13 at 2:55 PM, revealed the CNAs were responsible for placing the heel float boots on the residents and the nurse verified the heel float boots were in place every shift and initialed the TAR. Interview with LPN #3 and LPN #4, on 12/13/13 at 3:28 PM and 3:36 PM, revealed licensed staff initialed the TAR to verify CNAs have completed the task. Interview on 12/13/13 at 3:35 PM with Registered Nurse (RN) #2 revealed the CNAs were usually responsible for applying the heel protectors and the nurse verified they were in place. RN #2 revealed Resident #2 did not use heel protectors while in bed; however, heelboots were noted on the resident's TAR. Interview with the DON, on 12/12/13 at 11:00 AM, revealed she expected staff to follow the care plan. The DON stated the purpose of the air boots is to offload or to provide pressure reducing surface to protect the skin integrity.

Based on observation, interview, record review and review of the facility's guidelines, it was determined the facility failed to have an effective system to ensure provision of care in accordance with each resident's written plan of care for one resident (Resident #1), in the selected sample of five (5) residents. Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed Resident #1 at risk for elopement and implemented a plan of care for elopement initiating the wander guard/care alert device on 04/24/12. Resident #1 attempted to exit the building on 02/10/13, 03/09/13 and 03/27/13. On 03/28/13, the facility determined Resident #1 needed a more secure environment due to the resident's increased exit seeking behaviors and referred the resident to a facility with a locked ward. The care plan was revised to include fifteen (15) minute checks after the episode on 03/27/13; however, there was no documented evidence the fifteen (15) minutes checks were completed. On 04/13/13, Resident #1 exited the building unwitnessed at approximately 3:05 PM. Unsampled Resident A heard the door alarm sounding and went to the Hall II exit door because there was no staff on the hall. Resident A punched in the code which stopped the alarm from sounding and exited the building but did not see Resident #1. Resident #1 was found by staff at approximately 3:16 PM approximately one-tenth (0.1) of a mile from the facility. The resident had walked across a two-lane highway and was walking in the grass along another two lane highway with high traffic. The speed limit of both highways was 35 miles per hour. Interviews revealed staff had to obtain a wheelchair to bring the resident back to the building because the resident was tired and weak. The resident was assessed with [REDACTED]. Resident #1 was transferred to another facility on 04/18/13. The facility's failure to have provide care in accordance with Resident #1's care plan related to increased supervision has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/24/13 and was determined to exist on 04/13/13. The facility was notified of the Immediate Jeopardy on 04/24/13. An acceptable Allegation of Compliance (AoC) was received on 04/25/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 04/24/13, as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Guidelines for Resident Comprehensive Care Plan, dated 09/08, revealed the resident's comprehensive care plan should be viewed as an Interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. The comprehensive care plan should always have realistic goals and interventions to address the residents' needs. A record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Assessment, dated 09/24/12, revealed the facility assessed Resident #1 at risk for elopement because the resident was cognitively impaired and had a history of [REDACTED]. The assessment stated an elopement care plan should be initiated and reflect interventions appropriate to the resident which may include the use of the wander guard anklet. A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/12 revealed the facility assessed Resident #1's cognition as moderately impaired, required the extensive assistance of two staff for ambulation, and had behaviors of wandering. A review of the Elopement Plan of Care, Assessment, Prevention and Management, last reviewed and revised 12/10/12, revealed interventions for staff to initiate the wander alert system, photograph resident and document description, allow for safe wandering, offer redirection, and offer snack when wanders. A review of a SBAR report (Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note for New Symptoms, Signs and Other Changes in Condition), dated 02/10/13 at 10:45 AM, revealed Resident #1 attempted to exit the building at the back Hall II door. A review of the At Risk for Elopement Care Plan, dated 03/01/13, revealed interventions to monitor for behaviors of packing belongings, verbalization of leaving and attempts to leave facility, place wander guard on resident and check daily for placement, reassess for elopement risk as needed and with all OBRA assessments. A review of the annual MDS assessment, dated 03/11/13, revealed the facility assessed Resident #1 as severely cognitively impaired, requiring the assistance of one staff for ambulation and had behaviors of wandering four to six days but not every day. A review of the Nurse's Note, dated 03/09/13 at 8:00 PM, revealed Resident #1 was observed opening the back door of Hall II and stepping out through the doorway. The resident was easily redirected back into the facility and placed on 15 minute checks. A review of a Social Worker Note, dated 03/27/13, revealed Resident #1 went out the back door causing the door alarm to sound while in visual eye sight of a Nurse. The resident was escorted back in the building and placed on 15 minute checks. Further review of the At Risk for Elopement Care Plan, dated 03/01/13, revealed an intervention was added on 03/27/13 for increased observation; however review of the record revealed there was no evidence Supervision Flow Sheets were completed while the resident was on increased observation and no evidence the 15 minute checks were discontinued. A review of a Referral and Pre-Admission Screening form, dated 03/28/13, revealed the facility was trying to find placement at a facility with a locked ward due to Resident #1's wandering behavior and attempts of elopement. Interview with the Social Worker, on 04/22/13 at 1:55 PM, revealed the facility determined on 03/28/13, Resident #1 needed a more secure environment due to the resident's increased incidents of exit seeking behaviors so the Social Worker talked to the resident's guardian and made a referral to a facility that had a locked unit. She stated the locked unit facility agreed to take the resident on 04/13/13, however, the facility called and stated due to some issues at their building they would not be able to admit the resident until 04/18/13. A review of a SABR report, dated 04/13/13 at 3:15 PM, revealed Resident #1 eloped from the facility unwitnessed. A Code Wanda was called and the resident was located at 3:20 PM outside of the facility and was assessed with [REDACTED]. The Assistant Director of Nursing (ADON) and Administrator were notified. Interview with CNA #4, on 04/24/13 at 2:10 PM, revealed Resident #1 was wearing a pair of jeans, a blue short sleeve shirt and white sneakers. A review of a web site for the weather history of the area of the nursing facility revealed on 04/13/13 at 2:55 PM it was 61.2 degrees Fahrenheit with variable wind at 3.5 miles per hour and no precipitation. Interview with unsampled Resident A, on 04/23/13 at 8:30 AM, revealed Resident A was in his/her room at the back of Hall II when Resident A heard the Hall II back door alarm sounding. Resident A stated he/she went to the back door and punched in the code which stopped the alarm from sounding. Resident A exited the building and walked across the back of the building past the back of Hall I and looked in the parking lot along the side of the building and did not see anyone. Resident A stated he/she came back to the back of Hall II and sat outside in the wheelchair. The resident revealed a staff member came out of Hall II exit door and asked if he/she had seen Resident #1. Resident A stated he/she told the staff that if Resident #1 was outside, Resident #1 must have went up the hill and around the other side of the building where there was no parking lot. Resident A revealed when the Administrator interviewed him/her about the incident, he/she told the Administrator there was no staff on the hall when the Hall II alarm sounded and that was why he/she went to the door, punched in the code and went outside to see if Resident #1 was outside. Interview with CNA #1 and CNA #4, on 04/22/13 at 2:15 PM and 2:38 PM respectively, revealed Resident #1 was wandering up and down the hallway on 04/13/13 and CNA #1 walked the resident up to the lobby and sat the resident on the couch. CNA #1 and CNA #4 revealed they heard the Back Hall II door alarm sounding while they were in a resident's room providing care. CNA #4 and CNA #1 searched the resident rooms and bathrooms on Hall II and Hall I, then told LPN #2 that Resident #1 was missing. CNA #1 and CNA #4 revealed Resident #1 was found walking down the side of the road in front of a store. CNA #1 and CNA #4 said the resident was missing approximately 10-15 minutes. CNA #1 and CNA #4 revealed they were not told that Resident #1 was on 15 minute checks in report and they do not look at the care plan daily. The CNAs stated the Nurses made them aware if a resident was on increased supervision and this was not reported in change of shift report. Interview with Licensed Practical Nurse (LPN) #2, on 04/22/13 at 1:10 PM, revealed she was at the medication cart on Hall I when CNA #1 and CNA #4 entered the back door of Hall I. The LPN stated CNA #4 stated she thought the LPN needed to call a Code Wanda because they could not find Resident #1. A Code Wanda was called. LPN #2 revealed when a Code Wanda was called staff are supposed to complete a head count and if they determine a resident is missing they immediately began a search of the inside and perimeter of the building. The LPN stated staff immediately conducted a head count and began searching for the resident inside and outside of the building. She stated staff found the resident walking down the side of the highway in front of a store "three (3) minutes or so later". LPN #2 revealed she was not aware Resident #1 was supposed to be on 15 minute checks prior to the elopement and she was not told this in shift report. She stated she did not review the care plan everyday. Interview with LPN #1, on 04/22/13 at 1:35 PM, revealed she was in another resident's room on Hall II when two Nurses and a CNA asked her if she had seen Resident #1. She stated Resident #1 was found down the road, in front of a store standing in the grass at the side of the road holding the hand of another staff. LPN #1 stated Resident #1 was exhausted but was not injured. The LPN stated staff brought a wheelchair from the facility and assisted the resident back to the facility. The resident was placed on 1:1 supervision. LPN #1 revealed she was not informed Resident #1 was supposed to be on 15 minute checks during shift report that day. The LPN stated staff report to the next shift during shift report any residents on increased supervision. She stated she did not look at the care plan everyday. Interview with CNA #5 and CNA #6, on 04/22/13 at 2:50 PM and 3:00 PM respectively, revealed they were talking to each other on Hall I on 04/13/13 when CNA #1 and CNA #4 entered the back door of Hall I. The CNAs stated CNA #1 and CNA #4 had told them the back door alarm of Hall II had sounded, and they were unable to find Resident #1. CNA #4 and #6 revealed they had not heard the door alarm sound. The Nurse called a Code Wanda and staff began searching for the resident. The resident was found out in front of a store. CNA #5 and CNA #6 stated they were not told in shift report that Resident #1 was on 15 minute checks and they did not look at the care plan everyday. An interview with Licensed Practical Nurse (LPN) #1 and LPN #4 , on 04/22/13 at 1:35 PM and 04/23/13 at 9:40 AM, revealed they recalled Resident #1 being on 15 minute observations but did not remember how often or how long the resident was on the increased supervision. LPN #1 and LPN #4 stated the staff was made aware when a resident was on increased supervision during change of shift report. The LPNs revealed they did not look at a resident's care plan everyday. Interview with the Director of Nursing (DON), on 04/23/13 at 11:20 AM, revealed it was the Nurse's judgement whether to place a resident on increased supervision or not. The staff use the Supervision Flow Sheets to document the monitoring of the resident on increased supervision. The nurse should update the care plan when a resident is placed on increased supervision. The DON stated Licensed staff and CNAs were made aware a resident was on increased supervision through shift report. The DON stated the Resident #1 should have remained on increased supervision (15 minute checks) from the time the resident was placed on 15 minute checks after the 03/27/13 incident until the time of the elopement on 04/13/13. The DON revealed he was unable to find the Supervision Flow Sheets or any other evidence that verified Resident #1 was on 15 minute checks after the 03/27/13 incident of exit seeking behavior. Interview with the Administrator, on 04/23/13 at 12:10 PM, revealed Resident #1 was placed on 15 minute checks on 03/27/13 and the 15 minute checks were never discontinued . Interviews with members of the IDT (MDS Nurse, Life Enrichment Director, Dietary Service Manager, Director of Rehabilitation and Social Services Director) on 03/24/13 at 2:45 PM, 2:55 PM, 3:00 PM and 3:05 PM respectively, revealed they could not recall if Resident #1 was taken off increased observation or not. Observation of the area between the facility and the front of the store where Resident #1 was found revealed the area was approximately 0.1 mile from the facility. The resident had to cross a two lane highway with a speed limit of 35 miles per hour (mph) and was found walking down the side of another high traffic two lane highway with a speed limit of 35 mph. A review of the Supervision Flow Sheets, dated 04/13/13-04/18/13 revealed Resident #1 remained on 1:1 until he/she was transferred to a facility with a locked ward on 04/18/13. ** The facility implemented the following actions to remove the Immediate Jeopardy: *All current residents of the facility were reviewed by the IDT on 04/23/13, the IDT consisting of the DON, ADON, Minimum Data Set (MDS) Nurse, Social Services Director, Life Enrichment Director, Dietary Service Manager and Director of Rehabilitation. The IDT reviewed all residents to determine if the current level of supervision was adequate to meet the needs of the resident based on medical condition, behaviors, falls, elopement risk, safety awareness and cognition status. If increased supervision was warranted it was reflected on the resident's care plan. No residents were felt to have a need for increased supervision not already reflected on the care plan. * The IDT to include the Administrator was reeducated by the Regional Nurse Consultant related to the process of IDT review prior to decreasing supervision for the resident, as well as things to consider prior to decreasing the supervision to include but not limit to current behaviors, medications, patterns or trends, medical needs and activity needs. This education was provided on 04/23/13. Any supervision changes will be noted on the resident's plan of care. The DON will be responsible for ensuring this is completed. the Supervision Flow Sheet will be utilized to document increased supervision. This form will be reviewed by the DON and then given to Medical Records for storage. This education was provided on 04/23/13. *All licensed Nurses were re-educated on the following: licensed staff may increase supervision using their nursing judgement and should notify the DON when they have increased supervision. Licensed staff may recommend decreasing supervision to the DON for IDT review prior to changes being made. *The facility also provided re-education to all nursing staff that increased supervision will be noted on the staff assignment sheets. The Administrator is responsible to ensure this is completed. This education began 04/23/13 with no staff working after 04/23/13 without having received this education. The education was provided by the DON and ADON. *An ad hoc Quality Assurance Committee was convened on 04/23/14 to review the survey concerns related to supervision and the documentation of decreased supervision. In attendance was the Administrator, DON, ADON, Social Service Director, MDS Nurse, Activity Director and Dietary Services Manager. The Medical Director attended by conference. The above was reviewed with no further recommendations noted. *The facility will convene a Quality Assurance Committee weekly until substantial compliance to review all changes in supervision as well as any elopement attempts to assure that the interventions are carried out as care planned and that any decreases in supervision are reviewed by the IDT. The State Survey Agency validated the corrective action taken by the facility as follows: A record review of sampled resident revealed the residents were reviewed on 04/23/13 by the IDT team to determine if the current level of supervision was adequate and the care plan and assignment sheet showed the increased level of supervision. Interviews with the IDT team (Administrator, DON, ADON, Activity Director, Director of Rehabilitation, MDS Nurse, Social Service and Dietary Manager) on 04/24/13 at 3:05 PM, 3:40 PM, 3:45 PM, 3:50 PM, 4:00 PM, 4:05 PM, 4:10 PM, and 4:20 PM respectively, revealed they reviewed all residents' behaviors, falls, medical condition, elopement risk cognition and safety awareness to determine if they had the appropriate level of supervision and the care plans and assignment sheets reflected the appropriate level of increased supervision, if needed. In addition, the IDT team was re-educated on the process of reviewing to see if a resident was appropriate for decreased supervision by the Regional Nurse Consultant. Further interview with the DON revealed he was responsible for ensuring the increased level of supervision was noted on the resident's care plan and reviewing the increased supervision flow sheets to ensure staff were completing them. The DON revealed he was also responsible for ensuring the flow sheet were taken to Medical Records so the sheets could be place the the resident's overflow record. Further interviews with the Administrator, DON, Activity Director, Social Service Director and Activity Director and Dietary Service Manager revealed an Ad Hoc meeting was conducted on 04/23/13 with the Medical Director on conference call related to the concerns about supervision. No further recommendations were identified. Further interview revealed the Quality Assurance Committee would meet weekly to review all changes in supervision and if any elopement attempts were made by any residents. The IDT revealed their job during these meetings would be to ensure interventions were carried out and all increased supervision was reviewed by the IDT. The team revealed they would also be reviewing to ensure incidents of increased supervision was placed on the resident's care plan, on the assignment sheet and Supervision Flow Sheet were initiated. The Administrator revealed she received the same education and would be responsible to ensure the facility staff were following the facility's policy and procedures related to supervision. In addition, she stated she would be responsible for ensuring the daily Assignment Sheets included any residents on increased supervision and she would be supervising the weekly Quality Assurance Meetings to ensure the plan developed and initiated to correct the deficient practice is effective. Interviews with Registered Nurse (RN) #1 and LPN #6, on 04/24/13 at 4:50 PM and 4:55 PM respectively, revealed they were re-educated by the DON related to the fact they could place a resident on increased supervision if warranted but they must notify the DON. In addition, they can recommend a decrease in supervision but IDT makes the final decision that the decreased supervision is warranted. Interviews with RN #1, LPN #6, CNA #2, CNA #7 and CNA #8 on 04/24/13 at 4:35 PM, 4:40 PM, 4:42 PM, 4:48 PM, 4:50 PM, revealed they received education from the DON and ADON related to all increased supervision will be placed on the assignment sheet.

Based on interview, record review and facility policy and procedure review, it was determined the facility failed to have an effective system to ensure supervision to prevent accidents was provided for one resident (Resident #1), in the selected sample of five. (Refer to F282) Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed Resident #1 at risk for elopement and implemented a plan of care for elopement initiating the wander guard/care alert device. Resident #1 attempted to exit the building on 02/10/13, 03/09/13 and 03/27/13 by holding the door lever handle down for fifteen (15) seconds so the door lock would release. On 03/28/13, the facility determined Resident #1 needed a more secure environment due to the resident's increased incidents of trying to leave the facility and made a referral to a facility that had a locked unit. The resident was placed on fifteen (15) minute checks after the episode on 03/27/13; however, there was no documented evidence the fifteen (15) minutes checks were completed on a regular basis. Record review and staff interviews revealed the fifteen (15) minute checks were discontinued sometime between 03/27/13 and 04/13/13, however, no new interventions related to supervision were implemented for Resident #1. On 04/13/13, Resident #1 exited the building at approximately 3:05 PM. Unsampled Resident #A stated he/she heard the Hall II exit door alarm sounding and went to the door because there was not staff on the hall. Resident A punched in the code which stopped the alarm and then exited the building but did not see Resident #1 outside. Interviews revealed the door alarm sounded and a Certified Nurse Aide (CNA) responded; however, the CNA went out the door and observed only one side of the building. The CNA re-entered the building and made other staff aware Resident #1 was missing and the staff searched the inside of the building before notifying the Charge Nurse Resident #1 was missing. When the staff was unable to find the resident in the building, staff exited the building and began to search the facility's perimeter. Resident #1 was found by staff at approximately 3:16 PM approximately one-tenth (0.1) of a mile from the facility. The resident had walked across a two-lane highway and was walking in the grass along another two lane highway with high traffic. The speed limit of both highways was 35 miles per hour. Interviews revealed staff had to obtain a wheelchair to bring the resident back to the building because the resident was tired and weak. The resident was assessed with [REDACTED]. The facility's failure to have an effective system in place to provide supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/24/13 and was determined to exist on 04/13/13. The facility was notified of the Immediate Jeopardy on 04/24/13. An acceptable Allegation of Compliance (AoC) was received on 04/25/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 04/24/13, as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Missing Resident/Elopement policy and procedure, no date, revealed when staff identify a resident is missing staff should obtain assistance from other staff members in the immediate vicinity, instruct another staff member to make the Charge Nurse aware and conduct a thorough search of the building and premises. A review of the facility's Resident Elopement Policy, no date, revealed all residents should be assessed quarterly by the Social Services Director for potential for elopement. This should be completed using the AHT elopement risk assessment. A resident who is assessed as a potential risk will be assessed for the need of wander guard placement. Any residents with elopement attempts should be reassessed immediately for the need of further intervention to prevent elopement. A record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Assessment, dated 09/24/13, revealed the facility assessed Resident #1 at risk for elopement because the resident was cognitively impaired and had a history of [REDACTED]. The assessment stated an elopement care plan should be initiated and reflect interventions appropriate to the resident which may include the use of the wander guard anklet. A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/11/12 revealed the facility assessed Resident #1's cognition as moderately impaired, required the extensive assistance of two staff for ambulation, and had behaviors of wandering. A review of the Elopement Plan of Care, Assessment, Prevention and Management, last reviewed and revised 12/10/12, revealed interventions for staff to initiate the wander alert system, photograph resident and document description, allow for safe wandering, offer redirection, and offer snack when wanders. Observation of the Elopement Book at the nursing station revealed there was a page with a picture of Resident #1 and identifying descriptive information of the resident. A review of the February, March and April 2013 Treatment Records, revealed Resident #1's wander guard was in place and functioning. A review of a SBAR report (Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note for New Symptoms, Signs and Other Changes in Condition), dated 02/10/13 at 10:45 AM, revealed Resident #1 attempted to exit the building at the back Hall II door. The resident was placed on fifteen (15) minute checks. A review of Morning Meeting Minutes revealed the 15 minute checks were discontinued on 02/21/13, however, a review of the resident's record revealed there was no documented evidence the 15 minute checks were conducted or discontinued. An interview with Licensed Practical Nurse (LPN) #1, on 04/22/13 at 1:35 PM, revealed she was on Hall II on 02/10/13 and heard the back door alarm sounding. LPN #1 stated she went to the back door and saw Resident #1 had the lever handle of the door pressed down and then walked out the door. The LPN revealed she was able to go out the door and assist the resident back into the building. LPN #1 stated she placed the resident on 15 minute checks but she did not know how long the resident stayed on the 15 minute checks. LPN #1 stated Nurses could place the residents on increased supervision (15 minute, 30 minute, one hour, or other), but it was up to the Interdisciplinary Team (IDT) to discontinue the increased supervision. The nurse stated she recalled Resident #1 being on 15 minute observations but did not remember how often or how long the resident was on the increased supervision. LPN #1 stated the staff was made aware when a resident was on increased supervision during change of shift report. A review of the At Risk for Elopement Care Plan, dated 03/01/13, revealed interventions to monitor for behaviors of packing belongings, verbalization of leaving and attempts to leave facility, place wander guard on resident and check daily for placement, reassess for elopement risk as needed and with all OBRA assessments. A review of the annual MDS assessment, dated 03/11/13, revealed the facility assessed Resident #1 as severely cognitively impaired, requiring the assistance of one staff for ambulation and had behaviors of wandering four to six days but not every day. A review of the Nurse's Note, dated 03/09/13 at 8:00 PM, revealed Resident #1 was observed opening the back door of Hall II and stepping out through the doorway. The resident was easily redirected back into the facility and placed on 15 minute checks. A review of the Morning Meeting Minutes revealed the 15 minute checks were discontinued on 03/12/13; however a review of the resident's record revealed there was no evidence the 15 minute checks were conducted after 03/10/13 or discontinued. An interview with LPN #4, on 04/23/13 at 9:40 AM, revealed she was passing medications on 03/09/13 when she heard the alarm on the back door to Hall II sounding. She stated she locked the medication cart and went to the back door and when she arrived, Resident #1 was walking through the door to the outside. The LPN revealed she grabbed the back of the resident's shirt and was able to assist the resident back into the building. She stated she placed the resident on 15 minute checks but was not aware of how long the resident stayed on the 15 minute checks. LPN #4 stated Nurses could place the residents on increased supervision, but it was up to the IDT to discontinue the increased supervision. She stated the residents usually stay on 15 minute checks for approximately 72 hours. LPN #4 revealed the nurse made staff aware of when a resident was on increased supervision during the change of shift report. A review of a Social Worker Note, dated 03/27/13, revealed Resident #1 went out the back door causing the door alarm to sound while in visual eye sight of a Nurse. The resident was escorted back in the building and placed on 15 minute checks. Further review of the At Risk for Elopement Care Plan, dated 03/01/13, revealed an intervention was added on 03/27/13 for increased observation; however review of the record revealed there was no evidence any increased observation was conducted and/or discontinued. A review of a Referral and Pre-Admission Screening form, dated 03/28/13, revealed the facility was trying to find placement at a facility with a locked ward due to Resident #1's wandering behavior and attempts of elopement. Interview with the Social Worker, on 04/22/13 at 1:55 PM, revealed she and three other staff exited the morning meeting and exited out the back door of Hall II on 03/27/13. She stated they walked to the pavilion at the back of Hall I, and the Hall I door alarm was sounding. The Social Worker revealed she saw Resident #1 coming out the back door of Hall I with a Nurse several steps behind him/her. She stated the Nurse redirected the resident back into the building and placed the resident on 15 minute checks. She stated she thought the resident remained on 15 minutes checks for approximately 12 hours but was not sure. Further interview revealed the facility determined on 03/28/13, Resident #1 needed a more secure environment due to the resident's increased incidents of exit seeking behaviors so the Social Worker talked to the resident's guardian and made a referral to a facility that had a locked unit. She stated the locked unit facility agreed to take the resident on 04/13/13, however, the facility called and stated due to some issues at their building they would not be able to admit the resident until 04/18/13. The Social Worker stated Resident #1 had been on increased supervision in the past but she did not remember when or for how long. A review of a SABR report, dated 04/13/13 at 3:15 PM, revealed Resident #1 eloped from the facility unwitnessed. A Code Wanda was called and the resident was located at 3:20 PM outside of the facility and was assessed with [REDACTED]. The Assistant Director of Nursing (ADON) and Administrator were notified. Interview with CNA #4, on 04/24/13 at 2:10 PM, revealed Resident #1 was wearing a pair of jeans, a blue short sleeve shirt and white sneakers on 04/13/13 when the resident was found. A review of a website for the weather history of the area of the nursing facility revealed on 04/13/13 at 2:55 PM it was 61.2 degrees Fahrenheit with variable wind at 3.5 miles per hour and no precipitation. Interview with unsampled Resident A, on 04/23/13 at 8:30 AM, revealed the Resident A was in his/her room at the back of Hall II when he/she heard the Hall II back door alarm sounding. Resident A went to the back door and punched in the code which stopped the alarm from sounding. Resident A exited the building and walked across the back of the building past the back of Hall I and looked in the parking lot along the side of the building and did not see anyone. Resident A stated he/she came back to the back of Hall II and sat outside in the wheelchair. The resident revealed a staff member came out of Hall II exit door and asked if he/she had seen Resident #1. Resident A stated he/she told the staff that if Resident #1 was outside, Resident #1 must have went up the hill and around the other side of the building where there was no parking lot. Resident A stated he/she told the Administrator that he/she went to the door to look for Resident #1 when the door alarm sounded because there was no staff on the hall. Interview with CNA #1 and CNA #4, on 04/22/13 at 2:15 PM and 2:38 PM respectively, revealed Resident #1 was wandering up and down the hallway on 04/13/13 and CNA #1 walked the resident up to the lobby and sat the resident on the couch. CNA #1 stated she then went to another resident's room to toilet him/her. CNA #1 revealed CNA #4 entered the room to provide care to the roommate when they heard the Hall II back door alarm sounding. CNA #4 stated she went to the back door of Hall II but the alarm was no longer sounding. CNA #4 stated she saw unsampled Resident A sitting outside the door so she opened the door and asked Resident A if he/she had seen anyone come outside of the building and Resident A said no. CNA #4 stated she walked across the back of the building and up the side parking lot to the side door of Hall I and did not see anyone. CNA #4 stated she did not go out to the road or look up the road and did not go up the hill at the back of the building so she could observe the other side of the building. CNA #4 stated she reentered the building through the Hall I side door . CNA #4 told CNA #1 she had not seen Resident #1 outside. CNA #1 and CNA #4 checked the residents' rooms and bathrooms and asked staff if they had seen Resident #1 as they went up Hall II. The CNAs stated they exited the back door of Hall II and re-entered the building through the back door of Hall I. CNA #1 and CNA #4 said they checked the rooms and bathrooms on Hall I. CNA #1 stated LPN #2 was at the medication cart and the CNA told her Resident #1 was missing. CNA #1 went back outside and Resident A was still sitting at the back of Hall II. Resident #A told the CNA if Resident #1 came out there, Resident #1 must have walked up the hill and went around the other way. CNA #1 revealed she and some other staff walked up the hill and around the other side of the building which leads to the side road. CNA #1 stated they saw Resident #1 down the road in front of a store on the side of the highway in the grass with CNA #3 holding his/her hand. Meanwhile, CNA #4 had walked back out the side door of Hall I and walked from the side door to the front door of the building. CNA #4 revealed she entered the front door and CNA #3 immediately stuck her head in the front door and stated the resident was down the street. CNA #4 stated the resident was down the road in front of the store in the grassy area by the road. CNA #1 and CNA #4 said the resident was missing approximately 10-15 minutes. CNA #1 and CNA #4 revealed they were not told that Resident #1 was on 15 minute checks. The CNAs stated the Nurses made them aware if a resident was on increased supervision and this was not reported in change of shift report. Interview with Licensed Practical Nurse (LPN) #2, on 04/22/13 at 1:10 PM, revealed she was at the medication cart on Hall I when CNA #1 and CNA #4 entered the back door of Hall I. The LPN stated CNA #4 stated she thought the LPN needed to call a Code Wanda because they could not find Resident #1. She stated she attempted to call the code from the phone at the back of Hall I, but the phone would not work, so she walked to the Nurse's desk at the front of the hall and the weekend Supervisor called the Code Wanda. She revealed the Nurse called a Code Wanda when a door alarm sounds and staff cannot identify the cause or staff suspect a resident is missing. When the code is called staff are to complete a head count and if they determine a resident is missing they immediately began a search of the inside and perimeter of the building. The LPN stated the staff immediately conducted a head count and began searching for the resident inside and outside of the building. She stated staff found the resident walking down the side of the highway in front of a store "three (3) minutes or so later". LPN #2 revealed she was not aware Resident #1 was supposed to be on 15 minute checks prior to the elopement. Interview with LPN #1, on 04/22/13 at 1:35 PM, revealed she was in another resident's room on Hall II when two Nurses and a CNA asked her if she had seen Resident #1. The LPN stated she and CNA #1 walked out the back Hall II door and spoke to unsampled Resident A who was sitting outside the door. She stated Resident A stated if Resident #1 had come outside, the resident must have went up the hill and around the other side of the building. The LPN revealed her and the other staff went up the hill at the back of the building which goes around and comes out on a side road. She revealed they saw Resident #1 in front of a store standing in the grass at the side of the road holding the hand of another staff. They ran to the staff and resident to assist. LPN #1 stated Resident #1 was exhausted but was not injured. The LPN stated staff brought a wheelchair from the facility and assisted the resident back to the facility. The resident was placed on 1:1 supervision. LPN #1 revealed she was not informed Resident #1 was supposed to be on 15 minute checks during shift report that day. The LPN stated staff report to the next shift during shift report any residents on increased supervision. Interview with CNA #5 and CNA #6, on 04/22/13 at 2:50 PM and 3:00 PM respectively, revealed they were talking to each other on Hall I on 04/13/13 when CNA #1 and CNA #4 entered the back door of Hall I. The CNAs stated CNA #1 and CNA #4 had told them the back door alarm of Hall II had sounded, and they were unable to find Resident #1. CNA #4 and #6 revealed they had not heard the door alarm sound. The Nurse called a Code Wanda and staff began searching for the resident. The resident was found out in front of a store. CNA #5 and CNA #6 stated they were not told in shift report that Resident #1 was on 15 minute checks. Interview with the Assistant Director of Nursing (ADON) 04/23/13 at 11:10 AM, revealed it was the Nurse's judgement to place a resident on increased supervision. The ADON stated staff used the Supervision Flow Sheets to document a resident was on the increased supervision. The ADON revealed she was not aware of Resident #1 being on increased supervision at the time of the elopement. Interview with the Director of Nursing (DON), on 04/23/13 at 11:20 AM, revealed it was the Nurse's judgement whether to place a resident on increased supervision or not. The staff use the Supervision Flow Sheets to document the monitoring of the resident on increased supervision. The nurse should update the care plan when a resident is placed on increased supervision. The DON stated Licensed staff and CNAs were made aware a resident was on increased supervision through shift report. The Interdisciplinary Team conducts a morning meeting every day and discusses any residents on increased supervision and decides if the resident needs to continue on increased supervision or not. The DON revealed when a resident attempts to exit the facility the Interdisciplinary Team tries to determine the the cause of the resident attempting to leave. The DON stated if the IDT team determined the resident should be discontinued from increased supervision, the IDT team should update the care plan and make the Nurse on duty aware. The DON stated the Resident #1 should have remained on increased supervision (15 minute checks) from the time the resident was placed on 15 minute checks after the 03/27/13 incident until the time of the elopement on 04/13/13. The DON revealed he was unable to find the Supervision Flow Sheets or any other evidence that verified Resident #1 was monitored while on 15 minute checks after the 02/10/13, 03/09/13, and 03/27/13 incidents of exit seeking behavior. Interview with the Administrator, on 04/23/13 at 12:10 PM, revealed Resident #1 was placed on 15 minute checks on 03/27/13 and the 15 minute checks were never discontinued . Interviews with members of the IDT (MDS Nurse, Life Enrichment Director, Dietary Service Manager, Director of Rehabilitation and Social Services Director) on 03/24/13 at 2:45 PM, 2:55 PM, 3:00 PM and 3:05 PM respectively, revealed they could not recall if Resident #1 was taken off increased observation or not. Observation of the area between the facility and the front of the store where Resident #1 was found revealed the area was approximately 0.1 mile from the facility. The resident had to cross a two lane highway with a speed limit of 35 miles per hour (mph) and was found walking down the side of another high traffic two lane highway with a speed limit of 35 mph. A review of the Supervision Flow Sheets, dated 04/13/13-04/18/13 revealed Resident #1 remained on 1:1 until he/she was transferred to a facility with a locked ward on 04/18/13. ** The facility implemented the following actions to remove the Immediate Jeopardy: *All current residents of the facility were reviewed by the IDT on 04/23/13, the IDT consisting of the DON, ADON, Minimum Data Set (MDS) Nurse, Social Services Director, Life Enrichment Director, Dietary Service Manager and Director of Rehabilitation. The IDT reviewed all residents to determine if the current level of supervision was adequate to meet the needs of the resident based on medical condition, behaviors, falls, elopement risk, safety awareness and cognition status. If increased supervision was warranted it was reflected on the resident's care plan. No residents were felt to have a need for increased supervision not already reflected on the care plan. * The IDT to include the Administrator was reeducated by the Regional Nurse Consultant related to the process of IDT review prior to decreasing supervision for the resident, as well as things to consider prior to decreasing the supervision to include but not limit to current behaviors, medications, patterns or trends, medical needs and activity needs. This education was provided on 04/23/13. Any supervision changes will be noted on the resident's plan of care. The DON will be responsible for ensuring this is completed. the Supervision Flow Sheet will be utilized to document increased supervision. This form will be reviewed by the DON and then given to Medical Records for storage. This education was provided on 04/23/13. *All licensed Nurses were re-educated on the following: licensed staff may increase supervision using their nursing judgement and should notify the DON when they have increased supervision. Licensed staff may recommend decreasing supervision to the DON for IDT review prior to changes being made. *The facility also provided re-education to all nursing staff that increased supervision will be noted on the staff assignment sheets. The Administrator is responsible to ensure this is completed. This education began 04/23/13 with no staff working after 04/23/13 without having received this education. The education was provided by the DON and ADON. *An ad hoc Quality Assurance Committee was convened on 04/23/14 to review the survey concerns related to supervision and the documentation of decreased supervision. In attendance was the Administrator, DON, ADON, Social Service Director, MDS Nurse, Activity Director and Dietary Services Manager. The Medical Director attended by conference. The above was reviewed with no further recommendations noted. *The facility will convene a Quality Assurance Committee weekly until substantial compliance to review all changes in supervision as well as any elopement attempts to assure that the interventions are carried out as care planned and that any decreases in supervision are reviewed by the IDT. The State Survey Agency validated the corrective action taken by the facility as follows: A record review of sampled resident revealed the residents were reviewed on 04/23/13 by the IDT team to determine if the current level of supervision was adequate and the care plan and assignment sheet showed the increased level of supervision. Interviews with the IDT team (Administrator, DON, ADON, Activity Director, Director of Rehabilitation, MDS Nurse, Social Service and Dietary Manager) on 04/24/13 at 3:05 PM, 3:40 PM, 3:45 PM, 3:50 PM, 4:00 PM, 4:05 PM, 4:10 PM, and 4:20 PM respectively, revealed they reviewed all residents' behaviors, falls, medical condition, elopement risk cognition and safety awareness to determine if they had the appropriate level of supervision and the care plans and assignment sheets reflected the appropriate level of increased supervision, if needed. In addition, the IDT team was re-educated on the process of reviewing to see if a resident was appropriate for decreased supervision by the Regional Nurse Consultant. Further interview with the DON revealed he was responsible for ensuring the increased level of supervision was noted on the resident's care plan and reviewing the increased supervision flow sheets to ensure staff were completing them. The DON revealed he was also responsible for ensuring the flow sheet were taken to Medical Records so the sheets could be place the the resident's overflow record. Further interviews with the Administrator, DON, Activity Director, Social Service Director and Activity Director and Dietary Service Manager revealed an Ad Hoc meeting was conducted on 04/23/13 with the Medical Director on conference call related to the concerns about supervision. No further recommendations were identified. Further interview revealed the Quality Assurance Committee would meet weekly to review all changes in supervision and if any elopement attempts were made by any residents. The IDT revealed their job during these meetings would be to ensure interventions were carried out and all increased supervision was reviewed by the IDT. The team revealed they would also be reviewing to ensure incidents of increased supervision was placed on the resident's care plan, on the assignment sheet and Supervision Flow Sheet were initiated. The Administrator revealed she received the same education and would be responsible to ensure the facility staff were following the facility's policy and procedures related to supervision. In addition, she stated she would be responsible for ensuring the daily Assignment Sheets included any residents on increased supervision and she would be supervising the weekly Quality Assurance Meetings to ensure the plan developed and initiated to correct the deficient practice is effective. Interviews with Registered Nurse (RN) #1 and LPN #6, on 04/24/13 at 4:50 PM and 4:55 PM respectively, revealed they were re-educated by the DON related to the fact they could place a resident on increased supervision if warranted but they must notify the DON. In addition, they can recommend a decrease in supervision but IDT makes the final decision that the decreased supervision is warranted. Interviews with RN #1, LPN #6, CNA #2, CNA #7 and CNA #8 on 04/24/13 at 4:35 PM, 4:40 PM, 4:42 PM, 4:48 PM, 4:50 PM, revealed they received education from the DON and ADON related to all increased supervision will be placed on the assignment sheet.

Based on interview, record review, facility policy and procedure review, and the Administrator's job description it was determined the facility failed to be administered in a manner which enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for one resident (#1), in the selected sample of five residents. The Administrator failed to ensure policies and procedures were implemented to provide adequate supervision for Resident #1. (Refer to F282 and F323). Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed Resident #1 at risk for elopement and implemented a plan of care for elopement initiating the wander guard/care alert device. Resident #1 attempted to exit the building on 02/10/13, 03/09/13 and 03/27/13 by holding the door lever handle down for fifteen (15) seconds so the door lock would release. On 03/28/13, the facility determined Resident #1 needed a more secure environment due to the resident's increased incidents of trying to leave the facility and made a referral to a facility that had a locked unit. The resident was placed on fifteen (15) minute checks after the episode on 03/27/13; however, there was no documented evidence the fifteen (15) minutes checks were completed on a regular basis. Staff interviews revealed the fifteen (15) minute checks were either discontinued sometime between 03/27/13 and 04/13/13 or should have continued and were not being completed. On 04/13/13, Resident #1 exited the building at approximately 3:05 PM. Interviews revealed the door alarm sounded and a Certified Nurse Aide (CNA) responded; however, the CNA went out the door and observed only one side of the building. The CNA re-entered the building and made other staff aware Resident #1 was missing and the staff searched the inside of the building before notifying the Charge Nurse Resident #1 was missing. When the staff was unable to find the resident in the building, staff exited the building and began to search the facility's perimeter. Resident #1 was found by staff at approximately 3:16 PM approximately one-tenth (0.1) of a mile from the facility. The resident had walked across a two-lane highway and was walking in the grass along another two lane highway with high traffic. The speed limit of both highways was 35 miles per hour. Interviews revealed staff had to obtain a wheelchair to bring the resident back to the building because the resident was tired and weak. The resident was assessed with [REDACTED]. The facility's failure to administer the facility effectively and efficiently to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/24/13 and was determined to exist on 04/13/13. The facility was notified of the Immediate Jeopardy on 04/24/13. An acceptable Allegation of Compliance (AoC) was received on 04/25/13 and the State Survey Agency validated the Immediate Jeopardy was removed on 04/24/13, as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: A review of the Administrator's job description, no date, revealed the purpose of the Administrator was to direct the day to day functions of the facility in accordance with current federal, state, and local standard, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided residents at all times. Essential Functions of the position were to ensure excellent care for residents was maintained by overseeing and monitoring patient care services delivered and to direct committees and meetings per company policies. A review of the facility's Missing Resident/Elopement policy and procedure, no date, revealed when staff identify a resident is missing staff should obtain assistance from other staff members in the immediate vicinity, instruct another staff member to make the Charge Nurse aware and conduct a thorough search of the building and premises. A review of the facility's Guidelines for Resident Comprehensive Care Plan, dated 09/08, revealed the resident's comprehensive care plan should be viewed as an Interdisciplinary approach to managing the acute and chronic needs of the resident living in the facility. The comprehensive care plan should always have realistic goals and interventions to address the residents' needs. The facility assessed Resident #1 at risk for elopement and implemented a plan of care for elopement initiating the wander guard/care alert device. Resident #1 attempted to exit the building on 02/10/13, 03/09/13 and 03/27/13, and on 03/28/13, the facility determined Resident #1 needed a more secure environment and made a referral to a facility that had a locked unit. The resident was placed on fifteen (15) minute checks after the episode on 03/27/13; however, there was no documented evidence the fifteen (15) minutes checks were completed on a regular basis. Staff interviews revealed the fifteen (15) minute checks were either discontinued sometime between 03/27/13 and 04/13/13 or should have continued and were not being done. Review of the At Risk for Elopement Care Plan, dated 03/01/13, revealed an intervention was added on 03/27/13 for increased observation; however review of the record revealed there was no evidence Supervision Flow Sheets were completed while the resident was on increased observation and no evidence the 15 minute checks were discontinued. On 04/13/13, Resident #1 exited the building at approximately 3:05 PM. Interviews revealed the door alarm sounded and a CNA responded; however, the CNA went out the door and observed only one side of the building. Staff searched the inside of the building before notifying the Charge Nurse Resident #1 was missing. Resident #1 was found by staff at approximately 3:16 PM approximately one-tenth (0.1) of a mile from the facility. Interview with the Administrator, on 04/23/13 at 12:10 PM, revealed Resident #1 was assessed and care planned as an elopement risk. Resident #1 was placed on increased supervision (15 minute checks) on 03/27/13 after attempting to exit the building. The Administrator revealed as far as she was aware the resident should have been on 15 minutes checks at the time of the resident's elopement on 04/13/13. She stated staff were supposed to fill out the Supervision Flow Sheet while the resident was on increased supervision and the Interdisciplinary Team (IDT) was who determined if the increased supervision could be discontinued. The Administrator revealed when she conducted her investigation into the incident staff had told her they were conducting fifteen (15) checks on Resident #1 prior to him/her exiting the building. The Administrator stated she had determined staff had responded appropriately to the door alarm and thought the supervision forms were completed. However, interviews with CNA #1 and CNA #4 revealed they were not told that Resident #1 was on 15 minute checks and they were not conducting 15 minute checks on Resident #1 on 04/13/13. The CNAs stated the Nurses made them aware if a resident was on increased supervision and this was not reported in change of shift report. Interviews with Licensed Practical Nurse (LPN) #1 and LPN #2 revealed the LPNs were not aware Resident #1 was supposed to be on 15 minute checks on 04/13/13, prior to the elopement. Interview with the Assistant Director of Nursing (ADON) 04/23/13 at 11:10 AM, revealed she was not aware of Resident #1 being on increased supervision at the time of the elopement. Interview with the Director of Nursing (DON), on 04/23/13 at 11:20 AM, revealed he was unable to find the Supervision Flow Sheets or any other evidence that verified Resident #1 was monitored while on 15 minute checks after the 03/27/13 incident of exit seeking behavior. ** The facility implemented the following actions to remove the Immediate Jeopardy: *All current residents of the facility were reviewed by the IDT on 04/23/13, the IDT consisting of the DON, ADON, Minimum Data Set (MDS) Nurse, Social Services Director, Life Enrichment Director, Dietary Service Manager and Director of Rehabilitation. The IDT reviewed all residents to determine if the current level of supervision was adequate to meet the needs of the resident based on medical condition, behaviors, falls, elopement risk, safety awareness and cognition status. If increased supervision was warranted it was reflected on the resident's care plan. No residents were felt to have a need for increased supervision not already reflected on the care plan. * The IDT was reeducated by the Regional Nurse Consultant related to the process of IDT review prior to decreasing supervision for the resident, as well as things to consider prior to decreasing the supervision to include but not limit to current behaviors, medications, patterns or trends, medical needs and activity needs. This education was provided on 04/23/13. Any supervision changes will be noted on the resident's plan of care. The DON will be responsible for ensuring this is completed. the Supervision Flow Sheet will be utilized to document increased supervision. This form will be reviewed by the DON and then given to Medical Records for storage. This education was provided on 04/23/13. *All licensed Nurses were re-educated on the following: licensed staff may increase supervision using their nursing judgement and should notify the DON when they have increased supervision. Licensed staff may recommend decreasing supervision to the DON for IDT review prior to changes being made. *The facility also provided re-education to all nursing staff that increased supervision will be noted on the staff assignment sheets. The Administrator is responsible to ensure this is completed. This education began 04/23/13 with no staff working after 04/23/13 without having received this education. The education was provided by the DON and ADON. *An ad hoc Quality Assurance Committee was convened on 04/23/14 to review the survey concerns related to supervision and the documentation of decreased supervision. In attendance was the Administrator, DON, ADON, Social Service Director, MDS Nurse, Activity Director and Dietary Services Manager. The Medical Director attended by conference. The above was reviewed with no further recommendations noted. *The facility will convene a Quality Assurance Committee weekly until substantial compliance to review all changes in supervision as well as any elopement attempts to assure that the interventions are carried out as care planned and that any decreases in supervision are reviewed by the IDT. The State Survey Agency validated the corrective action taken by the facility as follows: A record review of sampled resident revealed the residents were reviewed on 04/23/13 by the IDT team to determine if the current level of supervision was adequate and the care plan and assignment sheet showed the increased level of supervision. Interviews with the IDT team (Administrator, DON, ADON, Activity Director, Director of Rehabilitation, MDS Nurse, Social Service and Dietary Manager) on 04/24/13 at 3:05 PM, 3:40 PM, 3:45 PM, 3:50 PM, 4:00 PM, 4:05 PM, 4:10 PM, and 4:20 PM respectively, revealed they reviewed all residents' behaviors, falls, medical condition, elopement risk cognition and safety awareness to determine if they had the appropriate level of supervision and the care plans and assignment sheets reflected the appropriate level of increased supervision, if needed. In addition, the IDT team was re-educated on the process of reviewing to see if a resident was appropriate for decreased supervision by the Regional Nurse Consultant. Further interview with the DON revealed he was responsible for ensuring the increased level of supervision was noted on the resident's care plan and reviewing the increased supervision flow sheets to ensure staff were completing them. The DON revealed he was also responsible for ensuring the flow sheet were taken to Medical Records so the sheets could be placed in the resident's overflow record. Further interviews with the Administrator, DON, Activity Director, Social Service Director and Activity Director and Dietary Service Manager revealed an Ad Hoc meeting was conducted on 04/23/13 with the Medical Director on conference call related to the concerns about supervision. No further recommendations were identified. Further interview revealed the Quality Assurance Committee would meet weekly to review all changes in supervision and if any elopement attempts were made by any residents. The IDT revealed their job during these meetings would be to ensure interventions were carried out and all increased supervision was reviewed by the IDT. The team revealed they would also be reviewing to ensure incidents of increased supervision was placed on the resident's care plan, on the assignment sheet and Supervision Flow Sheet were initiated. The Administrator revealed she received the same education and would be responsible to ensure the facility staff were following the facility's policy and procedures related to supervision. In addition, she stated she would be responsible for ensuring the daily Assignment Sheets included any residents on increased supervision and she would be supervising the weekly Quality Assurance Meetings to ensure the plan developed and initiated to correct the deficient practice is effective. Interviews with Registered Nurse (RN) #1 and LPN #6, on 04/24/13 at 4:50 PM and 4:55 PM respectively, revealed they were re-educated by the DON related to the fact they could place a resident on increased supervision if warranted but they must notify the DON. In addition, they can recommend a decrease in supervision but IDT makes the final decision that the decreased supervision is warranted. Interviews with RN #1, LPN #6, CNA #2, CNA #7 and CNA #8 on 04/24/13 at 4:35 PM, 4:40 PM, 4:42 PM, 4:48 PM, 4:50 PM, revealed they received education from the DON and ADON related to all increased supervision will be placed on the assignment sheet.

Based on observation, interview, record review and facility policy and procedure review, it was determined the facility failed to provide adequate supervision to prevent accidents for one resident (#3), in the selected sample of four. The facility failed to ensure their policies and procedures related to falls investigations and interventions were followed. The facility assessed Resident #3 as at high risk for falls. Resident #3 experienced 11 falls from the wheelchair from 01/25/12 through 06/02/12 (approximately four months). On 02/26/12, Resident #3 sustained a laceration to the right eyebrow from an unwitnessed fall that required sutures and had two more unwitnessed falls from the wheelchair (on 04/07/12 and 05/20/12) which resulted in the laceration being reopened. The facility failed to implement interventions for Resident #3 to be in visualized areas when up in wheelchair and to provide an activity box. The facility failed to conduct Interdisciplinary Team (IDT) meetings after each fall to identify if the fall interventions were implemented and if the interventions provided adequate supervision for Resident #3. The facility failed to identify Resident #3 had five unwitnessed falls even though there was an intervention for Resident #3 to be in visualized areas when in wheelchair. In addition, the facility failed to provide increased supervision for Resident #3 when the facility was knowledgeable the resident's self alarming seat belt was not working. These failures to ensure adequate supervision to prevent accidents resulted in Resident #3 having an unwitnessed fall on 06/02/12 which resulted in a fractured right hip. The facility's failures to prevent Resident #3 from experiencing multiple falls without effective intervention to result in a fractured right hip was identified as Substandard Quality of Care. Findings include: A review of the facility's Falls and Injuries policy and procedure, last revised 04/2012, revealed the facility strives to reduce the risk of falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program, and strives to provide supervision and assistance devices to each resident to prevent avoidable accidents. Adequate supervision is defined as the type and frequency of supervision, based on the individual residents assessed needs. Supervision may vary from time to time and resident to resident. The use of tools or items such as personal alarms can help monitor resident's activities but does not eliminate the need for staff vigilance and are not to be utilized in lieu of supervision. A review of the facility's Fall/Injury Management-Post Fall or injury policy and procedure, last revised 04/2012, revealed actions that need to be taken following a fall includes: determining what may have caused the fall, addressing the contributing factors of the fall and revising the plan of care to reduce the likelihood of another fall. The fall/injury should be reviewed at the next scheduled appropriate daily clinical meeting. The review should include a review of current assessments, a review and discussion of the residents previous fall/injury history and identifying trends or potential new risk factors. The care plan should be revised to include new interventions and the interventions should be communicated to staff through the 24 hour status report, Nursing Assistant Assignment Sheet and Plan of Care. A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Falls/Injury Assessment, dated 01/24/12, revealed the facility assessed Resident #3 at risk for falls/injury due to unsteadiness, Traumatic Brain Injury and anti-anxiety medication. A review of the Fall/Injury, Prevention and Management Plan of Care, dated 01/24/12, revealed staff should keep frequently used items within reach of the resident and provide a bed alarm, low bed and mat to floor. Further review revealed an intervention was added on 01/25/12 for staff to conduct 15 minutes checks on Resident #3 due to a fall from his/her bed. A review of the Accident/Injury report, dated 01/28/12 at 11:45 AM, revealed Resident #3 had a witnessed fall from the wheelchair in the common area. The resident sustained [REDACTED]. A review of the 24 hour flow checks revealed the facility continued monitoring Resident #3 every 15 minute checks, an intervention which the facility had initiated on 01/25/12. The facility shortened the chair alarm cord. An interview with Licensed Practical Nurse (LPN) #4, on 07/13/12 at 3:42 PM, revealed she witnessed the fall on 01/28/12. She stated she was at the medication cart and the resident was leaning forward and fell before she could get to him/her. She stated the chair alarm sounded. She revealed the resident often leaned to the right side as was in this instance. She stated the chair alarm was shortened so it would sound if the resident leaned forward. A review of the IDT Notes, dated 01/28/12-02/01/12, revealed there was no evidence the IDT met to discuss this fall. In addition, there was no evidence the facility evaluated the effectiveness of the 15 minute checks to prevent falls. A review of an Accident/Injury report, dated 02/01/12 at 1:40 PM, revealed Resident #3 had an un-witnessed fall in the hall from the wheelchair with no obvious injury reported. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes as was initiated on 01/25/12. The facility implemented laboratory studies to include urinalysis and anti-anxiety medications. A review of the IDT Notes, dated 02/01/12-02/04/12, revealed there was no evidence the IDT met to discuss this fall. In addition, there was no evidence the facility evaluated the effectiveness of the 15 minute checks to prevent falls. A review of a Nurses Note and an Accident/Injury Report, dated 02/04/12 at 2:20 PM, revealed Resident #3 had a witnessed fall from the wheelchair resulting in an abrasion. The staff determined the resident was incontinent and he/she was taken to his/her room for incontinent care. The resident was placed on a toileting program. A review of the 24 hour flow checks revealed Resident #3 continued on 15 minute checks that were initiated on 01/25/12. A review of the Interdisciplinary Team (IDT) Notes, dated 02/04/12-02/06/12 revealed there was no evidence the IDT met to discuss this fall. In addition, there was no evidence the facility identified the 15 minute checks did not provide adequate supervision to prevent a fall. An interview with LPN #4, on 07/13/12 at 3:42 PM, revealed she witnessed the fall on 02/04/12 when the resident fell in the lobby but she was unable to get to the resident before he/she fell . She stated the resident had been incontinent so staff provided incontinent care and placed the resident on a toileting program. A review of the Accident/Injury Report, dated 02/06/12 at 10:00 AM, revealed Resident #3 sustained an unwitnessed fall at 8:20 AM in the lobby from the wheelchair with no apparent injury. The staff reattached the chair alarm and monitored the resident. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes as was initiated on 01/25/12. A review of an IDT note, dated 02/06/12 at 3:10 PM, revealed the IDT met to discuss Resident #3's fall at 8:20 AM. The IDT had therapy evaluate the resident and therapy placed a self releasing alarming seatbelt on the resident's wheelchair. However, there was no evidence the facility identified the 15 minute checks did not provide adequate supervision to prevent a fall. A review of the Minimum Data Set (MDS) assessment, dated 02/06/12, revealed the facility assessed Resident #3 as severely cognitively impaired requiring extensive assistance for transfers, toileting and walking did not occur. In addition, Resident #3 had two falls with one injury since admission. A review of the Comprehensive Care Plan, last updated 01/25/12, revealed there were no new interventions added to address prevention of falls. A review of the nurse's note and review of the Accident/Injury Report, dated 02/26/12 at 8:25 PM, revealed Resident #3 was found in the hallway outside of his/her room lying on the floor on his/her right side. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes, the same intervention that was initiated on 01/25/12. The resident had a two centimeter (cm.) laceration noted to the right periorbital area across eyebrow. The facility transferred the resident to the emergency room and the resident received five sutures to the right eyebrow. In addition, neuro-checks were conducted when the resident returned to the facility. A review of the IDT Note, dated 02/27/12 at 4:00 PM, revealed the IDT team developed an intervention for staff to ensure when the resident was up in the wheelchair the resident should be in visualized areas. In addition, the resident's Ativan was decreased from Ativan 0.5 mg. three times a day to two times a day related to lethargy. A review of the Nurses Notes and Accident/Injury Report, dated 03/13/12 at 5:10 PM and 5:20 PM respectively, revealed Resident #3 had a witnessed fall from the wheelchair in the dining room and sustained an abrasion to the jaw. The resident was assisted back in the wheel chair. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes, as initiated on 01/25/12. An interview, on 07/14/12 at 5:10 PM with a dietary employee, revealed that he saw Resident #3 in the dining room during meal time on 03/13/12. He stated Resident #3 released his/her seat belt and fell , hitting his/her head on the table. He revealed he did not recall hearing an alarm sound. The dietary window was open during meal times and dietary staff was able to view the residents from the kitchen. Interviews with LPN #2 ,LPN #5, LPN #7, Certified Nurse Aide (CNA) #3, CNA #4, CNA #5, CNA #8 and a Physical Therapist Assistant, on 07/12/12 at 9:10 AM, 9:30 AM, and 12:40 PM, on 07/13/12 at 2:25 PM and 4:10 PM, on 07/15/12 at 5:05 PM and on 07/16/12 at 9:10 AM and 1:50 PM respectively, revealed the staff interpreted the intervention for Resident #3 to be in visualized areas as the resident should have been in an area where the resident was in view of staff at all times. The staff revealed Resident #3 should not have been left in the dining room without staff present. A review of the IDT note, dated 03/14/12 at 2:00 PM, revealed the IDT team developed an intervention for staff to offer Resident #3 a nap after lunch. In addition, a review of the facility's timeline and an interview with the Activity Director, on 07/13/12 at 2:37 PM, revealed an activity box was put together and kept in the resident's room. However, review of the Comprehensive Care Plan, last updated 03/14/12, and CNA Assignment Sheet, dated 07/10/12, revealed the care plan did not include an intervention to provide an activity box for the resident. Interviews with LPN #4, LPN #5, LPN #7, CNA #5, CNA #6 and CNA #8 on 07/13/12 at 3:42 PM and 4:10 PM, on 07/15/12 at 5:05 PM and on 07/16/12 at 8:05 AM, 9:10 AM and 1:50 PM respectively, revealed they were not aware of the resident having an activity box. Interview conducted with the Unit Manager after reviewing the CNA care plan, on 07/11/12 at 11:17 AM, revealed the Activity box was not placed on the CNA care plan. She revealed it was the Social Worker's responsibility to update the CNA Care Plans. An interview with the Social Services Director, on 07/11/12 at 1:10 PM, revealed that the social worker is responsible for updating the CNA Care Plans. He stated he should have updated the CNA care plan to include the activity box. A review of an electronic Incident Report, dated 04/07/12 at 1:28 PM, revealed Resident #3 had an unwitnessed fall from the wheelchair and he/she was found on the floor beside his/her wheelchair. The fall resulted in reopening the laceration to the right eyebrow. The resident stated he/she was trying to go smoke. A review of the 24 hour flow checks revealed the facility had discontinued the 15 minute checks on 03/19/12. An interview, on 07/16/12 at 8:05 AM with CNA #6, revealed she was at the nurse's station when Resident #3 fell on [DATE] in the hallway in front of the dining room. She stated she was working on the computer at the nurse's desk and when she looked up she saw Resident #3 had fallen. A review of the IDT note, dated 04/09/12 at 2:45 PM, revealed the resident was sent to the hospital and received sutures to the laceration that was reopened. The IDT requested a therapy evaluation to drop the resident's wheelchair seat; however, there was no evidence the IDT team identified Resident #3 was not in a visualized area according to care plan. A review of the Nurse's Note and Accident/Injury Report, dated 04/26/12 at 6:10 PM, revealed Resident #3 was observed lying on the floor with the wheelchair tipped over and no injury. The resident was assisted back to the wheelchair, vital signs were taken and the resident was placed on 15 minute checks. The resident stated he/she was trying to get his/her keys. An interview, on 07/13/12 at 4:10 PM with LPN #5, revealed she was working on 04/26/12 getting ready to clock out when she turned and saw Resident #3 with wheelchair tipped over in the lobby. She stated the resident was still in the wheelchair. A review of the IDT Note, dated 04/27/12 (no time), revealed anti-tippers and a basket were applied to the resident's wheelchair, however, there was no evidence the IDT identified the resident was not visualized at the time of the fall. A review of the electronic Incident Report, dated 05/06/12 at 1:30 PM, revealed Resident #3 had an unwitnessed fall from the wheelchair in the dining room after the resident released the self release seatbelt and tried to walk. There was no injury identified. The staff was educated on making sure the alarm was always on and to make sure to get to resident as soon as the alarm goes off, because the resident can move quick. A review of the IDT Notes, dated 05/04/12 -05/15/12, revealed there was no evidence the IDT met to discuss the 05/06/12 fall. In addition, there was no evidence the facility identified the resident was not visualized at the time of the fall. A review of the electronic Incident Report, dated 05/20/12 at 4:00 PM, revealed Resident #3 was found on the floor, in the dining room, under the wheelchair with a puddle of blood on the floor. The resident reported he/she was trying to walk to the window. The fall caused the laceration to the resident's right eyebrow to reopen. The resident was sent to the emergency room and returned with five sutures to the right eyebrow. Further review revealed the self-release alarming seat belt was not in good repair. The seat belt was not working properly as the alarm would not sound. Administration was aware and a new lap belt had been ordered but had not been received yet. The incident report noted the "lap belt is not working properly. Administration is aware, and a new lap belt has been ordered, but not received. " An interview with CNA #10, on 07/16/12 at 12:05 PM, revealed Resident #3 was left unattended in the dining room on 05/20/12 by the assigned CNA and Activity Director. She revealed all aides were aware Resident #3 should not be left unattended because of his/her risk of falls. She stated she was charting at the nursing desk on hall 2 when a dietary staff told her that Resident #3 had fallen in the dining room. Resident #3 was laying on his/her right side with his/her eye busted open and blood everywhere. She stated the resident's alarm was not sounding because it had not been working for a couple of days. She stated Administration was aware and a new self releasing alarming lap belt had been ordered. She was not aware of any interventions put in place to address the fact that the resident's alarming seat belt was not working. Interview with Registered Nurse (RN)#3, on 07/16/12 at 9:50 AM, revealed when Resident #3 fell on [DATE], the resident's self alarming lap belt was not working. She stated she called Administration and was told a new one had been ordered and had not come in yet. She was not aware of any interventions put in place to address the resident's risk for falls with the self releasing alarming seat belt not working. A review of an e-mail (proof of order form) and interview with the Nurse Consultant, on 07/16/12 at 11:20 AM, revealed a self alarming Velcro seat belt was ordered on [DATE] and was delivered on 05/26/12. A review of the IDT Note, dated 05/22/12 at 5:00 PM, revealed the resident was referred to therapy and the seat belt was replaced; however, there was no evidence the IDT identified the resident was not visualized by staff at the time of the fall and there was no evidence the facility identified no intervention was put in place to address the resident's lack of supervision related to the self releasing alarming seat belt not working. A review of the nurse's note and electronic Incident Report, dated 06/02/12 at 4:30 PM and 6:00 PM respectively, revealed Resident #3 had an unwitnessed fall in the dining room. The resident was found under the table, bleeding from the left hand. The resident denied pain after the fall. An interview with LPN #2, on 07/11/12 at 3:50 PM, revealed she was made aware of the fall by CNA #3 & LPN #3. They reported to her that the resident was found in the dining room floor by a kitchen staff worker. She revealed LPN #3 assessed the resident after the fall. She stated staff was not assigned to the dining room area when there are no meal times. An interview, on 07/12/12 at 3:20 PM with a cook, revealed that she was working on the day of the 06/02/12 fall. She revealed the kitchen window was open to the dining room and the next thing she knew Resident #3 was on the floor under the table. She notified a nurse but didn't remember which one. She did not recall if the alarm was sounding or not. She stated all staff was supposed to watch out for the residents but kitchen staff was not specifically assigned to watch residents while working in the kitchen. An interview with CNA #3, on 07/12/12 at 12:40 PM, revealed she was at the nurse's station when Resident #3 had the fall on 06/02/12. She stated she and a kitchen staff had just left the dining room approximately three (3) minutes prior to the resident fall. She revealed the kitchen staff and she went to the dining room when they heard the fall. The alarm was not sounding. The resident was found on the floor under the table and was bleeding. She notified the nurse and the nurse told staff to get the resident back into the wheelchair without assessing the resident. She stated she did not recall the name of the nurse. The resident denied pain after fall. The CNA revealed she only worked at the facility for 1 ? months and had never received a copy of the CNA Care Plan and wasn't aware of where to locate a copy in the facility. An interview, on 07/12/12 at 3:55 PM with LPN #3, revealed she recalled the fall on 06/02/12 with Resident #3 in the dining room. She stated she was called to the dining room by kitchen staff. She revealed she and a CNA responded. The resident was under the table. She did not recall if the alarm was sounding or not. She reported the fall to Resident #3's nurse, then went back to her assigned hall. An interview, on 07/11/12 at 5:05 PM and 07/12/12 at 2:35 PM, with the Unit Manager revealed she was the weekend manager on 06/02/12. She stated she was doing rounds when she heard an alarm sounding. She revealed she went into the dining room and saw the resident on the floor under the table. She stated she "checked over" the resident and did range of motion. The resident denied pain and the resident was assisted back into the wheelchair. A review of the IDT Note, dated 06/03/12 at 4:45 PM, revealed an intervention for therapy to evaluate Resident #3 for an activity tray; however, there was no evidence the IDT identified the resident was not visualized by staff at the time of the fall. An interview, on 07/13/12 at 2:25 PM with the Physical Therapist Assistant, revealed Resident #3 was impulsive and tried to get up on his/her own. He stated as far as he knew there was always someone watching him in the lobby. He revealed Resident #3 was always under constant supervision while in their department. An interview, on 07/13/12 at 2:37 PM with the Activity Director, revealed she attended the IDT meetings and meetings after the falls. She stated she set up the activity box and placed it in the resident's room so any one could assist the resident with the box. She revealed she would do the activity box with the resident once a week for about 15 minutes. A review of a Nurse's Notes revealed Resident #3 was assessed every shift after the fall until 06/03/12 at 8:00 AM when staff identified Resident #3's toes were blue and the right ankle and toes were swollen. The physician was called with orders were received to x-ray under the right knee and ankle. A review of an x-ray report of the right knee, dated 06/06/12, revealed there was no evidence of a fracture or dislocation. A review of a nurse's note, dated 06/08/12 at 6:00 PM revealed Resident #3 complained of right leg pain at times. The resident was complaining of pain less frequently and reported the pain is better. A review of a Nurse's Note, dated 06/08/12 at 10:00 PM, revealed Resident #3 complained of pain to the right knee. Pain medication was administered. Further review of the nurse's notes, dated 06/09/12, revealed Resident #3 was identified as having edema to the right hip and thigh. The physician was notified and orders were received to x-ray the right hip. A review of the x-ray report, dated 06/09/12, revealed there was an acute verses subacute intertrochanteric fracture with mild angulation deformity to the right hip. A review of the hospital's history and physical, dated 06/10/12, revealed Resident #3 had surgery to perform an open reduction internal fixation of the right hip. An interview, on 07/13/12 at 3:02 PM with the Social Services Director, revealed he attended the IDT meetings and had discussed the resident's falls. He revealed the staff discussed whether interventions had been effective or not. He stated IDT meetings were done daily. An interview with the Unit Manager, dated 07/16/12 at 10:35 AM, revealed she attended most of IDT meetings as well as meetings after falls. She stated the incident reports were brought to the meetings and the IDT discussed whether past interventions had been effective or not. She revealed when Resident #3 was in visualized areas of staff, it was determined that the resident interacted more with staff and other residents which kept him/her occupied. She stated they had not identified that the resident was continuing to have unwitnessed falls even when in a visualized area and had not identified eight out of eleven (8 of 11) falls from the wheelchair occurred on weekends. An interview with the Director of Nursing (at the time of the falls), dated 07/12/12 at 4:00 PM, revealed she would investigate the falls by interviewing staff present, look at medical history, medications, and environment. She stated falls were tracked and trended by times, residents, shifts, where in the building and days. She was unable to give an explanation as to why there were no interventions put in place to address the seat belt alarm not working, the resident continuing to have falls even when in visualized areas and having unwitnessed falls when the resident was supposed to be visualized.

Based on interviews, record review and review of the facility's policy and procedure it was determined the facility failed to implement the care plan for two residents (#3 and #4), in the selected sample of four. The facility failed to implement the care plan for activity box, failed to ensure the alarming seat belt was functioning, and failed to ensure Resident #3 was in a visualized area when up in wheelchair. A record review revealed Resident #3 had a total of seven unwitnessed falls and sustained a laceration to the right eyebrow from an unwitnessed fall that required sutures on 02/26/12 and had two more unwitnessed falls from the wheelchair (on 04/07/12 and 05/20/12) which resulted in the laceration being reopened. In addition, Resident #3 had an unwitnessed fall on 06/02/12 which resulted in a fractured right hip. In addition, the facility failed to implement non-skid socks and non-skid strips to the floor for Resident #4 per the resident's plan of care. Findings include: A review of the facility's policy and procedure related to Plans of Care, dated January 2012, revealed the plan of care provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well being. A review of the Fall/Injury Management policy and procedure, last revised April 2012, revealed interventions should be communicated to staff through the Care Delivery Guide/Nursing Assistant Assignment Sheet. 1. A record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Falls/Injury Assessment, dated 01/24/12, revealed the facility assessed Resident #3 at risk for falls/injury due to unsteadiness, [MEDICAL CONDITION] and on anti-anxiety medication. A review of the Fall/Injury, Prevention and Management Plan of Care, dated 01/24/12, revealed staff should keep frequently used items within reach of the resident and provide a bed alarm, low bed and mat to floor. Further review revealed an intervention was added on 01/25/12 for staff to conduct 15 minutes checks on Resident #3 due to a fall from his/her bed. A review of the Accident/Injury Report, dated 02/06/12 at 10:00 AM, revealed Resident #3 sustained an unwitnessed fall at 8:20 AM in the lobby from the wheelchair with no apparent injury. The staff reattached the chair alarm and monitored the resident. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes as was initiated on 01/25/12. A review of an IDT note, dated 02/06/12 at 3:10 PM, revealed the IDT met to discuss Resident #3's fall at 8:20 AM. The IDT had therapy evaluate the resident and therapy placed a self releasing alarming seatbelt on the resident's wheelchair. A review of the nurse's note and review of the Accident/Injury Report, dated 02/26/12 at 8:25 PM, revealed Resident #3 was found in the hallway outside of his/her room lying on the floor on his/her right side. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes, the same intervention that was initiated on 01/25/12. The resident had a two centimeter (cm.) laceration noted to the right periorbital area across eyebrow. The facility transferred the resident to the emergency room and the resident received five sutures to the right eyebrow. In addition, neuro-checks were conducted when the resident returned to the facility. A review of the IDT Note, dated 02/27/12 at 4:00 PM, revealed the IDT team developed an intervention for staff to ensure when the resident was up in the wheelchair the resident should be in visualized areas. A review of the Nurses Notes and Accident/Injury Report, dated 03/13/12 at 5:10 PM and 5:20 PM respectively, revealed Resident #3 had a witnessed fall from the wheelchair in the dining room and sustained an abrasion to the jaw. The resident was assisted back in the wheel chair. A review of the 24 hour flow checks revealed the facility continued to monitor Resident #3 every 15 minutes, as initiated on 01/25/12. A review of the IDT note, dated 03/14/12 at 2:00 PM, the facility's timeline and an interview with the Activity Director, on 07/13/12 at 2:37 PM, revealed an activity box was put together and kept in the resident's room. However, review of the Comprehensive Care Plan, last updated 06/18/12 and Nurse Assistant Assignment Sheet, last updated 07/10/12, revealed the care plans were not updated to provide an activity box for the resident. Interviews with LPN #4, LPN #5, LPN #7, CNA #5, CNA #6 and CNA #8 on 07/13/12 at 3:42 PM and 4:10 PM, on 07/15/12 at 5:05 PM and on 07/16/12 at 8:05 AM, 9:10 AM and 1:50 PM respectively, revealed they were not aware of the resident having an activity box. Interview conducted with the Unit Manager after reviewing the CNA care plan, on 07/11/12 at 11:17 AM, revealed the Activity box was not placed on the CNA care plan. She revealed it was the Social Worker's responsibility to update the CNA Care Plans. An interview with the Social Services Director, on 07/11/12 at 1:10 PM, revealed that the social worker was responsible for updating the CNA Care Plans. He stated he should have updated the CNA care plan to include the activity box. A review of an electronic Incident Report, dated 04/07/12 at 1:28 PM, revealed Resident #3 had a fall from the wheelchair while not being visualized by staff and was found on the floor beside his/her wheelchair. The fall resulted in reopening the laceration to the right eyebrow. An interview on 07/16/12 at 8:05 AM with CNA #6 revealed she was at the nurse's station when Resident #3 fell on [DATE] in the hallway in front of the dining room. She stated she was working on the computer at the nurse's desk and when she looked up she saw Resident #3 had fallen. A review of the Nurse's Note and Accident/Injury Report, dated 04/26/12 at 6:10 PM, revealed Resident #3 had a fall in the wheelchair while not being visualized by staff. An interview on 07/13/12 at 4:10 PM with LPN #5 revealed she was working on 04/26/12 getting ready to clock out when she turned and saw Resident #3 with wheelchair tipped over in the lobby. She stated the resident was still in the wheelchair but sustained no injuries. A review of the electronic Incident Report, dated 05/06/12 at 1:30 PM, revealed Resident #3 had a fall from the wheelchair in the dining room while no being visualized by staff. There was no injury identified. A review of the electronic Incident Report, dated 05/20/12 at 4:00 PM, revealed Resident #3 was found on the floor under the wheelchair with a puddle of blood on the floor in the dining room while not being visualized by staff. The unwitnessed fall caused the laceration to the resident's right eyebrow to reopen. The resident was sent to the emergency room and returned with five sutures to the right eyebrow. Further review revealed the self-release alarming seat belt was not in good repair. The seat belt was not working properly as the alarm would not sound. Administration was aware and a new lap belt had been ordered but had not been received yet. Incident report noted the "lap belt is not working properly. Administration is aware, and a new lap belt has been ordered, but not yet received. " An interview with CNA #10, on 07/16/12 at 12:05 PM, revealed Resident #3 was left unattended in the dining room on 05/20/12 by the assigned CNA and Activity Director. She revealed all aides were aware Resident #3 should not be left unattended because of his/her risk of falls. She stated she was charting at the nursing desk on at hall 2 when a dietary staff came out and told her that Resident #3 had fallen in the dining room. Resident #3 was laying on his/her right side with eye busted open and blood everywhere. She stated the resident's alarm was not sounding because it had not been working for a couple of days. She stated Administration was aware and a new self releasing alarming lap belt had been ordered. She was not aware of any interventions put in place to address the fact that the resident's alarming seat belt was not working. Interview with Registered Nurse (RN) #3, on 07/16/12 at 9:50 AM, revealed when Resident #3 fell on [DATE], the resident's self alarming lap belt was not working. She stated she called Administration and was told a new one had been ordered and had not come in yet. She was not aware of any interventions put in place to address the resident's risk for falls with the self releasing alarming seat belt not working. A review of e-mail of a proof of order form and interview with the Nurse Consultant on 07/16/12 at 11:20 AM, revealed a self alarming Velcro seat belt was ordered on [DATE] and was delivered on 05/26/12. A review of the nurse's note and electronic Incident Report, dated 06/02/12 at 4:30 PM and 6:00 PM respectively, revealed Resident #3 had an unwitnessed fall in the dining room. The resident was found under the table, bleeding from the left hand. The resident denied pain after the fall. An interview with the Unit Manager, LPN #2, LPN #3, CNA #3 and the Cook (staff #2), on 07/11/12 at 3:50 PM and 5:05 PM and on 07/12/12 at 12:40 PM, 2:35 PM, 3:20 PM and 3:55 PM respectively, revealed Resident #3 was in the dining room with no staff present and not visualized when the fall occurred. The staff revealed that staff were not assigned to the dining room area when meals were not being provided. Interviews with Licensed Practical Nurse (LPN) #2 ,LPN #5, LPN #7, Certified Nurse Assistant (CNA) #3, CNA #4, CNA #5, CNA #8 and a Physical Therapist Assistant, on 07/12/12 at 9:10 AM, 9:30 AM and 12:40 PM, on 07/13/12 at 2:25 PM and 4:10 PM, on 07/15/12 at 5:05 PM and on 07/16/12 at 9:10 AM and 1:50 PM respectively, revealed the staff interpreted the intervention for Resident #3 to be in visualized areas as the resident should have been in an area where the resident was in view of staff at all times. The staff revealed Resident #3 should not have been left in the dining room without staff present. An interview with the Director of Nursing (at the time of the falls), dated 07/12/12 at 4:00 PM, revealed staff should implement the interventions on the care plan. A review of a Nurse's Notes revealed Resident #3 was assessed every shift after the fall until 06/03/12 at 8:00 AM when staff identified Resident #3's toes were blue and the right ankle and toes were swollen. The physician was called with orders were received to x-ray under the right knee and ankle. A review of an x-ray report of the right knee, dated 06/06/12, revealed there was no evidence of a fracture or dislocation. Further review of the nurse's notes, dated 06/03/12-06/09/12 revealed the nursing staff continued to assess Resident #3 and identified the resident had right leg pain at times. A review of the nurse's notes, dated 06/09/12 revealed Resident #3 was identified as having [MEDICAL CONDITION] to the right hip and thigh. The physician was notified and orders were received to x-ray the right hip. A review of the x-ray report, dated 06/09/12, revealed there was an acute verses subacute intertrochanteric fracture with mild angulation deformity to the right hip. A review of the hospital's history and physical, dated 06/10/12, revealed Resident #3 had surgery to perform an open reduction internal fixation of the right hip. 2. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Comprehensive Care Plan for fall/injury assessment: prevention and management, dated 05/31/12, revealed Resident #4 was at risk for falls related to pain, Diabetic [MEDICAL CONDITION], Arthritis, Weakness, High Blood Sugar, Exhaustion, Hypertension, Bowel/Bladder Incontinence, Sensory Impairment and Pharmacologic factors. Further review revealed interventions for one staff to assist with ambulation and transfer, provide increased supervision and a high/low bed. A review of Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4 as cognitively intact and the resident required extensive assistance of one staff for transfers, walking and toilet use. A record review of Accident/Incident report, dated 06/17/12 at 8:05 PM, reveals that Resident #4 had an un-witnessed fall in her room. A record review of the Fall/Injury Assessment, dated 06/18/12, revealed the addition of interventions for non-skid adhesive to floor and non-skid socks. An observation on 07/10/12 at 8:50 AM and 1:56 PM respectively, revealed Resident #4 was ambulating in room with walker, there were no non-skid strips noted on the floor beside resident's bed or bathroom and the resident did not have non-skid socks on his/her feet. Interviews with CNA #1 and CNA #8, on 07/10/12 at 2:47 PM and 4:00 PM and on 07/11/12 at 8:22 AM and 9:40 AM respectively, revealed that they were unaware of any special fall precautions in place for this resident. An interview with Unit Manager, LPN #1, on 07/11/12 at 10:20 AM, revealed Resident #4 should have non-skid strips on the floor and should have non-skid socks on his/her feet. After reviewing the Comprehensive Care Plan and CNA assignment sheet the Unit Manager noted the interventions for the non-skid socks and strip was not transferred to the CNA Assignment Sheet. An interview with Social Services Director, staff #1, on 07-11-12 at 1:10 PM revealed that he/she was aware that he failed to get the non-skid strips and non-skid socks listed on the Comprehensive Care Plan for Resident #4 transferred to the CNA Assignment Sheet. This resulted in the CNAs not knowing about the interventions so they could ensure the interventions were implemented.

Based on interview, record review, closed record review and review of the facility's social services job description, it was determined the facility failed to provide medically related social services for four (4) of six (6) sampled residents (Resident #1, #2, #4 and #6). The facility failed to ensure social service staff was provided adequate orientation in order to effectively meet State and Federal regulations; failed to address specific resident behaviors; failed to identify and implement specific social service interventions to assist with resident goal achievement; failed to provide evidence of social service interventions successfully addressing resident needs; failed to document monitoring of resident progress; and failed to assess the effectiveness of antipsychotic medications. Resident #1, having a history of suicidal attempt in 1995, and verbalizing suicidal ideations during his/her residence, committed suicide in the facility on 07/24/11. The facility provided a credible allegation of compliance on 07/28/11. The state agency verified Immediate Jeopardy was removed 07/28/11 prior to exit on 07/29/11; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: Review of the job description for the Social Services Director (SSD), dated 08/07/06, revealed the SSD was responsible for initiating and maintaining a comprehensive social services program, assisting residents to achieve and maintain their maximum psychosocial functioning and independence, coordinated behavior management programs and maintained resident records in accordance with state and federal regulations. 1. Review of the closed clinical record revealed Resident #1's history and physical from a psychiatric hospital, dated 09/23/10, documented the resident tried to overdose in 1995. The resident experienced delusions, hallucinations and would sometimes refuse medication and care. The Comprehensive Evaluation For Mental Illness and Mental Retardation (PASRR) Level II, completed on 11/11/10, revealed the resident had a history of [REDACTED]. The document detailed Resident #1 had [DIAGNOSES REDACTED]. The social worker documented the antipsychotic medications during the admission assessment; however, there was no documented evidence the social worker implemented care plan interventions to address the resident's mental condition related to history of attempted suicide. Review of the hospital's History and Physical (H&P) revealed, on 01/14/11, the resident was admitted having the chief complaint of refusing to eat and stating he/she wanted to die. The document revealed the resident was admitted related to suicidal ideations, paranoid schizophrenia, dehydration and possible urinary tract infection. The resident was readmitted to the facility on [DATE]. Review of the comprehensive care plan, dated 01/20/11, two months after the resident was admitted , revealed the facility identified the resident's mood and behaviors, that might be harmful to self, as schizophrenia, psychosis, hallucinations, delusions and paranoia; however, reality orientation, psychotropic medications, and providing the resident with foods he/she liked were the only documented interventions provided by the facility. There was no evidence the facility documented specific details or interventions related to addressing the resident's risk of suicide. Review of the January 2011 social services notes revealed no documented evidence that social services assessed the resident related to her suicidal ideation after the hospitalization of 01/14/11. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/08/11, revealed the facility assessed the resident as having continuous disorganized thinking, felt little pleasure or interest in doing things, was feeling down, was depressed, felt hopeless, had little energy, was feeling bad about him/herself and was having thoughts that he/she would be better off dead. The assessment detailed the resident felt this way nearly every day of the assessment period. There was no documented evidence the facility added interventions or made changes to the care plan to reduce the resident's risk of suicide. Interview with Licensed Practical Nurse (LPN) #1, on 07/26/11 at 11:00 AM, revealed Resident #1 had moods. She detailed reality orientation and redirection failed to bring the resident back to reality. She stated once the resident was in his/her world, nothing could bring him/her back. In addition, the resident would refuse psychotropic medication. Review of the Psychological Progress Note and Treatment Plan, dated 02/26/11, revealed Resident #1 had increased agitation, anxiety, crying, depressed, paranoid delusions, and auditory hallucinations. The Psychologist trained the resident on relaxation skills, and developed psychosocial interventions to be used when the resident exhibited resistance to care, anxiety, agitation, and delusions. Record review revealed no evidence social services implemented the pschosocial interventions the Psychologist recommended to use. Review of the Psychologist visit with the resident on 04/26/11 revealed the resident stated "I just don't want to live". Record review revealed no documented evidence the Social Services addressed the resident's continued verbalizations of suicidal ideation. The psychologist saw the resident again on 05/19/11 at which time the Psychologist determined the resident had increased anxiety, increased delusions, visions of demons, and increased auditory hallucinations. Review of the Physician notes, dated 05/20/11, revealed the resident had complaints of anxiousness/stress at all times, hallucinations-paranoid schizophrenia, worrying-about everything, and visual and auditory hallucinations. Review of the Social Service progress notes, dated 05/23/11, revealed Resident #1 had behaviors over the weekend and received post acute monitoring for three (3) days and the care plan was reviewed and updated. However, there was no evidence of documentation regarding the type of behavior the resident was having, what interventions were not effective, or what was being monitored or what actually occurred over the weekend. In addition, there was no documented evidence the resident's psychotropic medications were reviewed for efficacy. Review of the June and July 2011 Medication Administration Records (MAR) revealed the resident was compliant with the administration of an injectable antipsychotic used to treat the symptoms of schizophrenia, delusions and hallucinations. The resident refused other oral antipsychotic medications. There was no evidence provided to demonstrate the facility assessed the effectiveness of the resident's antipsychotic medication. Continued review of the Psychological Progress Note and Treatment Plan, revealed the resident exhibited a reduction in behaviors/thoughts/sensory issues/mood; however, the resident continued to see evil people when seen on 07/10/11. Review of the Social Services notes and care plan revealed there was no evidence the facility assessed the frequency of behaviors, the effectiveness of the behavior interventions or attempted different interventions to address the residents' behaviors. Record review of nurses notes dated 07/24/11 revealed facility staff found Resident #1 dead with a trash bag over his/her head, having committed suicide. Refer to F323. Interview with the Social Services Director, on 07/28/11 at 11:10 AM, revealed she utilized the MDS, psychiatrist notes, staff documentation, behavior notes, and progress notes to assess residents and to develop a care plan and interventions for each resident. She stated she was not aware Resident #1 had suicidal ideation, though she had reviewed the clinical record. 2. Record review for Resident #2 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. Social Service notes, dated 02/18/11 and 04/28/11, revealed the resident was unhappy at the facility, cursed and hit staff during care and voided on the floors; however, review of Resident #2's care plan, dated 07/05/11, revealed the facility did not develop a plan of care for the resident urinating on the floors and a plan to protect other residents from harm related to the resident's hitting behaviors. Progress notes, dated 07/06/11, revealed the resident was urinating on the floors; however, the quarterly MDS assessment, dated 07/09/11, revealed the resident had no behaviors. 3. Review of the clinical record for Resident #4 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The PASRR II completed 11/23/10 revealed the resident sustained [REDACTED]. The resident had a history of [REDACTED]. The PASRR indicated the resident needed to be monitored for mood swings. The psychologist visit on 04/07/11 revealed the resident had an obsession with an employee. The quarterly MDS assessment completed by the facility on 05/23/11 revealed the resident had no behaviors. Social Services progress notes, dated 05/27/11 revealed the resident resisted care and hallucinated and staff needed to remind the resident of the facility being a safe environment. There was no evidence provided to demonstrate the facility assessed and developed interventions to address the resident's mood swings, obsession with a staff member, agitation or threatening behaviors were assessed and interventions on the care plan were effective or not effective. In addition, there was no evidence documented to determine the effectiveness of the resident's antipsychotic medications. 4. Review of the clinical record for Resident #6 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. Review of the care plan, dated 06/20/11, revealed the resident had delusions, was distracted, restless, resisted care, and easily agitated. Review of the quarterly MDS assessment, dated 07/04/11 revealed the resident had no behaviors during the assessment period. Social Service notes, dated 07/12/11, revealed the resident received antipsychotic medications; however, there was no documentation which demonstrated the facility assessed the effectiveness of the medications. Review of the behavior section of the social services notes revealed no documentation. On 07/19/11, the nursing progress notes indicated the resident was combative to staff during care. The facility failed to develop a care plan to protect residents from harm related to the resident's hitting behaviors. Interview with the Social Services Director, on 07/28/11 at 11:10 AM, revealed she was responsible to manage resident concerns, needs, assessments, psychosocial care plans, referrals, moods and behaviors. She stated she had no experience as a Social Services Director; however, she had worked in a nursing home before as a nurse aide. She stated she utilized the MDS, psychiatrist notes, staff documentation, behavior notes, and progress notes to assess the residents and develop a care plan and interventions for each resident. Review of the social service's orientation documents revealed the SSD was hired on 05/02/11 and visited with a SSD from another facility for orientation on an unknown date. A Social Services Competency was completed on 05/17/11 indicating the SSD was evaluated and competent in all areas. No other evidence of orientation or follow-up specific to social services was provided by the facility. Interview with the Administrator, on 07/28/11 at 11:50 AM, revealed there were plans for the SSD to receive further orientation to the position. She stated the SSD was hired three (3) months ago. Review of the allegation of compliance, dated 07/29/11, with an alleged removal date of 07/28/11 and interview with the Administrator on 11/28/11 at 11:50 AM and the Regional Consultant on 07/28/11 at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past 07/27/11 without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past 07/27/11 without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past 07/27/11 without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on 07/27/11 and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting.

Based on observations, interviews, record review, closed record review and facility policy review, it was determined the facility failed to conduct a comprehensive assessment of each residents' functional capacity for two (2) of six (6) sampled residents (Resident #1 and #2). The facility failed to document care area assessment (CAA) summary information completed on triggered care areas resulting in the facility's failure to identify and address all resident needs. Residents #1 and #2 were admitted to the facility with active psychiatric care needs. The facility failed to use available resources in the medical record to complete additional assessments as required. Resident #1 had a history of [REDACTED]. Resident #1 committed suicide on [DATE]. The facility provided a credible allegation of compliance on [DATE]. The state agency verified Immediate Jeopardy was removed [DATE] prior to exit on [DATE]; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: The facility used the MDS 3.0 Manual as their policy. All residents will have triggered areas assessed using the CAAs. Interview with the Regional Director of Clinical Services, on [DATE] at 10:30 AM, revealed the MDS CAAs were to be completed on triggered care areas. 1. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The admission Comprehensive Evaluation For Mental Illness and Mental [MEDICAL CONDITION] (PASRR) Level II, dated [DATE] revealed the resident had a history of [REDACTED]. The resident attempted to overdose in 1995, had extreme anxiety, and difficulty sorting thoughts and attempting to talk about concerns. On [DATE], the facility completed an admission Minimum Data Set (MDS) assessment which indicated the resident had no behaviors during the assessment period. Review of the triggered Care Area Assessment (CAA) section of the MDS for [MEDICAL CONDITION] medications, revealed no evidence the facility identified the resident's risk for suicide. This failure prevented the facility from ensuring appropriate interventions were developed through care plan to address the resident's risk for suicide. Review of the nursing notes for [DATE] at 6:45 AM, revealed Resident #1 was found in bed with a plastic trash bag covering the head with a hand clenched around the bag. 911 was called as the resident was a full code and the facility staff initiated cardiopulmonary resuscitation (CPR) until emergency medical staff (EMS) took over and later pronounced the resident dead. Refer to F323. 2. Review of the clinical record for Resident #2 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The resident had periods of noncompliance with medications, hit staff when he/she ran out of cigarettes, and urinated on the floors. The facility completed an annual MDS assessment, dated [DATE], which revealed [MEDICAL CONDITION] medications were triggered as an area for further assessment of care needs. Review of the CAA assessment for [MEDICAL CONDITION] medications revealed the facility did not complete a summary and did not identify behaviors associated with the use of [MEDICAL CONDITION] medications. Interview with the MDS Coordinator, on [DATE] at 10:30 AM, revealed CAA's were used to develop care plans for residents. She stated she did not know why the CAA summary was not completed for Residents #1 and #2. She stated each discipline had certain MDS items to complete and the risk factors were considered for each triggered area. She stated she was responsible for nursing and the social worker was responsible for mood and behavior CAAs. She stated she could not do their work for them. Interview with the Social Services Director, on [DATE] at 11:10 AM, revealed she was not employed at the facility until [DATE] and did not realize Resident #1 had a problem with a past suicide attempt, though she stated she did review the resident's clinical record. Review of the allegation of compliance, dated [DATE], with an alleged removal date of [DATE] and interview with the Administrator on [DATE] at 11:50 AM and the Regional Consultant on [DATE] at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past [DATE] without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past [DATE] without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past [DATE] without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on [DATE] and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting.

Based on interview, record review, closed record review and facility policy review, it was determined the facility failed to develop comprehensive care plans for two (2) of six (6) sampled residents (Resident #1 and #2). Residents #1 and #2 were admitted to the facility with histories of behaviors which were not addressed by the admission Minimum Data Set (MDS) assessments resulting in the facility failing to develop individualized care plans. The facility provided a credible allegation of compliance on 07/28/11. The state agency verified Immediate Jeopardy was removed 07/28/11 prior to exit on 07/29/11; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: The facility's policy for Care Plans, dated October 2008, revealed the appropriate plan of care would be initiated and individualized for the resident. In addition the facility utilized the MDS Manual for care planning. 1. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident with Paranoid [MEDICAL CONDITION] on 11/16/10. Review of the admisssion Comprehensive Evaluation For Mental Illness and Mental [MEDICAL CONDITION] (PASRR) Level II, dated 11/15/10 revealed the resident had a long history of psychiatric hospitalization s with a suicide attempt in 1995. The PASRR revealed the resident had a history of [REDACTED]. The facility completed an admission MDS assessment, on 11/23/10, which indicated the resident rejected care one (1) to three (3) days per week and received [MEDICAL CONDITION] medication ordered by the physican for a history of mental illness and behaviors that included agitation, anxiety, delusional thinking and hallucinations. Review of the Care Area Assessment (CAA) revealed the resident's resistance to care triggered behaviors for further assessment. The CAA for [MEDICAL CONDITION] medications was triggered for further assessment related to the resident's reliance on antipsychotic and antianxiety medication to control symptoms of paranoid [MEDICAL CONDITION] and anxiety which included, agitation, anxiety, delusional thinking and hallucinations. Review of the CAA summary for behaviors revealed the resident rejected care and had periods of hallucinations. There was no evidence to demonstrate the facility identified the resident's risk of suicide. Review of the CAA summary for [MEDICAL CONDITION] medications revealed the resident received an antipsychotic for [MEDICAL CONDITION]. There was no evidence provided to demonstrate the facility assessed the medication for effectiveness. A visit be the psychologist on 12/04/10, revealed the resident was anxious and had an agitated mood. Review of the comprehensive care plan developed from the admission MDS assessment, dated 11/23/10, revealed the facility did address the [MEDICAL CONDITION] medications; however, there was no evidence provided to demonstrate how the facility planned to monitor the medications for effectiveness/noneffectiveness. There was no evidence the facility planned interventions to manage the resident's behaviors or protect the resident from another suicide attempt, except for reality orientation, [MEDICAL CONDITION] medications, and providing food the resident liked. Interview with Licensed Practical Nurse (LPN) #1 on 07/26/11 at 11:00 AM, revealed Resident #1 had moods and reality orientation and redirection failed to bring the resident back to reality. She stated once the resident was in his/her world, nothing could bring him/her back. In addition, the resident would refuse [MEDICAL CONDITION] medication. 2. Review of the clinical record for Resident #2 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. The resident had periods of noncompliance with medications, hit staff when he/she ran out of cigarettes, and urinated on the floors. The facility completed an annual MDS assessment, dated 01/08/11, which revealed [MEDICAL CONDITION] medications were triggered as an area for further assessment of care needs. The facility provided no evidence a CAA assessment for [MEDICAL CONDITION] medications was completed. Review of the comprehensive care plan revealed no evidence the facility implemented interventions to monitor the effectiveness/noneffectivenenss of the resident's [MEDICAL CONDITION] medication or to manage the resident's behaviors. Interview with the MDS Coordinator, on 07/28/11 at 10:30 AM, revealed she did not know why comprehensive care plans addressing behaviors for Residents #1 and #2 were not completed. She stated the Social Services person would be responsible for completing any behavior care plans. She stated it was not her job to oversee other disciplines' work. Interview of the Social Services Director, on 07/28/11 at 11:10 AM, revealed she was not hired by the facility until March 2011. She stated she had reviewed Resident #1 and #2's care plans since March 2011; however, she did not notice any problems with those care plans. Interview with the Regional Director of Clinical Services, on 07/27/11 at 10:30 AM, revealed Resident #1's suicide attempt was in the past and the care plan team felt the resident was stable and not at risk for suicide. Review of the allegation of compliance, dated 07/29/11, with an alleged removal date of 07/28/11 and interview with the Administrator on 11/28/11 at 11:50 AM and the Regional Consultant on 07/28/11 at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past 07/27/11 without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past 07/27/11 without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past 07/27/11 without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on 07/27/11 and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting. During an interview with LPN #2, on 07/28/11 at 9:20 AM, he revealed the nurse was responsible for monitoring rounds every two hours and documenting the rounds. He stated a list of high risk residents was developed and posted at each nursing station. He stated staff were trained to recognize the signs of possible suicide and report to the nurse right away. During an interview with LPN #3, on 07/28/11 at 9:40 AM, the LPN revealed all staff were trained on the signs of possible suicide and behaviors and to report this information to the nurse. Review of the in-service attendance records was completed and all nursing staff were trained on making rounds and seeing the resident every two (2) hours and completing the documentation. The nurse was to supervise and sign off. The Administrator will monitor. Review of the in-service attendance records was completed and all nursing staff were trained on psychotic signs and symptoms and suicide prevention, interventions, and the reporting process. Observation of A High Risk for suicide list of residents, based on the MDS, physician notes, and history, was posted at both nursing stations and was on the CNA assignment sheet along with interventions. Observation of the high risk resident rooms, 07/28/11 at 2:30 PM, revealed any self-harm objects were removed. All plastic trash bags were removed, long electrical cords were tied with plastic ties to shorten the length of the cords, plastic bags covering respiratory and suction equipment were removed and items were covered with clean towels. All staff were trained not to leave plastic trash bags around that were not in use. Review of the attendance record for a Quality Assurance Committee meeting held on 07/27/11, addressing the facility's Immediate Jeopardy and the actions taken to resolve the jeopardy, were reviewed and the medical director, staff and managers were present.

Based on interview, closed record review, psychiatric hospital history and physical and facility policy review, it was determined the facility failed to revise a comprehensive care plan for one (1) of six (6) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE] having paranoid [MEDICAL CONDITION] and a history of a failed suicide attempt. On [DATE], the facility transferred the resident to the hospital related to his/her chief complaint including wanting to die. On [DATE], the facility assessed the resident as having feelings of being better off dead. On [DATE], the resident expressed he/she wanted to die. The facility failed to revise/update the care plan and implement interventions to address the resident's mental decline. On [DATE] at 6:45 AM, the facility found the resident deceased , having successfully committed suicide. The facility provided a credible allegation of compliance on [DATE]. The state agency verified Immediate Jeopardy was removed [DATE] prior to exit on [DATE]; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: Review of the facility policy for Care Plans, dated [DATE], revealed the facility documented the date the resident's need was identified, the need identified, measurable goals and specific individualized interventions. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment completed by the facility and dated [DATE] revealed the resident refused care one (1) to three (3) times per week. On [DATE], the resident was admitted to the hospital related to refusing to eat and stating she wanted to die. The resident was readmitted to the facility on [DATE]. Review of the care plan, dated [DATE] revealed no documented evidence the facility developed interventions related to the [DATE] hospital admission where the resident was refusing to eat and wanting to die. The quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident as having continuous disorganized thinking, felt little pleasure or interest in doing things, felt down, depressed, hopeless, had little energy, was feeling bad about him/herself and was having thoughts that he/she would be better off dead. Review of the comprehensive care plan, dated [DATE], revealed the facility had identified the resident's behaviors, that might be harmful to self, as [MEDICAL CONDITIONS], hallucinations, [MEDICAL CONDITION] and paranoia; however, reality orientation, [MEDICAL CONDITION] medications, and providing the resident with foods he/she liked were the only documented interventions provided by the facility. There was no evidence provided to demonstrate the resident's hospital stay, related to not eating and suicidal ideation, resulted in added interventions. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:00 AM, revealed Resident #1 had moods and reality orientation and redirection failed to bring the resident back to reality. She stated once the resident was in his/her world, nothing could bring him/her back. In addition, the resident would refuse [MEDICAL CONDITION] medication. Review of the psychologist's notes, dated [DATE], revealed the resident exhibited anxiety, increased agitation, depression, refused oral medication, and had fixed paranoid [MEDICAL CONDITION]. Review of the notes dated [DATE] revealed the resident told the psychologist he/she "just did not want to live". Refer to F323. Interview with the Social Services Director, on [DATE] at 11:10 AM, revealed she was not employed at the facility until [DATE] and did not realize Resident #1 had a problem with a past suicide attempt. She stated she did review the resident's clinical record; however, she did not remember reading the PASRR or the hospital history. Interview with the MDS Coordinator, on [DATE] at 10:30 AM, revealed the information on the MDS was reviewed during the care plan meeting and compared to previous assessments. She stated each discipline had their own part of the care plan they were responsible for completing. She stated the mood and behavior care plans were managed under social services and not her responsibility. She stated she did not realize the MDS Coordinator was responsible to ensure the MDS process was carried out as required. She stated the Director of Nursing signed off on each MDS. Interview with the Regional Director of Clinical Services, on [DATE] at 10:30 AM, revealed the care plan team felt Resident #1 was stable and therefore, a revision to the care plan was not made. Interview with the Acting Director of Nursing, on [DATE] at 10:30 AM, revealed he was from another skilled facility and had been here for two (2) weeks. He stated he reviewed each MDS prior to signing off. There was no documented evidence that the facility reviewed the resident's assessments, interview results, and psychologist's notes to revise the care plan with effective interventions to address the resident's mental health concerns and the risk of suicide. Review of the allegation of compliance, dated [DATE], with an alleged removal date of [DATE] and interview with the Administrator on [DATE] at 11:50 AM and the Regional Consultant on [DATE] at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past [DATE] without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past [DATE] without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past [DATE] without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on [DATE] and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting. Interview with CNA #6, on [DATE] at 8:15 AM, revealed she received training to make rounds and see each resident every two (2) hours and to document these rounds. She stated she was trained on recognizing the signs of possible suicide thinking and was to report immediately to the nurse. She also received training on using the CNA assignment sheet for information on taking care of high risk residents. Interview with CNA #4, on [DATE] at 9:00 AM, revealed she received training on the list of residents considered high risk for behaviors and possible suicide. This list is at the nursing station and on the CNA assignment sheet with actions to take. She stated any sign was to be reported to the nurse. There are to be no plastic bags around unless we are using them. She indicated the high risk residents' rooms were reviewed for possible dangerous items and they were removed. Staff must make rounds every two (2) hours and see the resident then document on the sheet. Interview with LPN #2, on [DATE] at 9:20 AM, revealed the nurse was responsible for monitoring rounds every two hours and documenting the rounds. He stated a list of high risk residents was developed and posted at each nursing station, as well as on the CNA assignment sheet with actions to take. He indicated these residents rooms were reviewed for potentially dangerous items and these items were removed and plastic bags were not to be left around the facility. He stated staff were trained to recognize the signs of possible suicide and report to the nurse right away. Interview with LPN #3, on [DATE] at 9:40 AM, revealed all staff were trained on the signs of possible suicide and behaviors and to report this information to the nurse. She stated a list of residents at high risk for suicide was developed and posted at the nursing station and on the CNA assignment sheet along with interventions to take. She stated rounds were to be made by the CNA and the nurse and the nurse was to make sure the rounds were made and all staff were to sign off on the rounds. She indicated resident rooms were reviewed, high risk, and any dangerous items were removed. Review of the in-service attendance records was completed and all nursing staff were trained on making rounds and seeing the resident every two (2) hours and completing the documentation. The nurse was to supervise and sign off. The Administrator will monitor. Review of the in-service attendance records was completed and all nursing staff were trained on psychotic signs and symptoms and suicide prevention, interventions, and the reporting process. Observation of A High Risk for suicide list of residents, based on the MDS, physician notes, and history, was posted at both nursing stations and was on the CNA assignment sheet along with interventions. Observation of the high risk resident rooms, [DATE] at 2:30 PM, revealed any self-harm objects were removed. All plastic trash bags were removed, long electrical cords were tied with plastic ties to shorten the length of the cords, plastic bags covering respiratory and suction equipment were removed and items were covered with clean towels. All staff were trained not to leave plastic trash bags around that were not in use. Review of the attendance record for a Quality Assurance Committee meeting held on [DATE], addressing the facility's Immediate Jeopardy and the actions taken to resolve the jeopardy, were reviewed and the medical director, staff and managers were present.

Based on interview, closed record review and hospital history and physical review, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #1) had a safe environment as free of accident hazards as possible; and that each resident received adequate supervision to prevent accidents. The facility failed to ensure staff was trained and knowledgeable regarding caring for residents with psychiatric [DIAGNOSES REDACTED]. The facility failed to identify and evaluate Resident #1's risk for suicide based on history of suicidal attempt in 1995, suicidal ideations expressed on [DATE], [DATE], and [DATE]. The facility failed to identify potential hazards that could be utilized for suicidal acts in the resident's environment. The facility failed to implement interventions, including the need for supervision, to reduce the risk of suicide. The facility failed to make rounds and visualize the resident between the hours of approximately 12 AM and 6:45 AM on [DATE] at which time staff discovered the resident had committed suicide. The facility's failure to ensure residents with psychiatric [DIAGNOSES REDACTED].#1's suicide and was likely to contribute to other residents' injury, harm, impairment or death. Immediate Jeopardy was determined to exist from [DATE] at F 250 S/S "J", F272 S/S "J", F 272 S/S "J", F280 S/S "J", F323 S/S "J", F490 S/S "J", and F520 S/S "J". The facility provided a credible allegation of compliance on [DATE]. The state agency verified Immediate Jeopardy was removed [DATE] prior to exit on [DATE]; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: Interview with the Regional Director of Clinical Services, on [DATE] at 1:00 PM, revealed the facility had reviewed clinical records and developed a list of residents, on [DATE], the facility considered high risk for possible suicide. The facility identified twelve (12) residents as high risk. Continued interview with the Regional Director of Clinical Services, on [DATE] at 6:30 AM, revealed the facility had no written policy for nursing to conduct rounds to monitor residents every 2 hours. However, interview with Registered Nurse (RN) #1, on [DATE] at 9:45 AM, revealed the facility policy was to make rounds on residents every two (2) hours. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:00 AM, revealed the facility required nursing rounds to be made on resident's every two hours and more often as needed, and she expected CNAs to do the same. Interview with CNA #2, on [DATE] at 5:30 AM, revealed she was trained to check residents every two (2) hours and provide the care needed. Interview with CNA #1, on [DATE] at 5:15 AM, revealed she checked on residents every two (2) hours. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident with [DIAGNOSES REDACTED]. Review of the Comprehensive Evaluation For Mental Illness and Mental Retardation (PASRR) Level II completed on [DATE] revealed the resident had a long history of mental illness with numerous psychiatric hospitalization s and an attempted suicide in 1995. The resident was extremely anxious, experienced difficulty sorting out thoughts and trying to explain feelings. The resident was found to have poor insight/judgement and a history of refusing medications and meals. The resident required nursing supervision for medications and management of physical needs and monitoring of agitation, paranoia and delusional thinking. Review of the admission Minimum Data Set (MDS) assessment completed by the facility on [DATE] revealed Resident #1 rejected care one (1) to three (3) days per week. Behaviors and psychotropic medications were triggered for further assessment by the Care Area Assessments (CAA). Review of the behavior CAA revealed the facility identified the resident's refusal of care and periods of hallucinations were related to the psychotic disorder. There was no documented evidence the facility identified and detailed as part of further assessment the resident's agitation, anxiety, delusional thinking, numerous psychiatric hospitalization s, and attempted suicide when the behavior CAA was completed. Review of the CAA for psychotropic medications revealed the resident received an antipsychotic medication. There was no documented evidence that the facility assessed and determined whether the resident's medication was effective or noneffective since admission. Review of the admission comprehensive care plan developed from the admission MDS assessment, dated [DATE], revealed the facility addressed the resident's psychotropic drug use and the potential for side effects related to agitation, psychosis and schizophrenia; however, there was no specific plan, goal or interventions documented to address the resident's history of suicide attempts, hallucinations or delusional thinking. Review of the Psychologist's notes, dated [DATE], revealed Resident #1 had anxiety, had an agitated mood and was acutely psychotic with delusional thinking. The resident refused medications frequently. Facility staff were provided with psychosocial interventions including: supportive listening, invite to activities, use soothing voice and praise compliance; however, there was no evidence these interventions were integrated into the resident's comprehensive care plan. Review of the hospital history and physical (H&P), dated [DATE], revealed the facility had transferred Resident #1 to the hospital with the chief complaint that the resident was "refusing to eat, stating (he/she) wants to die." The H&P revealed the hospital admitted Resident #1 with suicidal ideation, dehydration, history of paranoid schizophrenia and possible urinary tract infection. Record review revealed the facility readmitted Resident #1 on [DATE]. Review of the comprehensive care plan revealed the facility developed a care plan for behavior symptoms that may be harmful to self or others as evidenced by schizophrenia, cognitive deficits, resists care and false allegation that food is being poisoned. The facility established goals that the resident would not injure self or others, would accept care, reduce the frequency of behavior symptoms, would exhibit socially appropriate behaviors and would eat food. Further review revealed the facility detailed only two interventions which were to offer alternative foods from the kitchen that are on the resident "likes" list and to see Psychosocial well-being care plan. Review of the Psychosocial well-being care plan developed on [DATE] revealed problems were identified as hallucinations, delusions, and suspiciousness/paranoia with goals detailed to maintain safety with activity of daily livings skills and will not cause injury to self. The facility developed the following interventions: when having hallucinations/delusions provide reality orientation, as needed medications, psychotropic medications and refer to the psychotropic medication care plan. Further review revealed there were no specific details related to the resident's history of suicide attempts, suicidal ideations during the hospital visit of [DATE] and no interventions detailed to address specific actions to reduce the resident's risk for attempting suicide. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #1 as feeling bad regarding self, had little to no interest in doing things, and feeling he/she would be better off dead nearly every day during the assessment period. Review of the care plan following the quarterly MDS assessment, dated [DATE], revealed there was no documented evidence the facility made revisions to reflect the resident's verbalizations of suicidal ideations and there were no changes to interventions previously established and no new interventions had been added to the care plan to protect the resident from harming him/herself. Record review of Psychologist's notes, dated [DATE], revealed Resident #1 was agitated, anxious, had increased depression, and verbalized "I just don't want to live" to the psychologist. Review of the care plan revealed there was no documented evidence the facility revised the care plan interventions to address the resident's verbalizations of suicidal ideations. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:00 AM, revealed she reported to work, on [DATE] at 6:20 AM, and received report from the off-going nurse. She stated a Certified Nurse Aide (CNA) came to her crying and said we need you in Resident #1's room. She went into the resident's room and found the resident with a plastic trash bag over the resident's head with the bottom just above the resident's open mouth. She could not remember if the resident held the bag or not. She indicated the resident was pale, sweaty, cool to the touch and CPR was started; however, no response was noted during the CPR. She stated EMS arrived at the facility and took over CPR until approximately 7:15 AM when they pronounced the resident dead. Interview with Registered Nurse (RN) #1, on [DATE] at 9:45 AM, revealed she reported for duty on Resident #1's hall, on [DATE] at 6:00 PM, to do a twelve (12) hour shift. She observed Resident #1 at approximately 12:00 midnight and did not see the resident again until 6:45 AM when a CNA discovered the resident had expired. She stated rounds were not made during the night due to issues with other residents needing care. She assumed CNA #3 made rounds throughout the shift as assigned. She went to the resident's room when she heard what had happened and saw the resident in bed with a plastic bag up by the head and staff started CPR. She stated EMS pronounced the resident dead. Review of the nursing notes, for [DATE] at 6:45 AM, revealed Resident #1 was found in bed with a plastic trash bag covering his/her head with a hand clenched around the bag. 911 was called as the resident was a full code and the facility staff initiated cardiopulmonary resuscitation (CPR) until emergency medical staff (EMS) took over and later pronounced the resident dead. Telephone interview with the County Coroner, on [DATE] at 2:50 PM, revealed the resident expired at approximately 12:00 Midnight based on the rigor mortis noted in the body. Interview with the Regional Director of Clinical Services, on [DATE] at 10:30 AM, revealed she was present when CNA #3 was interviewed and verified she worked with Resident #1 and had last seen the resident around 12:45 AM on [DATE]. She stated CNA #3 did not make rounds on Resident #1. She indicated CNA #3 was no longer employed by the facility. Further interview with RN #1 revealed she had no knowledge Resident #1 had attempted suicide in the past or had verbalized thoughts of harming self. She stated this information was important and it was not readily available to staff as she was sure it was not on the CNA assignment sheet. Continued interview with LPN #1 revealed she did not remember hearing of Resident #1's comment on suicide or threat to cause harm to self and was not aware of the resident's history or recent comments to the psychologist or the care plan team regarding suicide. She indicated she did not remember anything specific regarding care on the resident's care plan; however, she was sure there was nothing on the care plan regarding suicide. Interview with CNA #1, on [DATE] at 5:15 AM, revealed she did not remember anything regarding suicide on the CNA assignment sheet or instructions to check the resident more often than every two (2) hours and she was not aware Resident #1 had verbalized thoughts regarding harming self. Interview with CNA #2, on [DATE] at 5:30 AM, revealed she was not aware Resident #1 had a past suicide attempt or had verbalized to staff feelings regarding harming self. She indicated Resident #1's care plan did not mention the past suicide attempt. Interviews with CNAs #4, #5 and #6, on [DATE] at 1:30 PM, revealed they indicated they had provided care for Resident #1 in the past and approaches were listed on the CNA assignment sheet to talk calmly, invite to activities and be positive when the resident exhibited behaviors; however, were not aware the resident had attempted suicide in the past or talked about harming self. Continued interviews with CNAs #1, #2, #4, #5 and #6 revealed they had not received training on caring for psychiatric or suicidal residents. The facility was unable to provide documented evidence that they had provided training to staff to ensure their knowledge on how to provide care to residents with psychiatric [DIAGNOSES REDACTED]. Continued interview with the Regional Director of Clinical Services, on [DATE] at 6:30 AM, revealed Resident #1 had not required rounds every two (2) hours. However, interview with the Administrator, on [DATE] at 11:50 AM, revealed the when the Resident #1's brother was notified of Resident's suicide, he told her the resident had talked about suicide for many years. Review of the allegation of compliance, dated [DATE], with an alleged removal date of [DATE] and interview with the Administrator on [DATE] at 11:50 AM and the Regional Consultant on [DATE] at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past [DATE] without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past [DATE] without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past [DATE] without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on [DATE] and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting. Interview with CNA #6, on [DATE] at 8:15 AM, revealed she received training to make rounds and see each resident every two (2) hours and to document these rounds. She stated she was trained on recognizing the signs of possible suicide thinking and was to report immediately to the nurse. She also received training on using the CNA assignment sheet for information on taking care of high risk residents. Interview with CNA #4, on [DATE] at 9:00 AM, revealed she received training on the list of residents considered high risk for behaviors and possible suicide. This list is at the nursing station and on the CNA assignment sheet with actions to take. She stated any sign was to be reported to the nurse. There are to be no plastic bags around unless we are using them. She indicated the high risk residents' rooms were reviewed for possible dangerous items and they were removed. Staff must make rounds every two (2) hours and see the resident then document on the sheet. Interview with LPN #2, on [DATE] at 9:20 AM, revealed the nurse was responsible for monitoring rounds every two hours and documenting the rounds. He stated a list of high risk residents was developed and posted at each nursing station, as well as on the CNA assignment sheet with actions to take. He indicated these residents rooms were reviewed for potentially dangerous items and these items were removed and plastic bags were not to be left around the facility. He stated staff were trained to recognize the signs of possible suicide and report to the nurse right away. Interview with LPN #3, on [DATE] at 9:40 AM, revealed all staff were trained on the signs of possible suicide and behaviors and to report this information to the nurse. She stated a list of residents at high risk for suicide was developed and posted at the nursing station and on the CNA assignment sheet along with interventions to take. She stated rounds were to be made by the CNA and the nurse and the nurse was to make sure the rounds were made and all staff were to sign off on the rounds. She indicated resident rooms were reviewed, high risk, and any dangerous items were removed. Review of the in-service attendance records was completed and all nursing staff were trained on making rounds and seeing the resident every two (2) hours and completing the documentation. The nurse was to supervise and sign off. The Administrator will monitor. Review of the in-service attendance records was completed and all nursing staff were trained on psychotic signs and symptoms and suicide prevention, interventions, and the reporting process. Observation of A High Risk for suicide list of residents, based on the MDS, physician notes, and history, was posted at both nursing stations and was on the CNA assignment sheet along with interventions. Observation of the high risk resident rooms, [DATE] at 2:30 PM, revealed any self-harm objects were removed. All plastic trash bags were removed, long electrical cords were tied with plastic ties to shorten the length of the cords, plastic bags covering respiratory and suction equipment were removed and items were covered with clean towels. All staff were trained not to leave plastic trash bags around that were not in use. Review of the attendance record for a Quality Assurance Committee meeting held on [DATE], addressing the facility's Immediate Jeopardy and the actions taken to resolve the jeopardy, were reviewed and the medical director, staff and managers were present.

Based on interview, closed record review, history and physical, and facility investigations it was determined the facility was not administered in a manner that enabled it to attain or maintain the residents' highest well-being for one (1) of six (6) sampled residents (Resident #1). During an abbreviated survey, initiated on [DATE] and concluded on [DATE], Substandard Quality of Care and Immediate Jeopardy were identified to exist on [DATE] at 42 CFR 483.25 (F323) Supervision at a scope and severity level of a "J" related to the facility's failure to identify environmental hazards and individual resident risk of suicide, and failure to implement interventions and provide adequate supervision. Resident #1 was discovered in bed deceased with a plastic bag pulled over his/her head on the morning of [DATE]. Refer to F250, F272, F279, F280, and F520. The facility provided a credible allegation of compliance on [DATE]. The state agency verified Immediate Jeopardy was removed [DATE] prior to exit on [DATE]; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: The facility was unable to provide documented evidence that staff was provided with training on caring for residents with psychiatric [DIAGNOSES REDACTED]. Refer to F323. Record review revealed no eivdence the facility identified and evaluated Resident #1's risk for suicide based on past history from the Comprehensive Evaluation for Mental Illness and Mental [MEDICAL CONDITION] (PASRR). Review of the comprehensive care plan, revealed the facility did not address specific details or implement interventions related to the resident's risk for suicide. Resident #1 made verbalizations of wanting to die or being better off dead on [DATE], [DATE] and [DATE]. There was no evidence the facility implemented interventions to address the resident's mental health status or reduce the resident's risk of suicide. On [DATE], the facility discovered Resident #1 dead, having committed suicide. Interview with the Regional Director of Clinical Services, on [DATE] at 1:00 PM, revealed the facility had reviewed clinical records and developed a list of residents, on [DATE], the facility considered high risk for possible suicide. The facility identified twelve (12) residents as high risk. Interview with the Psychologist, on [DATE] at 10:15 AM, revealed the facility needed to provide training to staff, at orientation and ongoing, to ensure staff provided the appropriate care for psychiatric residents. Review of the facility investigation revealed employees were questioned and no one reported hearing Resident #1 express [MEDICAL CONDITION]. Interview with the Administrator, on [DATE] at 11:50 AM, revealed she arrived at the facility on [DATE] after Resident #1 was discovered dead. She did not have policies and procedures in place to address the care of psychiatric residents or residents with suicidal ideation and staff had not received training on providing care for these residents. She indicated the facility had no policies addressing the identification of hazards and resident risks or development of individualized interventions to ensure residents were protected from accidents. She stated Resident #1 had no recent history of suicide attempts or suicidal ideation. She was not aware the resident expressed thoughts regarding being better off dead during the assessment for the Minimum Data Set (MDS) completed on [DATE] or the psychologist's note, dated [DATE], which documented the resident's statement regarding not wanting to live. Interview with the Regional Director of Clinical Services, on [DATE] at 1:00 PM, revealed the facility had reviewed clinical records and developed a list of residents, on [DATE], the facility considered high risk for possible suicide. The facility identified twelve (12) residents as high risk. Review of the allegation of compliance dated [DATE] with an alleged compliance date of [DATE] and interview with the Administrator on [DATE] at 11:50 AM and the Regional Consultant on [DATE] at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past [DATE] without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past [DATE] without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past [DATE] without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on [DATE] and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting. Interview with CNA #6, on [DATE] at 8:15 AM, revealed she received training to make rounds and see each resident every two (2) hours and to document these rounds. She stated she was trained on recognizing the signs of possible suicide thinking and was to report immediately to the nurse. She also received training on using the CNA assignment sheet for information on taking care of high risk residents. Interview with CNA #4, on [DATE] at 9:00 AM, revealed she received training on the list of residents considered high risk for behaviors and possible suicide. This list is at the nursing station and on the CNA assignment sheet with actions to take. She stated any sign was to be reported to the nurse. There are to be no plastic bags around unless we are using them. She indicated the high risk residents' rooms were reviewed for possible dangerous items and they were removed. Staff must make rounds every two (2) hours and see the resident then document on the sheet. Interview with LPN #2, on [DATE] at 9:20 AM, revealed the nurse was responsible for monitoring rounds every two hours and documenting the rounds. He stated a list of high risk residents was developed and posted at each nursing station, as well as on the CNA assignment sheet with actions to take. He indicated these residents rooms were reviewed for potentially dangerous items and these items were removed and plastic bags were not to be left around the facility. He stated staff were trained to recognize the signs of possible suicide and report to the nurse right away. Interview with LPN #3, on [DATE] at 9:40 AM, revealed all staff were trained on the signs of possible suicide and behaviors and to report this information to the nurse. She stated a list of residents at high risk for suicide was developed and posted at the nursing station and on the CNA assignment sheet along with interventions to take. She stated rounds were to be made by the CNA and the nurse and the nurse was to make sure the rounds were made and all staff were to sign off on the rounds. She indicated resident rooms were reviewed, high risk, and any dangerous items were removed. Review of the in-service attendance records was completed and all nursing staff were trained on making rounds and seeing the resident every two (2) hours and completing the documentation. The nurse was to supervise and sign off. The Administrator will monitor. Review of the in-service attendance records was completed and all nursing staff were trained on psychotic signs and symptoms and suicide prevention, interventions, and the reporting process. Observation of A High Risk for suicide list of residents, based on the MDS, physician notes, and history, was posted at both nursing stations and was on the CNA assignment sheet along with interventions. Observation of the high risk resident rooms, [DATE] at 2:30 PM, revealed any self-harm objects were removed. All plastic trash bags were removed, long electrical cords were tied with plastic ties to shorten the length of the cords, plastic bags covering respiratory and suction equipment were removed and items were covered with clean towels. All staff were trained not to leave plastic trash bags around that were not in use. Review of the attendance record for a Quality Assurance Committee meeting held on [DATE], addressing the facility's Immediate Jeopardy and the actions taken to resolve the jeopardy, were reviewed and the medical director, staff and managers were present.

Based on interview, training record and closed record review, it was determined the facility failed to identify quality deficiencies regarding quality assessment activities necessary; and to develop and implement appropriate plans of action to address the care of three (3) of six (6) sampled residents admitted with [DIAGNOSES REDACTED].#2 and #4). The facility failed to recognize the need to train staff on care of psychiatric residents and to recognize the signs and symptoms of suicidal ideation/history of suicide attempts. The facility failed to recognize the need to develop and implement policies; and to train and evaluate staff compliance with supervision of these residents. The facility failed to recognize the need to identify and correct the lack of comprehensive and accurate Minimum Data Set (MDS) assessments which resulted in failure to develop/revise comprehensive care plans to include interventions recommended by the psychologist (PsychPhD) and interventions by the interdisciplinary care team (IDT) to ensure residents were safe and protected. Resident #1 was admitted with a history of a suicide attempt and paranoid [MEDICAL CONDITION]. The resident verbalized thoughts of being better off dead and the facility failed to take actions to address these [MEDICAL CONDITION]. The resident committed suicide on 07/24/11. The facility identified twelve (12) resdients at high risk for suicide. The facility provided a credible allegation of compliance on 07/28/11. The state agency verified Immediate Jeopardy was removed 07/28/11 prior to exit on 07/29/11; which lowered the scope and severity to a "D" at 42 CFR 483.15 Social Services (F250), 42 CFR 483.20 (F272) Resident Assessment, (F279) Develop Comprehensive Care Plans, (F280) Revise Care Plans, 42 CFR 483.25 (F323) Accidents, 42 CFR 483.75 (F490) Administration and (F520) Quality Assurance, while the facility's administration and the Quality Assurance Committee complete training and monitoring for psychiatric residents safety. The findings include: Refer to F250, F272, F280 and F490. Refer to F323 Based on interview, closed record review and hospital history and physical review, it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #1) had a safe environment as free of accident hazards as possible; and that each resident received adequate supervision to prevent accidents. The facility failed to ensure staff was trained and knowledgeable regarding caring for residents with psychiatric [DIAGNOSES REDACTED]. The facility failed to identify and evaluate Resident #1's risk for suicide based on history of suicidal attempt in 1995, [MEDICAL CONDITION] expressed on 01/14/11, 02/08/11, and 04/25/11. The facility failed to identify potential hazards that could be utilized for suicidal acts in the resident's environment. The facility failed to implement interventions, including the need for supervision, to reduce the risk of suicide. The facility failed to make rounds and visualize the resident between the hours of approximately 12 AM and 6:45 AM on 07/24/11 at which time staff discovered the resident had committed suicide. Review of the facility training records and employee orientation revealed the facility was unable to provide evidence of staff training on the care of psychiatric residents and signs and symptoms of suicidal ideation and behavior. The facility admitted residents with mental illness and behaviors; however, the facility did not identify that staff training was required to ensure appropriate care and services were provided to these residents. Interview with CNA's #4, #5 and #6, on 07/27/11 at 12:10 PM, revealed they had not received training on the care of psychiatric or suicidal residents. Interview with the Psychologist, on 07/28/11 at 10:15 AM, revealed the facility needed to provide training to staff, at orientation and ongoing, to ensure staff provided the appropriate care for psychiatric residents. Interview with the Administrator, on 07/28/11 at 11:50 AM, revealed she did not have policies and procedures in place to address the care of psychiatric residents or residents with suicidal ideation and staff had not received training on providing care for these residents. She indicated the facility had no policies addressing the identification of hazards and resident risks or development of individualized interventions to ensure residents were protected from accidents. She stated Resident #1 had no recent history of suicide attempts or suicidal ideation. She was not aware the resident expressed thoughts regarding being better off dead during the assessment for the Minimum Data Set (MDS) completed on 02/08/11 or the psychologist's note, dated 04/25/11, which documented the resident's statement regarding not wanting to live. Interview with the Medical Director, on 07/28/11 at 9:45 AM, revealed policies/procedures for care of psychiatric residents and residents with suicidal ideation were not discussed during quality assurance committee meetings until 07/27/11. The facility was not a psychiatric facility and he was not aware nursing staff had not received training regarding how to care for these residents. He stated the facility needed to develop policies to screen residents for mental illness and make the facility safer. Review of the allegation of compliance dated 07/29/11 with an alleged compliance date of 07/28/11 and interview with the Administrator on 11/28/11 at 11:50 AM and the Regional Consultant on 07/28/11 at 10:30 AM revealed the facility took the following immediate actions: 1. All residents were audited to ensure they received the appropriate level of supervision. 2. All residents clinical records were audited for histories of suicide attempts or suicidal ideation and a list of high risk residents was developed. 3. All high risk residents had their care plans updated and individualized interventions were developed by the care plan team based on individual resident history. 4. All residents determined to be high risk of suicide were assessed to ensure there were no items present in the room that would present a danger to the resident and included removal of plastic trash bags. 5. No staff had worked past 07/27/11 without having received education regarding psychotic symptoms, and suicide prevention to include detection of early warning signs of major mood changes or possible suicidal ideation and the procedure to obtain and provide appropriate interventions. 6. A list of high risk residents is now listed at the nursing stations and on the nurse aide assignment sheets with interventions included on the nurse aide assignment sheets and plan of care. 7. Staff were educated to report immediately any warning signs of major mood changes and/or possible suicidal ideation to their immediate supervisor and at a minimum, residents exhibiting warning signs will be placed immediately on increased supervision. The resident's environment will be assessed for safety and any objects which could be used for self harm will be removed. The resident's family and physician will be notified. The interdisciplinary team will review the resident to ensure appropriate interventions and goals are in place. 8. No nursing staff has worked or will work past 07/27/11 without having received education on the requirement to never leave plastic bags unattended and not in use. 9. No nursing staff have worked or will work past 07/27/11 without having received education regarding the requirement to conduct rounds every two (2) hours and visualize the resident by CNAs and nurses. The completed rounds are documented every two (2) hours, however, the CNAs and nurses are responsible for ensuring these rounds are documented. The Administrator will review the completed documents to ensure rounds are being made every two (2) hours. Any noted noncompliance will result in disciplinary action, up to and including termination. 10. All members of the interdisciplinary team (Social Service Director, Interim Director of Nursing, Clinical Reimbursement Coordinator, Life Enrichment Director and Nutrition Services Manager) were educated by the Regional Director of Clinical Services regarding the Behavior Review Process which includes admission and readmission review of behavior residents and ongoing behavior reviews to include the care planning completion process and interdisciplinary development and revision of care plans based upon resident history and current conditions and assessments. The Quality Assurance Committee met on 07/27/11 and reviewed the plan and the state agency's determination. The Medical Director was in attendance at the meeting. Interview with CNA #6, on 07/28/11 at 8:15 AM, revealed she received training to make rounds and see each resident every two (2) hours and to document these rounds. She stated she was trained on recognizing the signs of possible suicide thinking and was to report immediately to the nurse. She also received training on using the CNA assignment sheet for information on taking care of high risk residents. Interview with CNA #4, on 07/28/11 at 9:00 AM, revealed she received training on the list of residents considered high risk for behaviors and possible suicide. This list is at the nursing station and on the CNA assignment sheet with actions to take. She stated any sign was to be reported to the nurse. There are to be no plastic bags around unless we are using them. She indicated the high risk residents' rooms were reviewed for possible dangerous items and they were removed. Staff must make rounds every two (2) hours and see the resident then document on the sheet. Interview with LPN #2, on 07/28/11 at 9:20 AM, revealed the nurse was responsible for monitoring rounds every two hours and documenting the rounds. He stated a list of high risk residents was developed and posted at each nursing station, as well as on the CNA assignment sheet with actions to take. He indicated these residents rooms were reviewed for potentially dangerous items and these items were removed and plastic bags were not to be left around the facility. He stated staff were trained to recognize the signs of possible suicide and report to the nurse right away. Interview with LPN #3, on 07/28/11 at 9:40 AM, revealed all staff were trained on the signs of possible suicide and behaviors and to report this information to the nurse. She stated a list of residents at high risk for suicide was developed and posted at the nursing station and on the CNA assignment sheet along with interventions to take. She stated rounds were to be made by the CNA and the nurse and the nurse was to make sure the rounds were made and all staff were to sign off on the rounds. She indicated resident rooms were reviewed, high risk, and any dangerous items were removed. Review of the in-service attendance records was completed and all nursing staff were trained on making rounds and seeing the resident every two (2) hours and completing the documentation. The nurse was to supervise and sign off. The Administrator will monitor. Review of the in-service attendance records was completed and all nursing staff were trained on psychotic signs and symptoms and suicide prevention, interventions, and the reporting process. Observation of A High Risk for suicide list of residents, based on the MDS, physician notes, and history, was posted at both nursing stations and was on the CNA assignment sheet along with interventions. Observation of the high risk resident rooms, 07/28/11 at 2:30 PM, revealed any self-harm objects were removed. All plastic trash bags were removed, long electrical cords were tied with plastic ties to shorten the length of the cords, plastic bags covering respiratory and suction equipment were removed and items were covered with clean towels. All staff were trained not to leave plastic trash bags around that were not in use. Review of the attendance record for a Quality Assurance Committee meeting held on 07/27/11, addressing the facility's Immediate Jeopardy and the actions taken to resolve the jeopardy, were reviewed and the medical director, staff and managers were present.