Every finding on record at Daytona Beach Health and Rehabilitation Center

Based on interview with Long-Term Care Ombudsman, record review, staff interviews, and facility policy review, the facility failed to provide a copy of the Nursing Home Transfer and Discharge Notice (NHTDN) to the local Long-Term Ombudsman office for three (Resident #1, Resident #4, and Resident #5) out of five residents reviewed for discharge. The findings include: During an interview with the Long-Term Care Ombudsman on 6/13/25 at approximately 11:00 AM, she stated that the Long-Term Care Ombudsman office had only received one Transfer/Discharge notification from the facility for several months. 1. Review of Resident #1's admission record showed an admit date of 5/15/25. Review of Resident #1's NHTDN dated 5/23/25 did not show the local Long Term Care Ombudsman was notified of transfer to homeless shelter. 2. Review of Resident #4's admission record showed an admit date of 4/2/25. Review of Resident #2's NHTDN dated 4/24/25 did not show the local Long Term Care Ombudsman was notified of transfer to home. 3. Review of Resident #5's admission record showed an admit date of 4/12/25. Review of Resident #5's NHTDN was not dated and did not show the local Long Term Care Ombudsman was notified of transfer to home. An interview was conducted with the Social Services Director (SSD) on 6/17/25 at approximately 12:41 PM. She confirmed that she was responsible for providing the notification of transfer and discharge to the local state ombudsman office. She explained that once the form was completed by all disciplines, and the resident or resident representative signed the form, she would then send a copy of the notification to the ombudsman office via email. When she was asked to provide the email verification for Resident #1, Resident #4, and Resident #5, she stated she was going to resend them all now. No email verifying the Transfer/Discharge notification was provided to the Ombudsman for Resident #1, Resident #4, and Resident #5 was received. An interview with was conducted with the Administrator on 6/17/25 at approximately 1:48 PM. She stated that her expectation for the Transfer/Discharge notice was that the SSD email a copy of all Transfer/Discharge notifications issued to the Long-Term Care Ombudsman office on the first day of each month, with the previous month transfer/discharges. A review of the facility's policy Transfer, Discharge and Therapeutic Leaves (Including AMA) effective June 26, 2019, stated on page 2, section d) (In Florida, fax a copy of the discharge notice to the local Ombudsman Council within 5 business days after signature by resident/legal representative). (Photographic evidence obtained) .

Based on record reviews and staff interview, the facility failed to provide a notice of its bed hold policy prior to transfer of a resident to an acute-care facility to two (Residents #8 and #189) of a total sample of 34 residents. The facility also failed to provide a bed hold policy to 22 (Residents #201, #115, #273, #48, #44, #104, 1, #74, #123, #117, #136, #226, #339, #105, #16, #70, #19, #249, #112, #262, #120, and #9) of 22 additional residents transferred to an acute-care facility who were listed in the facility's January 2024 Discharge Report. The findings include: 1. A review of Resident #8's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, convulsions, genetic torsion dystonia (sustained muscle contractions), tremors, salivary secretions, a history of traumatic brain injury, cauda equina syndrome (lower spinal cord pressure and swelling), dysphagia, and language deficit. A review of a nursing progress note, dated 12/10/23, revealed that the resident was transferred to the hospital after choking during a meal. There was no indication in the record that a bed hold policy had been provided at the time of the resident's transfer to the hospital. 2. A review of Resident #189's medical recored revealed that he was admitted to the facility on [DATE] with diagnoses including, but not limited to schizophrenia, a history of alcohol abuse, bipolar disorder, a history of cannabis abuse, and a fracture of the lower end of the tibia. A review of a nursing progress note, dated 09/07/23, revealed that Resident #189 had been transferred out of the facility via [NAME] Act (involuntary psychiatric admission) due to the endangerment of other residents/staff in the facility. There was no indication in the record that a bed hold policy had been provided at the time of the resident's transfer to the hospital. A review of the facility's Discharge Report for the period of 01/01/24 through 01/31/24, revealed that the facility transferred 24 residents to an acute care facility during that time: Residents #201, #115, #273, #48, #44, #104, 1, #74, #123, #117, #136, #226, #339, #105, #16, #70, #19, #249, #112, #262, #120, and #9. (Copy obtained) On 02/01/24 at 1:05 p.m., an interview was conducted with the Social Services Director (SSD), and she was asked to provide a copy of the bed hold policy that had been provided to Residents #8 and #189 at the time of transfer. She stated she was not responsible for providing the bed hold policy to the residents. She stated she would ask the Director of Nursing (DON) who was responsible for providing that information. On 02/01/24 at 1:17 p.m., the SSD returned and stated per the DON, no one was completing the bed hold policy forms or providing them to the residents as required. She added that going forward, she would be the one responsible for that task. A review of the facility's policy and procedure titled Transfer, Discharge and Therapeutic Leave (including AMA (against medical advice), Policy Number NM 11-18, effective June 6, 2019, Page 2 III Emergency transfer/discharges, revealed that emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident/guest, or other residents/guests. Emergency transfer procedures should include the following: a. Obtain physician's orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. b. Contact an ambulance service and provider hospital, at facility of resident/guest's choice, for transportation and admission arrangements. c. Complete and send with the resident/guest a transfer form which documents diagnosis, reason for transfer/discharge, date, time, physician, current medications, treatments, functional status, and any special care needs and care plan goals. e. The original copies of the transfer form and advanced directives accompany the resident/guest. Copies are retained in the medical record. f. Document information regarding the transfer in the medical record. g. A copy of the resident/guest bed hold policy and admission policies/transfer to hospital notice should be provided upon transfer by the assigned nurse to the resident and/or representative of the resident.

Based on observations, interview, and record review, the facility failed to maintain privacy of residents' personal and medical records for two (Residents #113 and #1) of 34 sampled residents. The findings include: 1. On 02/01/24 at 9:49 a.m., a computer on the nurse's medication cart on the west wing hallway was observed to be unlocked. The computer screen displayed the medical record for Resident #113. The record revealed the resident's physician's orders, physician, and room number. (Photographic evidence obtained) Licensed Practical Nurse (LPN) D was observed exiting Resident #113's room on 02/10/24 at 9:53 a.m. She stated she had to give the resident his medication and forgot to close the computer. 2. On 02/01/24 at 9:59 a.m., the door to room [ROOM NUMBER] was observed with a yellow poster indicating that the resident in 318 bed A was NPO (nothing consumed by mouth) on 02/01/24. The resident's name was also displayed on the door identifying the resident in 318 bed A as Resident #1. In an interview on 02/01/24 at 11:03 a.m. with LPN E, she stated Resident #1was having an abdominal ultrasound and needed to be NPO. When asked about the sign on the door, she stated it should not have been placed there. During an interview with the Director of Nursing (DON) on 02/01/24 at 11:07 a.m., she stated the computer should be locked while the nurse is away from it. When asked about the sign on the door for room [ROOM NUMBER], she stated it should not have been there. She added that the staff should communicate the residents' information during report and the morning huddle meeting. A review of the facility's policy and procedure titled Confidentiality of Medical Information, Policy Number NM 11-10, effective October 1, 2010, revealed that the policy's purpose indicated that the resident had the right to privacy and confidentiality of clinical information. The policy standard read: The facility should keep confidential all information contained in a resident's record, regardless of the form of storage or location of the record, except when release is required to another health care facility or by law. To maintain confidentiality of resident medical information, employees should exercise caution during discussion of a confidential nature with the resident, in using medical record information for documentation purpose, and in the use of signs or care reminder information sheets that may be posted in the resident's room.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure that a resident who required respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive care plan for one (Resident #389) of a total sample of 34 residents. The findings include: On 01/29/24 at 12:23 PM, Resident #389 was observed sitting up in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. Resident #389 stated, My oxygen is set at 4 liters. On 01/30/24 at 10:50 AM, Resident #389 was observed lying in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. (Photographic evidence obtained) On 01/30/24 at 3:30 PM, Resident #389 was observed lying in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. (Photographic evidence obtained) A review of Resident #389's record revealed that he was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, and a dependence on supplemental oxygen. A review of the minimum data set (MDS) assessment with a reference date of 01/25/24 revealed that it was incomplete, in progress, and that the resident was a new admission. A review of the resident's 01/25/24 admission physician's orders revealed the following: Oxygen, 4 liters continuously via nasal cannula for chronic respiratory failure. A review of the care plan dated 1/26/24 revealed the following: FOCUS: Receiving oxygen therapy, continuous at 4 L/min (four liters of oxygen per minute). Goal: I will exhibit no shortness of breath x 90 days. Interventions included but were not limited to: Administer oxygen therapy as ordered. A review of the resident's progress notes from 01/25/24 through 02/01/24, revealed: 01/30/24 06:19 AM Resident is total care, 02 (oxygen) on per order. On 02/01/24 at 1:10 PM, an interview was conducted with Licensed Practical Nurse (LPN) F, who stated she had been trained to administer oxygen but she could not recall how recently that occurred. I can't say I have not had training, it's almost common sense, but we have had in-services and I'm sure oxygen has come up. When she was asked how the correct oxygen flow rate settings were communicated from one staff person to another, she said oxygen flow rate/settings information was passed on during change-of-shift report from nurse to nurse along with the resident's current condition. LPN F further stated she would check the orders against the flow rate setting every time she went into the resident's room. When she was asked about the certified nursing assistants' (CNAs') role regarding residents' oxygen therapy, LPN F stated, the CNAs don't really play a role except to know how many liters the resident is receiving, so they can be our eyes on the floor. A review of the facility's Nursing Procedures Manual revealed the following: Advanced Care Procedures, Policy Title: Oxygen Administration (Policy number: NP.VI-58, Effective date: December 8, 2005, Sepersedes: NP.VI-58 - Nov. 1, 2001), Page one of one - Purpose: To administer high purity oxygen for the treatment of certain diseases or conditions. Standard: Oxygen should be administered under orders of the attending physician, except in case of an emergency. Process: 1. Obtain physician's orders for the rate of flow and route of administration of oxygen. 8. Check oxygen flowmeter for correct liter flow.

Based on observation, interview, and record review, the facility failed to ensure that the resident's record was accurately documented for one (Resident #71) of a total of 34 residents sampled. The findings include: During a medication administration observation on 01/31/24 at 9:30 a.m., Licensed Practical Nurse (LPN) D stated the bumetanide (diuretic) for Resident #71 was not in the medication cart. She went to the emergency drug kit (EDK) and confirmed that the medication was not listed as available in the EDK. She said she would have to contact the Advance Practice Nurse Practitioner (ARNP). On 01/31/24 at 10:10 a.m., LPN D contacted the ARNP who stated he ordered bumetanide on 1/24/24 and asked the nurse to contact the pharmacy and get the estimated time of arrival (ETA) before he could write new orders. LPN D called the pharmacy and was informed that the pharmacy had not received the order for bumetanide. She was asked to send a new order. On 01/31/24 at 10:17 a.m., LPN D was asked to review the medication administration record (MAR) for Resident #71. She confirmed that bumetanide 1 milligram (mg) every day was marked as having been administered from 1/25/24 through 1/30/24 by LPN B. During an interview with the Director of Nursing (DON) on 02/01/24 at 11:07 a.m., she stated she was made aware of the issue. .

Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility's administration failed to provide appropriate supervision to ensure the protection of vulnerable residents from sexual abuse for one (Resident #1) of three residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #1 from unwanted sexual contact by Resident #2, who had a diagnosis of dementia, a history of physical aggression toward other residents, and was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually or physically assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F610, and F867 Review of a facility report revealed that on 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by CNA A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated. CNA A stopped the behavior and notified Licensed Practical Nurse (LPN) B. LPN B directed Resident #2 back to his room accompanied by CNA A. While CNA A was escorting Resident #2 to his room, she informed him that he would need to speak with the police and the Administrator. At that time, Resident #2 asked CNA A if he was going to jail. LPN B notified the House Supervisor of the event. On 2/18/23 at 7:15 p.m., Resident #2 was placed on one-to-one (1:1) supervision. Resident #1 was assessed for injuries with none noted. A review of the facility's Abuse Log from March 1, 2022 through April 13, 2023 revealed that Resident #2 was involved in two other physical resident-to-resident altercations. One occurred on 1/17/23, which involved Resident #2 and another resident in the TV room, when Resident #2's hand was pushed away from a third resident and Resident #2 punched the second resident who had pushed his hand away. During the other incident on 1/29/23, Resident #2 threw an empty chip bag, hitting another resident who wouldn't move, so he could get to the couch. A review of Resident #2's medical record revealed that he was admitted on [DATE] with diagnoses including dementia and depression. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #2's Quarterly MDS assessment, dated 12/22/22, revealed he had adequate vision and hearing, clear speech, he understood others and could be understood. Resident #2 had a BIMS score of 09 out of a possible 15 points, indicating moderate cognitive impairment. He was independently ambulatory. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He states, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. On 4/11/23 At 12:55 p.m., an interview was conducted with CNA M (West Wing). When she was asked if she was familiar with Resident #2, she stated, Yes. When she was asked if he wandered around the facility, she replied, Not really, he is usually in either the TV room or his room. He goes to dialysis and usually waits in the TV room for his ride. When asked if Resident #2 had any issues with other residents, she stated, He hit another resident and another time he threw an empty chip bag at a resident. When asked if he had ever been sexually inappropriate with another resident, she stated, Yes, he got put on 1:1 (one staff to one resident supervision), referring to this incident with Resident #1. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:12 p.m. an interview was conducted with the Administrator. When he was asked to define Resident #2's care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. A review of Resident #1's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease-early onset, depression, and anxiety. Further review of Resident #1's record revealed she was discharged to an ALF per her Power of Attorney's (POA's) wishes on 2/21/23. Resident #1's daughter was her POA. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #1's nursing progress notes from her date of admission on 2/9/23 through the date of the incident on 2/18/23, revealed no documented evidence of Resident #1's having wandering behavior, inappropriate sexual behavior, or disrobing in public. Review of a 2/15/23 Nursing Assessment, revealed that Resident #1 had unclear speech, moderately impaired cognition, short- and long-term memory deficit, and wandering behaviors. A review of Resident #1's 2/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. The following was also documented: Rejection of care, behavior symptoms directed towards others, wandering occurred daily, and independent for locomotion (ambulatory). A review of Resident #1's care plan, dated 2/10/23, revealed the following care areas: Assistance to complete Activities of Daily Living; Potential for Weight Loss; Incontinence with the Potential for Skin Breakdown; and a Potential for Falls related to the use of psychotropic medications. There was no mention of/care plan for resident behaviors prior to the 2/18/23 incident. On 2/20/23, after the incident occurred, the care plan was updated for Wandering with Potential for Elopement and Sexual Expression related to overly affectionate behaviors. On 2/21/23, Resident #1's care plan was again updated to include interventions for Impaired Cognition related to dementia. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A 4/11/23 review of Resident #1's medical record revealed that Resident #1 was to have received psychiatric services for medication management but was not seen while in the facility. She had no baseline psychiatric evaluation or post-incident psychiatric evaluation. Review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Page 1 revealed the following: Purpose: All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. Section III Prevention Policies and Procedures, Page 8, d) The facility will make all reasonable efforts to minimize instances of abuse, but in cases where such an instance occurs, the facility will use the event as an opportunity to develop new interventions in an attempt to prevent a reoccurrence. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on the need for assessment, care planning and monitoring of sexual behavioral issues, thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were also educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the education roster and sign-in sheets revealed that 92% of staff had been reeducated by the DON/designee on the need for assessment, care planning and monitoring of sexual behavioral issues, facility's abuse policy and procedure including sexual abuse and protection of all residents as of 4/13/23. Staff were also reeducated on the facility's 1:1 supervision process by the DON/designee. All staff not already educated would be educated prior to their next shift. Total staff (include PRN (as needed), PT (part time), and FT (full time) was 181. A 4/13/23 review of the facility's IJ removal plan revealed that prior to discontinuation of 1:1 supervision for Resident #2 or any other resident, the QA (Quality Assurance) team would review for appropriateness. A 4/13/23 review of Resident #2's medical record revealed that no decision had been made yet about discontinuing his 1:1 supervision. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly.

Based on interviews, record reviews, a review of the facility's policy and procedure for Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and the facility's policy and procedure for Quality Assurance/Quality Assurance Performance Improvement, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F610, and F835 A review of the facility's investigation of the 2/18/23 sexual abuse of Resident #1 by Resident #2, revealed that the facility had not documented how long Residents #1 and #2 were in the TV room on the date of the incident, nor were their levels of supervision noted. There was no indication in the facility's investigation of whether there were other residents in the TV room at the time the incident occurred. There were no interviews of other vulnerable female residents on the unit regarding possible inappropriate sexual behaviors exhibited by Resident #2 toward them. There were no interviews of staff regarding inappropriate sexual behaviors exhibited by either Resident #1 or Resident #2, and no Quality Assurance and Performance Improvement (QAPI) meeting had been held to review the incident and develop a plan to ensure sexual abuse did not recur. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. On 4/11/23 at 3:12 PM, an interview was conducted with the Administrator. When he was asked to define the care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days and with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He states, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. On 4/12/23 at 12:45 PM, the Director of Nursing (DON) and the Assistant Administrator were interviewed jointly. When they were asked how soon after an incident a QAPI meeting was held, the Assistant Administrator stated, If it's elopement, it is within 24 hours of the event. For substantiated allegations of abuse, there is an emergency QAPI. When asked if there had been an emergency QAPI for the 2/18/23 incident between Residents #1 and #2, the Assistant Administrator stated, No, because we did not substantiate the allegation. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Section III, Page 8, c) revealed the following: If an instance of resident-to-resident . abuse occurs, the facility will take reasonable measures to help prevent a reoccurrence. The facility's Quality Assurance committee is responsible for problem identification and for making certain that the facility takes appropriate corrective action. If actual abuse occurs, an emergency QAPI will be held to review interventions (reiterated on Page 10-11, Section VI, b), first bullet point on page 11). A review of the facility's policy titled Quality Assurance/Quality Assurance Performance Improvement (Effective 1/28/2019, Updated 10/15/2022), revealed: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care. Scope: Our facilities have a Performance Improvement Program which systematically monitors data, analyzes and improves its performance to improve resident/guest outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost. QAPI Plan Addresses: a. Clinical Care - Monitor existing QM results, NHS infonet monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, discharges and rehospitalization s. Governance and Leadership: Administration is responsible and accountable for developing, leading and closely monitoring of QAPI program. a. Input is obtained from facility staff on a monthly basis through the QAPI committees. The committees are responsible for talking to their employees before reporting findings to QAPI. b. The input given will be acted upon and brings QAPI to life in the facility. The concern will be discussed and action plans developed. If necessary, a chartered PIP (Performance Improvement Plan)will be established. c. The administrator will be the Quality Management Coordinator and responsible for QAPI Process. d. The Administrator ensures that consistent, appropriate and just in time training is provided to facility employees. QAPI Leadership: a. The QAPI Senior Committee provides the structure for QAPI. This group includes the Executive leadership team. Feedback, Data Systems and Monitoring: b. The following data is monitored through QAPI: ii. Adverse Events v. Survey Findings e. Dashboard for individual performance improvement projects are used to communicate progress and outcomes of individual QAPI Projects. Communications from the quality committee and its aubcommittees and their actions will be communicated based on the audience. i. For staff we plan to communicate via, monthly staff communication , department meetings and memos. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly. A 4/13/23 review of the education and sign-in sheets revealed that the Administrator and Assistant Administrator were reeducated by the Regional Director on thorough investigation protocols related to the facility's abuse policy and procedure on 4/12/2023. Education included sexual abuse and protection of all residents involved. A thorough investigation into any allegation must include record reviews, root cause analysis, and interviews. On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on the need for assessment, care planning and monitoring of sexual behavioral issues, thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were also educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the facility's IJ removal plan revealed that prior to discontinuation of 1:1 supervision for Resident #2 or any other resident, the QA (Quality Assurance) team would review for appropriateness. A 4/13/23 review of Resident #2's medical record revealed that no decision had been made yet about discontinuing his 1:1 supervision. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. The Administrator and Assistant Administrator were reeducated by the Regional Director on policy and procedures of the QAPI meeting for consistent monitoring of behaviors to ensure residents are protected and supervision is provided for any alleged/actual abuse on 4/12/2023. A QAPI meeting was held on 4/13/23 to address this identified noncompliance. Those in attendance included the QA team and additional members. .

Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in unwanted sexual contact for one (Resident #1) of three residents reviewed for abuse. The facility failed to develop and implement interventions necessary to protect Resident #1 from unwanted sexual contact by Resident #2, who had a diagnosis of dementia, a history of physical aggression toward other residents, and was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually or physically assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F610, F835, and F867 Review of a facility report revealed that on 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by CNA A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated. CNA A stopped the behavior and notified Licensed Practical Nurse (LPN) B. LPN B directed Resident #2 back to his room accompanied by CNA A. While CNA A was escorting Resident #2 to his room, she informed him that he would need to speak with the police and the Administrator. At that time, Resident #2 asked CNA A if he was going to jail. LPN B notified the House Supervisor of the event. On 2/18/23 at 7:15 p.m., Resident #2 was placed on one-to-one (1:1) supervision. Resident #1 was assessed for injuries with none noted. Review of a statement written on 2/18/23 by LPN B, revealed that Resident #2 stated to LPN B, Yes, I was sucking on her titty. A review of the facility's Abuse Log from March 1, 2022 through April 13, 2023 revealed that Resident #2 was involved in two other physical resident-to-resident altercations. One occurred on 1/17/23, which involved Resident #2 and another resident in the TV room, when Resident #2's hand was pushed away from a third resident and Resident #2 punched the second resident who had pushed his hand away. During the other incident on 1/29/23, Resident #2 threw an empty chip bag, hitting another resident who would not move, so he could get to the couch. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He stated, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. A review of Resident #2's medical record revealed that he was admitted on [DATE] with diagnoses including dementia and depression. A review of Resident #2's Quarterly MDS assessment, dated 12/22/22, revealed he had adequate vision and hearing, clear speech, he understood others and could be understood. Resident #2 had a BIMS score of 09 out of a possible 15 points, indicating moderate cognitive impairment. He was independently ambulatory. On 4/11/23 At 12:55 p.m., an interview was conducted with CNA M (West Wing). When she was asked if she was familiar with Resident #2, she stated, Yes. When she was asked if he wandered around the facility, she replied, Not really, he is usually in either the TV room or his room. He goes to dialysis and usually waits in the TV room for his ride. When asked if Resident #2 had any issues with other residents, she stated, He hit another resident and another time he threw an empty chip bag at a resident. When asked if he had ever been sexually inappropriate with another resident, she stated, Yes, he got put on 1:1 (one staff to one resident supervision), referring to this incident with Resident #1. At the time of the interview, the TV room was observed. There were several residents in the room, but there was no couch. (The 2/18/23 incident was noted to have occurred on the couch in the TV room.) A CNA was observed assisting a resident with lunch, but Resident #2 was not in the TV room at that time. On 4/11/23 at 1:15 p.m., an interview was conducted with LPN F/Unit Manager. When she was asked to define the word frequent as related to frequent observation in Resident #2's care plan interventions, she stated she wasn't sure how to define that. When she was asked how often a resident on frequent observation was to be checked, she stated, It depends on where they are. If they are in their room, then every hour or so. If they are in the TV room, then there is usually a staff member either in the TV room or sitting at the nursing station (which is in view of the TV room). On 4/11/23 at 1:18 p.m., Resident #2 was observed lying on his bed, dressed. When he was asked if he had been to dialysis today, he replied, Not yet. When he was asked if he had had any issues with other residents, he stated, No. When asked if any residents had tried to hit him, he replied, No. He stated he felt safe at the facility. He was alone in his room. No staff were providing 1:1 supervision, and no staff were outside his door. On 4/11/23 at 2:28 PM, LPN J/Unit Manager, was interviewed. When she was asked if there were any residents on the unit known for touching or grabbing at residents or staff. She stated, Not really. There was an incident with [Resident #2] who touched another resident's breast. When she was asked if Resident #2 was known for that kind of behavior, she replied, No. When she was asked if she was aware of how Resident #1's breast became exposed, she replied, She wore low-cut tops and she would wander around the day room where Resident #2 hung out. On 4/11/23 at 3:12 p.m. an interview was conducted with the Administrator. When he was asked to define Resident #2's care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. A review of Resident #1's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease-early onset, depression, and anxiety. Further review of Resident #1's record revealed she was discharged to an ALF per her Power of Attorney's (POA's) wishes on 2/21/23. Resident #1's daughter was her POA. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #1's nursing progress notes from her date of admission on 2/9/23 through the date of the incident on 2/18/23, revealed no documented evidence of Resident #1's having wandering behavior, inappropriate sexual behavior, or disrobing in public. Review of a 2/15/23 Nursing Assessment, revealed that Resident #1 had unclear speech, moderately impaired cognition, short- and long-term memory deficit, and wandering behaviors. A review of Resident #1's 2/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. The following was documented: Rejection of care, behavior symptoms directed towards others, wandering occurred daily, and independent for locomotion (ambulatory). A review of Resident #1's care plan, dated 2/10/23, revealed the following care areas: Assistance to complete Activities of Daily Living; Potential for Weight Loss; Incontinence with the Potential for Skin Breakdown; and a Potential for Falls related to the use of psychotropic medications. There was no mention of or care plan for resident behaviors prior to the 2/18/23 incident. On 2/20/23, after the incident occurred, the care plan was updated for Wandering with Potential for Elopement and Sexual Expression related to overly affectionate behaviors. On 2/21/23, Resident #1's care plan was again updated to include interventions for Impaired Cognition related to dementia. Resident #1 was to have received psychiatric services for medication management but was not seen while in the facility. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Pages 2 and 3 revealed the following: The following are definitions of specific types of abuse: 2. Sexual - Sexual abuse is a non-consensual sexual contact of any type with a resident/guest and includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident/guest either appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur. (Refer to Supplemental Questions for Determination of Capacity Related to Sexual Decisions) *Determination of capacity cannot necessarily be based on a diagnosis alone. Any sexual contact between staff and resident/guest unless staff and resident had a prior sexual relationship before resident admission or married to each other (even in a consensual relationship), will be considered an abuse of power. Any sexual contact between resident/guest if one or both lacks ability to consent. Any sexual contact between a visitor and resident/guest if either one lacks ability to consent. Sexual contact can include touching of breasts, genitalia, groin, inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Page 8: Prevention Policies and Procedures C) If an instance of resident-on-resident abuse occurs, the facility will take reasonable measure to help prevent a reoccurrence. The facility's Quality Assurance committee is responsible for problem identification and for making certain that the facility takes appropriate corrective action. If actual abuse occurs, an emergency QAPI will be held to review interventions. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: On 4/13/23 at 11:45 AM, an observation was made on the West Wing. Resident #2 was sitting in the TV room. CNA I was sitting next to him. At 12:35 PM, Resident #2 returned to his room accompanied by CNA I. 1:1 supervision was in place for Resident #2. On 4/13/23 at 12:05 PM, an interview was conducted with Registered Nurse (RN) K, assigned to Resident #2. When she was asked if she received information during the morning change-of-shift report, she stated the staff had to complete a read and sign training document related to abuse and neglect. She was told at that time that Resident #2 was on 1:1 supervision again. RN K was asked if she was familiar with Resident #2. She stated, Yes, this is my assigned area. RN K was asked if she had ever observed Resident #2 display any inappropriate behaviors. She stated, He sometimes has lashed out at other residents. She said he sometimes used inappropriate language toward staff, but she didn't know of him touching any staff. On 4/13/23 at 12:45 PM, an interview was conducted with LPN L. She confirmed that she had received education on abuse and neglect this morning. When she was asked if there were any residents on the unit receiving 1:1 supervision, she stated, Not in my area but (pointing to the hall Resident #2 was on) down that hall. On 4/13/23 at 12:55 PM, an interview was conducted with CNA I (assigned to 1:1 supervision with Resident #2). When asked if she had received education today, she stated, Yes, abuse and neglect and how to document on the 1:1 form. On 4/13/23 at 1:00 PM, the Q (every) 60-minute tool for 1:1 (supervision) was reviewed with no concerns. A process was in place for staff to hand-off the 1:1 supervision when going on break with the receiving person signing in. On 4/13/23, Resident #2's care plan was reviewed. It had been revised on 4/13/23 at approximately 4:00 PM by the Social Services Director to include 1:1 supervision and behavior monitoring. Review of a 2/18/23 nurse's statement revealed that Resident #1 was assessed by the nurse on that date with no obvious injuries identified. The nurse was to be reeducated by the DON/designee on documenting assessments in the nurses' notes prior to reporting to work. A review of the nurses' notes revealed that Resident #1's nurse practitioner was contacted on 2/21/23 by LPN N, Unit Manager, to obtain discharge orders and a signature was obtained on the discharge paperwork on 2/21/23. No psychiatric services were noted between 2/18/23 and 2/21/23 when Resident #1 was discharged . Resident #1 returned to her previous ALF upon her request on 2/21/23. No acute distress was noted. A 4/13/23 review of the facility's IJ removal plan and witness statements, dated 4/11/23 and 4/13/23, revealed that the Social Services department interviewed vulnerable female residents on 4/11/2023. There were no sexually inappropriate behaviors noted, and no one reported being fearful of Resident #2. Resident #2 was documented as back on 1:1 supervision as of 4/11/23 at 6:00 PM. The On 4/11/23, the Social Services Assistant conducted interviews with other alert and oriented residents regarding concerns about sexually inappropriate behaviors and none were voiced. No one reported being fearful. A 4/13/23 review revealed that the facility management interviewed staff on duty and were in the process of calling staff members not currently working. All staff were to be interviewed to determine whether they knew of any unreported sexually inappropriate behaviors prior to working their next shift. 53 of 181 staff members had been interviewed as of 4/13/23. Three current residents with sexually inappropriate behaviors were identified and care planned as of 4/13/23. Two residents including Resident #2 were receiving 1:1 supervision, and the third resident was wheelchair-bound requiring a two-person assist for all activities of daily living (ADLs). A review of Resident #2's physician's orders revealed that a psychiatric evaluation/consult was ordered, and the evaluation was completed on 3/1/23. The resident has continued to be followed by psychiatric services and his next scheduled visit was on 4/13/2023. On 4/13/23 at 1:30 PM, the Psychiatric Mental Health Nurse Practitioner (PMHNP) was interviewed after Resident #2 was seen. He stated he was covering for the usual practitioner and had been contacted to conduct an emergency evaluation. Resident #2's cognition was declining, and he had been started on Paxil (antidepressant) to help with feelings of depression and sadness. On 4/13/23, a review of the 1:1 Supervision sign-in logs, revealed that the Administrator had developed a schedule for the assignment of a staff member to provide 24-hour supervision for Resident #2. The schedule was implemented on 4/11/23 at 6:00 PM. On 4/13/23, a review of the staff education and sign-in sheets, revealed that 92% of staff had signed off as having received education on what constitutes abuse by the DON/designee. On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the education roster and sign-in sheets revealed that 92% of staff had been reeducated by the DON/designee on the facility's abuse policy and procedure including sexual abuse and protection of all residents as of 4/13/23. Staff were also reeducated on the facility's 1:1 supervision process by the DON/designee. All staff not already educated would be educated prior to their next shift. Total staff include PRN (as needed), PT (part time), and FT (full time) was 181.

Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to thoroughly investigate sexual abuse for one (Resident #1) of three residents reviewed for abuse. Failure to investigate sexual abuse thoroughly, contributed to the facility's female residents' risk of suffering the same sexual abuse resulting in serious psychosocial harm, which would diminish self-worth and self-respect. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the West Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023 after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to conduct a thorough investigation, resulting in the provision of inadequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F835, and F867 A review of the facility's investigation of the 2/18/23 sexual abuse of Resident #1 by Resident #2, revealed that the facility had not documented how long Residents #1 and #2 were in the TV room on the date of the incident, nor were their levels of supervision noted. There was no indication in the facility's investigation of whether there were other residents in the TV room at the time the incident occurred. There were no interviews of other vulnerable female residents on the unit regarding possible inappropriate sexual behaviors exhibited by Resident #2 toward them. There were no interviews of staff regarding inappropriate sexual behaviors exhibited by either Resident #1 or Resident #2. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. On 4/11/23 at 3:12 PM, an interview was conducted with the Administrator. When he was asked to define the care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days and with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. She stated, He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Page 10 revealed the following: Section VI. Investigations and Facility Response to Incidents or Accidents b) Bullet point 7-The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. Bullet point 8-A complete and thorough investigation must be conducted on all incidents . whether reportable or not, within five working days to determine the cause of the injury or incident. The outcome of the investigation must also determine whether or not the incident was abusive or neglectful in nature. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly. A 4/13/23 review of the education and sign-in sheets revealed that the Administrator and Assistant Administrator were reeducated by the Regional Director on thorough investigation protocols related to the facility's abuse policy and procedure on 4/12/2023. Education included sexual abuse and protection of all residents involved. A thorough investigation into any allegation must include record reviews, root cause analysis, and interviews. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. A review of Resident #2's care plan revealed that it had been reviewed by facility management as noted in their IJ removal plan. Care plans of residents directly involved would be reviewed during the investigation and psychiatric/psychological consultations would be ordered after the alleged incident. Resident #2 was seen by psychiatric services on 3/1/23 and 4/13/23 with ongoing evaluations to be provided. Resident #2's care plan was reviewed and updated on 2/20/23. 1:1 supervision was restarted on 4/12/23.

Based on record reviews and interviews, the facility failed to 1) Maintain a hospice plan of care and documentation of care in the resident record, 2) Designate a member of the facility's interdisciplinary team to coordinate care with Hospice, and 3) Coordinate Hospice care for two (Residents #57 and #68) of 20 residents reviewed for hospice services/coordination of care, from a total sample of 38 residents. The findings include: 1) A review of Resident #57's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Significant Change Minimum Data Set (MDS) assessment, dated 9/8/22, revealed he was receiving Hospice services. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/22 at 1:05 PM, a review of the medical record for Resident #57 revealed no documents related to the Hospice provider. 2) A review of Resident #68's medical record revealed that the resident was admitted to the faclity already on Hospice services on 8/16/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/22 at 3:15 PM, a review of the medical record for Resident #68 revealed no documents related to the Hospice provider. On 10/26/22 at 1:40 PM, an interview was conducted with the Director of Social Services (DSS). When asked of her involvement with the Hospice process, she stated when there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DSS explained that at times, she would work with the Hospice social worker, but she mostly worked with the residents. She was not aware of a Hospice coordinator in the facility. There were three Hospice providers that residents and family could choose from. She stated Resident #57 was admitted to Hospice on 9/5/2022. Per the DSS, care plan conferences were held quarterly and as needed. The last care plan meeting for Resident #57 was on 9/27/2022, which included the interdisciplinary team. Resident #57 and Hospice were invited but both declined. The DSS deferred to the Minimum Data Set (MDS) Office for the sign-in sheet for care plan meetings and the Business Office for signed Hospice consent. She stated Hospice care plans should be in the residents' charts. On 10/26/22 at 2:00 PM, an interview was conducted with the Administrator. He stated he believed the Hospice coordinators were the unit managers. On 10/26/22 at 2:02 PM, an interview was conducted with Employee B. Inquired about any signed Hospice consents the facility had for Resident #57. Per Employee B, the only signed consent for Hospice she had was the Facility Notification of Hospice Admission/Change consent. On 10/26/22 at 2:05 PM, the Director of Nursing (DON) was interviewed and was asked who in the facility was the Hospice coordinator. She stated she thought Social Services was in charge of Hospice coordination. The DON was not aware that there was no documentation on the Hospice charts. She stated she would follow up with the Hospice provider. On 10/26/22 at 3:00 PM, the DON produced the hospice consent which was signed by Resident #57. She stated the resident had the paperwork in his nightstand drawer. The DON provided a list of residents receiving services from this specific Hospice provider (Resident #57 and Resident #68). On 10/27/22 at 1:42 PM, Employee C was asked if she was the Hospice Coordinator. She stated the facility did not have one as far as she knew. She further explained, If a resident needs Hospice, we let Social Services know. On 10/27/22 at 1:51 PM, Employee D was asked if she was the Hospice Coordinator. She stated she was not, but if a resident was declining and needed services, she notified Social Services.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision to prevent accidents for three (Resident #52, Resident #9 and Resident #6) of 38 residents sampled, which could have affected the facility environment, all 142 residents as well as staff present. The findings include: On 10/24/2022 at 10:07 am, the Administrator advised that the current facility census was 142. During a tour of the facility on 10/24/2022 at 12:08 pm, Resident #52 was observed sitting on the side of her bed. She had cigarettes and a lighter in her possession. On 10/24/2022 at 12:25 pm, Resident #9 was observed sitting in a wheelchair in her room. She had cigarettes and a lighter on her person. When asked about the cigarettes and lighter, she stated she kept them, and that she could go out to smoke independently adding, It's ok, I know what I'm doing. (Photographic evidence obtained) On 10/24/2022 at 12:30 pm, a door that led to the resident smoking area was observed. Through the window in that door, there was a resident outside smoking without staff supervision. The door to the smoking area was observed to have a keypad for access. Ambulatory residents who could stand were observed entering a code into the keypad unlocking the door, allowing them and other residents to enter and leave the designated smoking area without staff assistance. On 10/26/2022 at 2:15 pm, Resident #6 was observed in her room sitting on the side of her bed. When asked, Resident #6 stated she kept her cigarettes and lighter in her room in her purse. She opened her purse and took out a pack of cigarettes and three lighters. She stated she did not allow any of the other residents to use her smoking supplies. She could smoke alone whenever she wanted to do so. She said there was no set time for smoking, she just went out when she wanted to go out. (Photographic evidence obtained) On 10/26/22 at 4:16 pm, Resident #9 was observed in her wheelchair in the hallway near the dining room. She was greeted and asked when she went outside to smoke. She stated she went to smoke at any time she felt inclined. She advised that she kept her cigarettes and lighter with her, then showed that she had them in her possession. She stated she knew not to share them with other residents. (Photographic evidence obtained) During an interview on 10/27/2022 at 12:52 pm with Resident #52, she stated she could smoke at anytime with the exception of meal times, when the staff requested that all residents come inside to eat. On 10/27/2022 at 1:05pm during an interview with the Administrator, he was asked about the process for determining whether a resident was a safe smoker. He advised that the nurses were responsible for conducting the smoking assessments. He was asked for the policy related to safe smoking. He said that he would check with the nurses regarding this policy. He was asked if residents could keep their cigarettes and lighters in their possession. He stated that residents could not keep their own smoking supplies. He stated the smoking supplies were kept in a lockbox. He stated the box was kept at the nurses' station, and the designated certified nursing assistant (CNA) took the smoking box out to the smoking area. During an interview on 10/27/2022 at 1:20 pm with CNA E, she stated she had been employed at facility for approximately three months. She was asked to describe her typical work routine. She stated she generally clocked in around 6:45 am and checked her assignment for the day, which was written on an assignment board located at the time clock. She stated she was usually assigned to the smoking area. She stated she retrieved the smokers' box from the nurses' station, then headed out to the smoking area. She was asked when the smokers were permitted to smoke. She replied that they could go out before and after meals. She stated she gave each resident two cigarettes, and she had the lighters and lit the cigarettes for the residents. She stated each resident had their own smoking supplies, which were stored in a plastic bag labeled with their name and room number, and that the plastic bags were kept in the smokers' lockbox held at the nurses' station. She stated smokers were not permitted to keep cigarettes and lighters on them. She stated there were designated smoking times throughout the day, before and after meals from 7:00 am until 11:00 pm, at which time she stated the door to the smoking area was locked. She was asked if any of the residents could go out to smoke on their own, and she replied that some of the smokers who could stand up to enter the keypad code to the door could go out by themselves. She stated she let the residents know when she is going to be away from the smoking area, and instructed them not to go out without her supervision. She denied observation of residents with cigarettes and lighters in their possession. She showed the lockbox which she brought to the smoking area. It appeared to be a toolbox with a lock which contained several clear plastic storage bags containing smoking supplies labeled with resident names and room numbers. During an observation of the designated smoking area at 1:30 pm on 10/27/2022 with CNA E, eleven residents were observed smoking unsupervised. The smoking lockbox was observed unattended in the area. When asked about this, CNA E stated a staff member should have been there. She speculated that maybe they had to leave to take care of something else. CNA E then exited the smoking area, leaving the eleven residents smoking without staff supervision. A review of the facility's policy and procedure revealed: Section: Basic Care Procedures Policy Title: Supervised Smokers Policy Number: NP.I -168 Effective Date: 10/15/2022 Supersedes: 05/03/2022 2. Smoking materials should be kept at the nurse's station, and staff should be informed to include electronic cigarettes and vaping materials. Staff should assist residents with recharging devices when needed and ensure safety. 3. No fire igniting materials (matches/lighters) should be kept in resident/guest(s) possession. Smokers should obtain lighting materials from staff.

Based on observation, interviews and record review, the facility failed to provide foot care and treatment, in accordance with professional standards of practice for one (Resident #2) of two residents reviewed for foot care. The findings include: A review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/04/22 at 8:59 AM, during an interview with Resident #2, she stated that her toenails needed to be trimmed. She explained that she asked the Podiatrist to cut her nails while he was treating her roommate, but he told her that she was not on the list to be seen. During an interview with Employee A, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 2/04/22 at 9:03 AM, she acknowledged overhearing Resident #2's request to see the Podiatrist. Employee A, LPN/UM then went to Resident #2's room and removed the residents left sock. As she removed the sock, Resident #2's toenail appeared to get snagged. After Employee A, LPN/UM removed the residents right sock, she confirmed that Resident #2's great toenails were very long. Resident #2 then told the nurse that she asked the podiatrist to cut her nails, but he told her that she was not on the list to be seen. Employee A, LPN/UM stated she would make the necessary arrangement to have Resident #2's toenails cut the next time the Podiatrist visits. (Photograph taken) A record review for Resident #2 revealed a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 12/27/21. She was documented with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. Resident #2 was care planned for Activities of Daily Living (ADLs) with interventions of Nail care as needed with start date of 12/22/21 and Refer to podiatry for toe nail with start date on 1/03/2022. (Copy obtained) A review of the progress note dated 12/21/2021 at 7:40 PM revealed Resident #2 arrived at 5:50 pm to the facility via stretcher and was extensive assist with peri care. Her toenails were long/thick and needs podiatry visit. (Copy obtained) A review of the January 2022 podiatrist list for residents to be seen revealed that Resident #2 was on the list, however, she was indicated as DNS (Do Not See) with notation, No Coverage Humana. (Copy obtained) During interviews with Social Service Director (SSD), Director of Nursing (DON) and Nurse Consultant, they indicated that Resident #2 was to be seen by the Podiatrist regardless of her ability to pay; however, the system missed her, and arrangements were made to have Resident #2 seen by the Podiatry on an emergency basis on 2/05/2022. The SSD confirmed that if she had seen the progress note documented on 12/21/2021 at 5:55 PM, Resident #2 would have already seen the podiatrist. During an interview with the Director of the Podiatry Service on 2/04/2022 at 12:08 PM, he confirmed Resident #2 was supposed to be seen; however, since Resident #2 was not, they arranged an emergency visit at the facility on 2/05/2022. A review of the facility's Resident Handbook included an outline of the Resident Rights under (c) Planning and implementing care. Subsection (c) (2) (iv) The right to receive the services and/or items included in the plan of care. (Copy obtained)

Based on observations and staff interviews, the facility failed to maintain food service equipment used for residents in a safe and sanitary manner. The facility failed to label and date food items in accordance with professional standards for food service. This practice placed all residents who consumed foods prepared in the facility's kitchen at risk for foodborne illness. The findings include: An initial tour of the kitchen was conducted with the Dietary Manager (DM) on 3/22/21 at 10:03 a.m. During the tour, the handwashing sink was soiled/stained with gray matter embedded in the porcelain and behind the spicket. The floor underneath the [MEDICATION(S)] station was covered with a buildup of dust and dirt. A hole was observed in the wall under the [MEDICATION(S)] station where the pipes entered the kitchen. The pipes were coated with dirt and grime. The trash can at the handwashing sink was soiled with brown/gray smudges on the surface. A clear plastic container full of adaptive cups was stored on a rack in the clean dish room. The corners of the container were coated with a gold/brown substance. The same substance was observed on cups and lids stored inside the container. Trash and debris were observed on the floor underneath the ice machine, plate warmers, tray line, stove, and adjacent equipment. The equipment adjacent to the stove was soiled with a buildup of gray/dark brown dust and grime. During an interview at the time of the observations, the DM stated the floors were recently done with a machine. He acknowledged that they did not get underneath the equipment. (Photographic evidence obtained) On the dirty side of the dishwashing room(s), Employee K, Dietary Aide, was observed washing dishes. His pants sagged. The waistband of his pants was lowered approximately 4 to 6 inches below the brand label on the waistband of his underwear. The indentation of the crevice between his buttocks was visible through the underwear material. The commercial mixer was observed with a buildup of what appeared to be dried food and oil dripping from the dial on the face of the machine. When asked about the condition of the mixer, the DM had no explanation. The wall and the sanitizer dispenser behind the three-compartment sink was coated with buildup of a dark substance. There were two, deep serving pans drying underneath. The DM stated the adjacent air conditioning unit was just replaced, and he speculated that the dark buildup of matter on the sanitizer dispenser behind the sink was from that. The floor underneath the dry storage pantry's first set of shelves had dark buildup of what appeared to be dirt and old wax from the floor machine. (Photographic evidence obtained) The reach-in refrigerator on the south wall of the kitchen near the dry storage pantry, had a large bundle of unidentifiable food that was not dated/labeled. The DM identified it as sausage. A one-gallon container of whole milk, observed in the milk cooler, was opened and approximately 2/3 of the milk was used. There was no open date on the container. In the walk-in cooler, a gallon of whole milk was open with 1/3 of the milk used. It was not labeled with an open date. (Photographic evidence obtained) Outside of the kitchen, one of two trash dumpsters was observed with a missing drain plug. Plastic debris was observed coming out of the hole, which appeared to have been forcefully pulled from the outside. The plastic was heavily shredded into long strands and loose pieces. The DM acknowledged all of the findings. He stated the drain plug needed to be replaced in the dumpster. He stated it appeared a fairly large animal had been attempting to pull the debris through the drain hole in the dumpster. (Photographic evidence obtained) A tour of the facility's three nourishment rooms was conducted on 3/25/21 at 3:28 p.m. In the nourishment room on the West Unit, grapes, identified by staff as belonging to a resident, were observed wrapped in a napkin and stored in the cabinet to the left of the refrigerator. The shelf of the cabinet was soiled and covered with debris. (Photographic evidence obtained) During a tour of the East Unit nourishment room, an accumulation of food splatter was observed on the inside top, sides, and turntable of the microwave oven. Spillage was observed inside the refrigerator in front of the drawer, on the back of the second shelf and on the bottom shelf of the refrigerator door. A 64 ounce bottle of sugar-free, French vanilla coffee creamer was not labeled. A zip-loc bag with two sausages was observed in the freezer with no label or date. In the cabinet above the ice machine, a box of breakfast biscuits was observed with a Best if Used By date of [DATE]. A bag of cereal and a box of Nilla wafers were observed with no date labels. During an interview with Employee I, East Wing Unit Manager, on 3/25/21 at 3:52 p.m., she stated the microwave was cleaned daily by anybody, but preferably housekeeping. The refrigerator was cleaned during Wednesday's 11:00 p.m. to 7:00 a.m. shift, and the food items in the cabinet belonged to a resident, but she was unsure of which resident. An interview and second tour of the kitchen was conducted on 3/25/21 at 4:53 p.m. with the Registered Dietician (RD) and DM. The RD acknowledged that a deep clean was needed. The cleaning schedule was obtained on 3/25/21. There was no indication of deep cleaning. During this tour, another gallon of milk was observed in the walk-in cooler opened and undated. The RD stated the milk was used so quickly that they didn't label it. Both the RD and the DM acknowledged the requirement for date-marking the milk when opened. They stated the nourishment rooms were not part of the kitchen, and that either housekeeping or maintenance was responsible for the upkeep of the equipment and the nourishment refrigerators. An interview was conducted with the Administrator on 3/25/21 at 5:35 p.m., and all of the photographic evidence was shared with her at that time. She acknowledged the findings.

Based on observations, a review of resident records and resident and staff interviews, the facility failed to develop a comprehensive care plan that reflected the resident's desires, abilities and choices for one (Resident #7) of one resident who managed his own oxygen therapy, out of five residents reviewed for unnecessary medications, from a total of 48 residents in the sample. The findings include: During an interview with Resident #7 on 3/24/21 at 9:36 a.m., he expressed detailed knowledge of his medical conditions and treatments, explaining that he had [CONDITION(S)] and heart problems. He detailed some of the medications he was taking, his pain management regimen and a recent spike in his blood pressure. During the interview, a running oxygen concentrator was observed in the room. The attached tubing led to a nasal cannula that was lying on the bed next to Resident #7. When asked about the oxygen, he stated he removed the nasal cannula himself. He said he set his oxygen at 4 liters per minute (LPM), but turned the flow rate down to 2 to 2.5 LPM at night. The oxygen concentrator was inspected, and the gage confirmed the flow rate set at 4 LPM. The attached humidifier container (a vessel holding sterile water to provide humidification of the oxygen in order to prevent drying of the nasal passages) was observed to be empty. There was no sterile water in the 540 milliliter (ml) container, nor was there a date on the outside of the bottle indicating when it was last replaced. (Photographic evidence obtained) When asked about the empty humidifier, Resident #7 stated It runs out all the time. It only lasts about three days. The existing container was put on five days ago. He said he obtained the humidifier refills from the nurses' station and connected the bottles himself. Resident #7 was observed in his room again on 3/25/21 at 9:44 a.m. His oxygen concentrator was on but the cannula was not in place. When asked about his oxygen, he replaced the cannula and explained that the flow rate was currently set at 4 LPM. Observation of the concentrator's gage found it was set at 3.5 LPM. The humidifying solution container was still empty and unlabeled. Resident #7 said he had to go to the nurses' station to get more. When asked about the undated bottle, he said the nurses usually dated it, but the nurse was in a hurry that day. A clinical record review for Resident #7 found a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 3/12/21. He was documented with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. He was independent with the completion of activities of daily living (ADLs). His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 was care planned for his use of oxygen with a goal of no shortness of breath for 90 days. The approaches included: Provide humidification, observe for changes in symptoms, ensure a supply is available at all times and administer oxygen therapy as ordered. He was also care planned for the risk of complications related to his altered respiratory function, as evidenced by unrelieved shortness of breath and congestion. The goal was to be symptom free for 90 days. Approaches included, but were not limited to, oxygen per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) During an interview with Employee F, Licensed Practical Nurse (LPN), on 3/24/21 at 4:57 p.m., she stated Resident #7 was involved in his care and very vocal about his treatment decisions. During an interview with Employee G, LPN, on 3/25/21 at 10:03 a.m., she stated Resident #7 was very independent and came to the nurses' station to get his medications. She did not usually have this resident on her assignment, but if he ever asked for a bottle of sterile water for humidification, she would put the container on the concentrator for him. Employee G said the bottle should be dated once it was opened and attached. She turned to Employee B, West Wing Unit Manager, to confirm the sterile water bottle should be dated once opened and attached. The Unit Manager confirmed it should not only be dated, but should be changed weekly with the tubing. When asked about his oxygen self-management tendencies, Employee G stated there should be something in his chart or care plan about his independent choices with oxygen management. During an interview with Employee J, Certified Nursing Assistant, on 3/25/21 at 12:31 p.m., she stated Resident #7 was independent and very involved in his medical care. She confirmed he always did his own thing like adjust his oxygen up and down, despite her reminders to wait for the nurse.

Based on interviews and record reviews, the facility failed to provide health care services that met professional standards of quality, by failing to ensure qualified staff assessed residents for staging of pressure ulcers for two (Residents #96 and #100) of 13 residents with pressure ulcers, from a total of 48 residents in the sample. The facility's wound care nurse was a licensed practical nurse (LPN), who was assessing, measuring and staging pressure ulcers independently, without the oversight of a registered nurse (RN). Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. The Nurse Practice Act, 464.003 states, The practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. The practice of practical nursing means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The findings include: 1. A record review for Resident #96 revealed an [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Assessment report, dated 3/17/2021, revealed an assessment was competed by Employee C, Licensed Practical Nurse (LPN), who was the facility's Wound Nurse (WN). The assessment revealed a new pressure ulcer to the top of the right foot on the medial side (inner aspect of the foot), that was identified on 3/15/2021. The wound was unstageable due to suspected deep tissue injury. The wound measurements were as follows: Length (L) 2.00 cm (centimeters), Width (W) 5.50 cm, Depth (D) was left blank. The note read, Right medial deep tissue injury, non-blanchable area. Wound bed is partially visible, part of wound bed is bright red with serosanguineous drainage. Surrounding skin very dry to touch, warm and dry. Treatment order to follow. Provider and son notified. A Wound Assessment report, dated 3/17/2021, revealed an assessment was completed by Employee C, LPN/WN. The assessment revealed a new pressure ulcer to the left lateral malleolus (left outer ankle bone) that was identified on 3/15/2021. The wound was documented as a Stage 1 with measurements as follows: (L) 1.30 cm, (W) 0.80 cm, (D) was left blank. The note read, Patient with a stage 1 left lateral malleolus, dark pink non-blanchable area. Skin still intact. Surrounding area very dry. Preventive measures in place, repositioning, and booties in place. Treatment orders to follow. During an interview with Employee C, LPN, on 3/24/2021 at 10:55 a.m., she was asked if a wound care physician provided services in the facility. Employee C stated no, she reported her findings to the primary care physician (PCP). The PCP provided treatment orders and sometimes a referral to a wound specialist or podiatrist. During an interview with Employee C on 3/24/2021 at 12:51 p.m., she was asked how wounds were measured and staged. She stated she did the measurements and staged the wounds, then called the PCP with the findings, and obtained treatment orders or referrals for specialized care. During an interview with Employee D, Regional Registered Nurse (RRN), Employee E, RRN, and Employee C, LPN, on 3/4/21 at 2:10 p.m., Employee C was asked whether a RN was ever present when she staged a wound. Employee C stated, no. When asked whether a RN followed up and visually validated Employee C's wound assessments, Employee C stated she did not know, but the Director of Nursing (DON) was usually the RN who signed off on her assessment notes. Employee D, RRN, and Employee E, RRN, stated Employee C had her certification as a WN. During an interview with the DON via telephone on 3/24/2021 at 2:47 p.m., she was asked if she accompanied the WN to stage wounds. The DON stated, Quite honestly, I do not. I review her documentation and sign off on it. 2. A record review for Resident #100 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Wound Assessment report completed by a RN on 10/23/2020, revealed a stage 2 pressure ulcer to the right lateral malleolus (right outer ankle). A Wound Assessment report completed by Employee C, LPN/WN on 12/31/2020, revealed the right lateral malleolus wound was a stage 3. A review of the Notes section revealed: Update 12/9/20 pressure ulcer to right ankle shows signs of worsening, area of the wound has increased in size, full thickness skin loss noted, wound bed, adipose tissue is visible with some slough. Provider notified and will change treatment. Booties still to be worn while in bed, resident needs assistance with repositioning. Responsible party notified. The Treatment section revealed on 12/11/2020: Stage 3 pressure ulcer to right lateral malleolus, change dressing as needed, cleanse with Vashe, apply skin prep to perimeter of the wound, apply calcium alginate to wound bed, cover with foam dressing. A telephone order was documented by Employee C.

Based on observations, interviews and record reviews, the facility failed to provide specialized rehabilitative services for one (Resident #126) of 48 sampled residents. The findings include: During an interview with Resident #126 on 3/22/21 at 11:50 a.m., he stated he didn't know why he could only use a wheelchair; he wanted to use a cane to ambulate. During a second interview with Resident #126 on 3/24/21 at 9:25 a.m., he was asked when he last had PT (physical therapy), OT (occupational therapy), or Restorative Nursing services. He stated, I haven't had therapy in a year. At least give me a cane. They told me they can't do nothing more, you're done. A medical record review for Resident #126, revealed orders written upon re-admission to the facility on [DATE], following a five-day hospital stay for a [CONDITION(S)] (TIA - mini stroke), which read: 1/13/2021 - OT to evaluate and treat, and 1/13/2021 - PT to evaluate and treat. Further review found this order was not transcribed or acted upon. During an interview with Employee B, West Wing Unit Manager, on 3/24/21 at 12:25 p.m., she was asked if Resident #126 had had any therapy evaluations or treatments since he returned to the facility on [DATE]. She checked the resident's electronic medical record and stated, No, he hasn't had any therapy since then. Oh, but I see it was ordered on January 13th for a PT and OT eval and treat. Let me call [Employee A, Physical Therapist] and ask her if she knows anything about this. Employee B called Employee A. Employee B then stated, [Employee A] said she never got the order, but if he needs to be evaluated, he'll be treated. Employee B was asked if she knew why the order had not been acted upon. She stated, Well, I think he came back to the East Wing first, since he was at the hospital and needed to be quarantined, but that doesn't matter. When he came back for re-admission, they should have generated a UDA (User Defined Assessment), and then each department would be aware he was back and what his new orders were. If PT wasn't started, the order wasn't generated. During an interview with Employee A on 3/25/21 at 9:45 a.m., she was asked if she was familiar with Resident #126. She replied, Yes, I know him well. He's been here for a couple of years. She was asked if she was aware that he had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, No, we hadn't received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked if she knew why her department hadn't received the order on 1/13/21 when it was written. She replied, No, I don't know why. I mean, the reason we didn't receive it is because it wasn't put into the system, but I don't know why it wasn't put into the system. A review of the facility's policy: Restorative Services ([DATE]), revealed: Purpose: To assure that residents receive necessary rehabilitative services as determined by comprehensive reviews and care plan to prevent avoidable physical and mental deterioration and to assist the in obtaining or maintaining their highest practicable level of functioning and psychosocial well being.

Based on resident and staff interviews and a review of clinical and facility records, the facility failed to maintain accurate medical records for one (Resident #1) of five residents reviewed for unnecessary medications, from a total of 48 residents in the sample. The findings include: An interview was conducted with Resident #1 on 3/22/21 at 1:58 p.m. She stated the facility ran out of her anxiety medication for five days and as a result, she was shaky. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 3/1/21, found she had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating she was cognitively intact. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 received antianxiety medications all seven days during the 7-day assessment look-back period. Resident #1 was care planned for the potential for adverse drug reactions (ADRs) related to her use of antianxiety medication, with a goal of having no ADRs for 90 days. Interventions included observing for drug reactions, and physician and psychiatry to follow for medication management. (Photographic evidence obtained) Resident #1 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the electronic medication administration record (MAR) found there were several missed doses, which were annotated by the letter N, and explanatory notes at the bottom of the MAR. A key code was available for deciphering the reasons the medication was not given and included reasons such as awaiting script from the physician, held, resident asleep or refused. However, on the following days, the reason the medication was held was not made evident by the codes: 12/18/20 at 2:00 p.m. - Held for presence of target behavior. 12/19/20 at 2:00 p.m. - Held for presence of target behavior. 12/22/20 at 2:00 p.m. - Held for presence of target behavior. 12/23/20 at 8:00 a.m. and 2:00 p.m. - other special requirement not met 1/17/21 at 2:00 p.m. - No explanation code was used. 1/26/21 at 2:00 p.m. - Held for presence of target behavior. 2/28/21 at 2:00 p.m. - Held for presence of target behavior. (Photographic evidence obtained) A review of the electronic nursing progress notes for the above corresponding days found no further explanation for Held for presence of target behavior. or other special requirement not met. An interview was conducted with Employee H, Licensed Practical Nurse (LPN), on 3/24/21 at 4:44 p.m. She stated when a medication was not administered for any reason, she entered a code that indicated not administered. The system then prompted the user to enter an explanation, but one could bypass that explanation. When asked about the above explanations, she stated she was not aware of what Held for presence of target behavior. meant. She checked the electronic MAR to verify that this answer was an option and confirmed that it was. She remained unable to explain when that code should be used or what it meant. An interview was conducted with Employee F, LPN, on 3/24/21 at 4:53 p.m. She was asked what Held for presence of target behavior. meant when holding Resident #1's medication, but she did not know. She explained that Resident #1 was scheduled to receive [MEDICATION(S)] three times daily and was doing much better with her anxiety. Employee F stated she had never held Resident #1's [MEDICATION(S)], explaining she needed it and got nervous without it. An interview was conducted with Employee G, LPN, on 3/25/21 at 10:20 a.m. She stated when a medication was held, the nurse entered an electronic explanation in the computer software. She did not know what Held for presence of target behavior. meant. She stated maybe that meant the behavior was occurring at the time of the administration. She stated an antianxiety medication should not be held when anxiety was present. She reviewed the electronic MAR and confirmed that code was an option, but still could not explain when or why it should be noted. She turned and asked the West Wing Unit Manager what the code meant. The Unit Manager reviewed the MAR and stated she did not know. The Assistant Director of Nursing (ADON) was interviewed on 3/25/21 at 11:37 a.m. When asked what Held due to presence of target behavior. meant, she reviewed the MAR codes. She could not explain what the code meant or why the medication was not administered. The facility's Policy and Procedure 6.0 General Dose Preparation and Medication Administration (revised 1/1/13), was reviewed and a photocopy was obtained. It instructed under Procedure: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, . if medications are refused) .

Based on observation, interview and record review, the facility failed to ensure it provided medication administration in accordance with facility policy and procedure, and utilized proper storage practices for those medications (locked compartments) for two (Residents #3 and #4) of five sampled residents. The findings include: On 08/13/2020 at 8:30 AM on the rehabilitation unit, an unlocked medication cart was observed outside of resident rooms E15 and E16. The cart was examined and two clear plastic medication cups were observed with ten total pre-poured loose pills and capsules in them. One medication cup had seven medications marked for Resident #4 and a second medication cup had three medications marked for Resident #3. Employee A, Licensed Practical Nurse (LPN), confirmed the residents that each medication cup was designated for, and confirmed that the medications were scheduled for 9:00 AM. Resident #3 only took medications sporadically and the nurse had to return with the rest. An interview was conducted with LPN A on 08/13/2020 at 8:35 AM. She confirmed the medications were pulled for two different residents (Resident #3 and Resident #4.) One of the medication cups included the controlled substance [MEDICATION NAME] 0.5 milligram (mg) tablet, which was intended for Resident #3. An interview was conducted with LPN B/Unit Manager on 08/13/2020 at 8:42 AM. She stated if she found an unlocked medication cart and loose medications, this was against the facility's policy and procedure and the nurse would be addressed and disciplined for a violation of the policy. An interview with the Assistant Director of Nursing (ADON) was conducted on 08/13/2020 at 10:46 AM. She confirmed that the medication cart should not have been left unsecured with medications poured for more than one resident at a time. She further stated that the facility's Staff Educator provided 1 on 1 education that included a read and sign about privacy, unlocked medication carts and multiple resident medications prepared at the same time. She stated this education would be provided to all nursing staff. A review of Resident #3's current Medication Administration Record [REDACTED] [MEDICATION NAME] 0.5 mg; give one tablet by mouth twice a day for agitation. No documented administration time. [MEDICATION NAME] 100 mg tablet and [MEDICATION NAME] 50 mg tablet. No documented administration time. A review of Resident #4's current MAR indicated [REDACTED] Aspirin 81 mg; give one tablet by mouth daily. [MEDICATION NAME] 500 mg tablet; give one tablet by mouth every 12 hours. B-12 500 mcg (microgram) tablet, give 2 tablets (1000 mcg) by mouth every day. [MEDICATION NAME] 100 mg capsule every day for constipation. [MEDICATION NAME] 145 mg tablet; give one tablet by mouth daily. Vitamin C 500 mg tablet; give one tablet by mouth one time a day. A review of the facility's policy (6.0 General Dose Preparation and Medication Administration) for Pharmacy Services revealed that at 3.2, the procedure was to prepare medications for one resident at a time, and at 3.9, Facility staff should not leave medications unattended.

Based on review of glucometer control logs, facility's policy and procedures and staff interview, the facility failed to document, validate, and verify the manner in which the test is performed by using control testing which ensure the results of the glucometer test will be accurate and reliable on 6 out of 10 glucometers. The findings included: Policy and Procedures: Policy Title - Glucose monitoring equipment - Care, cleaning, disinfecting, and quality control testing. Policy Number NP.V-16. Effective Date: (MONTH) 30, 2010. Purpose: To properly maintain glucose monitors, maintain proper infection control measures, and to validate its accuracy. Quality control testing of glucose monitoring equipment should be done, according to the (Clinical Laboratory Improvement Amendments) CLIA waiver laboratory certificate requirements, daily. Assure Platinum Blood Glucose Monitoring System Manufacturer recommendation Page 20 When set to on , the reminder will prompt you to do a control solution test every 24 hours. If a control test has not been performed within the 34 hours of the previous test, PCS (Perform Control Solution Test) will flash on the screen along with (picture of a bell), PCS will flash three times and then disappear. The (picture of a bell) will stay on the screen and also mark a result in the memory mode. On each of the six medication carts, there was a binder with nurse duties instructions: One of them was to check the glucose monitors. In these binders, there were sheets labeled Assure Pro Blood Glucose Monitoring System Daily Quality Control Record. The nurses were to record, date, station/shift, operator initial/shift, meter cleaned Y/N (Yes/No), test strip log # (number), code #, test strip expiration date, level 1 Lot #, level 1 expiration date, level 1 control range, level 1 control results, level 2 Lot #, level 2 expiration date, level 2 control range, level 2 control results, and correction actions. Review of glucometer log sheet for South Cart 1, there was 1 monitoring sheet in the binder for (MONTH) 2019. The dates of 3/4/19, 3/5/19, 3/6/19, 3/14/19, and 3/15/19 were all without information (blank). There was 1 glucometer on this medication cart. Review of the glucometer log sheet for West Cart 2, there was a binder with two monitoring sheets for (MONTH) 2019 and both had incomplete documentation. The first monitoring sheet had missing information on the following dates 3/6/19, 3/8/19, 3/11/19, 3/13/19, 3/17/19, and 3/18/19. The second monitoring sheet had missing information on the following dates 3/6/19, 3/8/19, 3/13/19, 3/17/19, and 3/18/19 all without information. Review of the glucometer log sheet for East Cart 2 and East Cart 1, there was only one binder with one monitoring sheets and two glucometers for the month of March. There was no serial number to indicate which glucometer was being tested . There was missing information on (MONTH) 19, 2019. On 3/20/19 at 3:20 PM, an interview was conducted with Licensed Practical Nurse (LPN)/Employee [NAME] She was asked why there were not two sheets per cart as there were two glucometers on East Cart 1. She replied she did not know. LPN/Employee J was asked about the same issue on the East Cart 2. She replied she would get another monitoring sheet so each glucometer had one. LPN/Employee J was asked how would she know which glucometer was tested on the sheet that was being used? She stated she did not know but confirmed that the sheet that was filled out did not specify which glucometer was being tested .

Based on observation, record review, and staff interview, the facility failed to provide appropriate care and services for Gastrointestinal tubes ([DEVICE] (a tube placed directly into the stomach)) for 3 (Resident #237, #185, and #126) of 8 residents with [DEVICE]s. The findings included: 1. On 03/19/19 03:30 PM, an observation of medication administration was observed by Licensed Practical Nurse (LPN)/Employee A, for Resident # 237. LPN/Employee A prepared [MEDICATION NAME]/[MEDICATION NAME] 7.5 milligrams (mg)/325 mg, crushing it and adding 60 milliliters (ml) of warm water to dissolve it. He prepared 10 ml of [MEDICATION NAME] 100 mg/5 milliliter (ml). Each medication was in a separate medication cup. He brought in a cup of 30 ml of tap water. LPN/Employee A placed a syringe into [DEVICE] and pulled back on the plunger, revealing about 10 ml of fluid (residual). He then reinserted the fluid back into the [DEVICE]. He was not observed to insert air into the tube and listen with a stethoscope for placement of the tube. He then poured the 30 ml of tap water into the G tube and it went in by gravity. LPN/Employee A then poured in the dissolved [MEDICATION NAME]/[MEDICATION NAME] into the [DEVICE] which went in by gravity. LPN/Employee A then poured the liquid [MEDICATION NAME] into the [DEVICE] which when in by gravity. LPN/Employee A did not flush with water in between the two medications. On 3/19/2019 at 340 PM, LPN/Employee A was interviewed. He confirmed he did not flush the [DEVICE] in between the two medications. He stated he should have flushed the tube with 30 ml of water in between. He stated there were 4 ways to check for placement of the [DEVICE]. He stated pulling back on the syringe (aspirating) for stomach contents was fine to do. He did not need to put any air the tube. He stated that 30 ml is the standard flush. The Director of Nursing (DON) presented the facility's policy on medication administration through [DEVICE] on 3/20/2019 at 8:30 AM. The DON stated she did not have a chance to review the policy. She stated the staff nurses orient new nurses and complete their competency checklist. The 10/31/2016 - 6.7 Medication Administered through Enteral Tube Policy revealed: Flush with at least 15 ml of warm after each individual medication is given. It revealed, insert a small amount of air into the tube with a syringe and listen with a stethoscope for placement. The policy did not address checking for residual. Record review for Resident #237 revealed physician orders [REDACTED]. There was a 3/20/2019 physician order [REDACTED]. Record review for LPN/Employee A revealed a 2/7/2019 Nurse Day 1 Floor orientation which included [DEVICE] procedures. It was signed off by the Staff Developer (as Supervisor) and co-signed by the Director of Nursing. The Staff Developer/LPN/Employee B was interviewed on 3/20/2019 at 9:00 AM. She stated she has been the Staff Developer since (MONTH) (YEAR). She stated she did the Competency checklist for LPN/Employee [NAME] She stated nurses should check for placement of [DEVICE] using air and auscultation before administering any medication. She stated facility policy was nurses should flush with 15 ml of water in between each medication administered. The DON was interviewed on 3/20/2019 at 9:05 AM. She stated the online learning (T-3) instructs nurses to flush 30 ml of water before and after administration. This is in conflict to their written policy and procedure. 2. On 03/19/19 at 12:35 PM Resident #185 was observed in bed in his room with an open system tube feeding infusing [MEDICATION NAME] 1.5 at 50 ml/hr; it was labeled hung 7-3 , 3/18/19. Water bag was hung and it was to flush the tube 120 ml of water every 4 hrs. Interview with LPN/Employee N on 3/18/19 at 12:50 PM stated the formula was hung during the 7-3 shift on Sunday 3/17/19 and it will end 3:00 PM 3/18/19 at the end of the morning shift. The surveyor questioned the Open system used was left for 24 hrs. The Director of Nursing was asked to provide the policy on the use of open system gastrostomy feeding on 3/18/19 at 5:00 PM. A review of the policy revealed it should only be used for 8 hours and should be changed every 8 hours. On 03/19/19 at 2:54 PM, Resident #185 was observed in bed eyes gazing at the ceiling. His [MEDICATION NAME] 1.5 was infusing at 50 ml/hr from an open system. It was hung on 3/19/19, but no time was placed on it. The pump had dispensed 195 ml of [MEDICATION NAME] and 120 ml of water. Record review revealed Resident #185 had [DIAGNOSES REDACTED]. Interview with his Registered Nurse (RN)/Employee Q, on 3/20/2019 at 9:50 AM stated the open system has to be changed every 8 hours (hrs). It should never be left over 8 hrs or else, there may be contamination. 3. On 3/18/2019 at 11:10 AM, Resident #126 was observed in bed in her room. A tube feeding pole was observed beside the bed with a closed container of liquid nutrition. The container was marked with a start time of 1:00 PM. Resident #126 was not receiving tube feeding at the time of the observation. Record review for Resident #126 found she was admitted to the facility on [DATE] with the most recent admission on 2/13/2019. [DIAGNOSES REDACTED]. Record review of the (MONTH) 2019 physician orders [REDACTED].@ 72 cc/HR via g tube X 20 hours off @ 8:00 AM and on at 1:00 PM. Record review of the Medication Administration Record [REDACTED]. A calculations of the time from 1:00 PM to 8:00 AM came to 19 hours. During an interview with Resident #126's RN/Employee G on 03/19/2019 at 2:47 PM, she stated, Resident #126 goes on her tube feeding at 1:00 PM and is taken off at 8:00 AM. During an interview with the East Wing Unit Manager on 3/19/2019 at 2:52 PM, she was asked to review the physician orders [REDACTED].#126 was off of tube feeding from 8:00 AM until 1:00 PM that would be for 19 hours. She stated she would get an order clarification from the physician. Further record review of the physician orders [REDACTED].#126 was not laid flat at night or dung peri-care. Record review of the MAR for (MONTH) 2019 found the nurse did not check she monitored the resident at 6:30 AM (11:00 PM to 7:00 AM shift) for 10 out of 21 days in March. The findings were confirmed during further interview with the East Wing Unit Manager on 3/21/2019 at 10:53 AM. She confirmed the findings and stated it is an education problem the staff do not know how to use the computer system.

Based on record review and staff interviews the facility failed to appropriately assess 1 resident (Resident #1) for significant change in condition (sudden decline related to excessive [MEDICATION NAME] administration), out of 17 sampled residents. The findings include: Review of records for Resident #1 revealed an [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was documented as alert with [MEDICAL CONDITION] (unable to speak), and required extensive assist with bathing, dressing, transfers and mobility due to [MEDICAL CONDITION] (paralysis on one side). He was incontinent of bowel and bladder. Resident #1 was able to propel his own wheelchair and needed supervision with eating. Further record review revealed the resident was prescribed [MEDICATION NAME] for [MEDICAL CONDITION]. A [MEDICATION NAME] level was ordered on [DATE]. Results showed a [MEDICATION NAME] level of 1.8mcg/mL (normal range 10-20mcg/mL). The physician increased the [MEDICATION NAME] to 200mg twice a day to obtain an optimum therapeutic level of the medication. The [MEDICATION NAME] level was repeated on 1/8/14. Results showed a level of less than 1mcg/mL. The physician was notified and he increased the dose to 300mg twice a day. The [MEDICATION NAME] order on the electronic Medication Administration Records (MAR) was transcribed as [MEDICATION NAME] 50mg [MEDICATION NAME] give 6 tablets to equal 600mg twice a day (double the dose ordered). Interview with the medical records nurse on 3/10/14 at 10:00 am revealed that she reviewed the 1/8/14 [MEDICATION NAME] order and questioned the increase in dose at the morning meeting per the facility protocol. She stated the Unit Manager (UM) said she would take care of clarifying the order. Review of the Medication Administration Records (MAR) for January and February, 2014 revealed Resident #1 received [MEDICATION NAME] 600mg twice daily (double the dose ordered) from 1/9/14 thru 1/22/14. A review of laboratory reports revealed the [MEDICATION NAME] level on 1/22/14 was 22mcg/mL (normal range 10-20mcg/mL). Record review revealed the Advanced Registered Nurse Practitioner (ARNP) reduced the pm dose of [MEDICATION NAME] from 600mg to 400mg at that time. An interview conducted on 3/11/14 at 11:00 am with Licensed Practical Nurse (LPN) #1 revealed Resident #1 had a routine he followed everyday like clockwork. He liked to be up early, wheeled himself to the medication cart to see the nurse, went to the dining room for meals, wheeled himself up and down the corridors, and went outside on the patio. He was always on the move. When asked if there had been a change in condition for Resident #1 she stated she had observed changes in the resident at the end of January, 2014. His appetite had decreased and he often refused to eat. He experienced weight loss, was not as active, and was often lethargic. She stated he had a urinary tract infection and was treated, however his condition did not improve. When asked if she reported the changes she noted in January to the physician, she stated she reported the changes to the UM. She stated the UM referred the resident to hospice, but she did not know why. On 2/8/14, LPN #1 recognized the change in the resident's condition could be related to his [MEDICATION NAME]. LPN #1 called the physician to request a [MEDICATION NAME] level. An interview with the resident's son on 3/7/14 at 8:20 am revealed he noticed that his father had been declining steadily since mid January, 2014. The son voiced his concerns repeatedly to the UM. He stated that the Certified Nursing Assistants (CNAs) also shared with him their concerns with his father's decreased activity levels and increased lethargy. He stated he spoke to the UM on 2/5/14 regarding his father's continued weight loss, poor appetite, and incoherence. The UM's response was that the resident had given up. She suggested a DNR (Do Not Resuscitate) order and hospice for the resident. The UM presented the DNR paperwork to the son, which he signed, and hospice came in that evening to admit the resident to their service. The son stated he was still concerned about his father's level of consciousness, and asked the nurse on duty to call the physician. Review of the nursing notes for January and February, 2014 revealed a decrease in appetite. The significant changes in condition reported to the UM by nursing staff and the resident's son (weight loss, and changes in level of consciousness or activity) were not documented. The notes did not reflect any changes that would indicate a need for DNR or hospice services. Record review revealed that the ARNP responding to the nurse's call ordered labs for the resident, including a urinalysis and CBC (complete blood count). The urinalysis report of 2/7/14 showed numerous bacteria indicating a urinary tract infection, and treatment was ordered. On 2/8/14 the resident ' s [MEDICATION NAME] level was discovered to be at a critical level of 55.4mcg/mL (normal range 10-20mcg/mL). The physician was notified of the result, and placed the [MEDICATION NAME] on hold until further notice. An interview was conducted at 11:20 a.m on 3/7/14 with the Medical Director, the resident's physician. When asked about the resident's [MEDICATION NAME] dose he stated, "The pharmacy should have questioned this; 300mg to 600mg is a big jump." He went on to say that a [MEDICATION NAME] dose increase is never made at an interval that large. He stated that the [MEDICATION NAME] level on 1/8/14 was low. He asked staff if the resident was receiving [MEDICATION NAME]. "They told me 'Yes', so I increased the [MEDICATION NAME] to 300mg twice daily." He stated the [MEDICATION NAME] was changed from 300mg to 600mg in the liquid form; "that is when the mistake happened." He explained that the family went to the supervisor (UM) about the changes in the resident, and she recommended hospice due to his decline. The Medical Director stated that the supervisor should have let him know about the change in the resident's condition sooner; my ARNP or I would have looked at the resident. He said the nurse saw some changes in the resident in February. The nurse notified the Medical Director's ARNP, and requested an order for [REDACTED]. The Medical Director stated that the resident is now on [MEDICATION NAME] 200 mg twice a day. He explained that the maximum [MEDICATION NAME] dose is 400 mg three times a day, and in this case the maximum dose was erroneously given. An interview conducted on 3/11/14 at 11:30 am with the acting Director of Nursing revealed that the UM was suspended on 2/24/14 pending the facility ' s investigation of the resident ' s [MEDICATION NAME] dosing and sudden decline. The UM was terminated on 3/11/14. Package insert [MEDICATION NAME]? [MEDICATION NAME]? ([MEDICATION NAME] Chewable Tablets, USP) Pfizer Parke-Davis, Revised September 2013. DOSAGE AND ADMINISTRATION: [MEDICATION NAME]? [MEDICATION NAME]? is formulated with the sodium salt of [MEDICATION NAME]. The free acid form of [MEDICATION NAME] is used in [MEDICATION NAME]-125 Suspension and [MEDICATION NAME]. Because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa.Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. Adult Dosage: Patients who have received no previous treatment may be started on two [MEDICATION NAME] three times daily, and the dose is then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be six to eight [MEDICATION NAME] daily. PRECAUTIONS: If early signs of dose-related CNS toxicity develop, plasma levels should be checked immediately. OVERDOSAGE: The initial symptoms are [DIAGNOSES REDACTED], ataxia, and dysarthria. Other signs are tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting. The patient may become comatose and hypotensive. [DIAGNOSES REDACTED] on lateral gaze usually appears at 20 mcg/mL, ataxia at 30 mcg/mL, dysarthria and lethargy appear when the plasma concentration is over 40 mcg/mL, but as high a concentration as 50 mcg/mL has been reported without evidence of toxicity. .

Based on record review and staff interviews the consultant pharmacist failed to identify excessive dosing related to anti-seizure medication (Dilantin), and failed to monitor response to the medication (sudden decline) for 1 resident (Resident #1), out of 6 residents reviewed for anti-seizure medication. The findings include: Record review of Resident #1 revealed an [AGE] year old male with the following diagnoses; Stroke, difficulty swallowing, diabetes, high blood pressure, anemia, convulsions, vascular dementia, and glaucoma. Resident #1 was documented as alert with aphasia (unable to speak), required extensive assist with bathing, dressing, transfers and mobility due to [DIAGNOSES REDACTED] (paralysis on one side). He was incontinent of bowel and bladder. Resident #1 was able to propel his own wheelchair and needed supervision with eating. Further record review revealed the resident was prescribed Dilantin for seizures. A Dilantin level was ordered on [DATE]. Results showed a Dilantin level of 1.8mcg/mL (normal range 10-20mcg/mL). The physician increased the Dilantin to 200mg twice a day to obtain an optimum therapeutic level of the medication. The Dilantin level was repeated on 1/8/14. Results showed a level of less than 1mcg/mL. The physician was notified and he increased the dose to 300mg twice a day. The Dilantin order on the electronic Medication Administration Records (MAR) was transcribed as Dilantin 50mg infatabs give 6 tablets to equal 600mg twice a day (double the dose ordered). An interview was conducted at 10:12 a.m. on 3/11/14 with the 11-7 shift Licensed Practical Nurse (LPN) #2. She stated that Resident #1 was originally on Dilantin capsules 200 mg twice daily, which the physician changed to 300 mg twice daily. She stated the original order to change the dose read "Dilantin 50 mg give 6 tabs po." She stated the order did not have "equal to" to account for the total dose. She stated she couldn't find the original order, so she didn't do the facility matchback protocol to verify accurate transcription of the order. She alerted the Unit Manager (UM) that she couldn't verify the order transcription. "The Unit Manager found the order and said it was 300 mg. It was end of shift and I put the order in the electronic MAR and I didn't read the order. I put = 600mg. I did not re-fax the order to pharmacy due to the previous nurse already sending the order. The print out sheet was available and the original order was in the chart 50 mg 6 tabs, and I wrote in = 300 there. I am not sure why the capsules were changed to infatabs. The medication was later changed to a liquid." Review of the Medication Administration Records (MAR) for January and February, 2014 revealed Resident #1 received Dilantin 600mg twice daily (double the dose ordered) from 1/9/14 thru 1/22/14. A review of laboratory reports revealed the Dilantin level on 1/22/14 was 22mcg/mL (normal range 10-20mcg/mL). Record review revealed the Advanced Registered Nurse Practitioner (ARNP) reduced the pm dose of Dilantin from 600mg to 400mg at that time. An interview conducted on 3/11/14 at 11:00 am with Licensed Practical Nurse (LPN) #1 revealed Resident #1 had a routine he followed everyday like clockwork. He liked to be up early, wheeled himself to the medication cart to see the nurse, went to the dining room for meals, wheeled himself up and down the corridors, and went outside on the patio. He was always on the move. When asked if there had been a change in condition for Resident #1 she stated she had observed changes in the resident at the end of January, 2014. His appetite had decreased and he often refused to eat. He experienced weight loss, was not as active, and was often lethargic. She stated he had a urinary tract infection and was treated, however his condition did not improve. When asked if she reported the changes she noted in January to the physician, she stated she reported the changes to the UM. She stated the UM referred the resident to hospice, but she did not know why. On 2/8/14, LPN #1 recognized the change in the resident's condition could be related to his Dilantin. LPN #1 called the physician to request a Dilantin level. An interview with the resident's son on 3/7/14 at 8:20 am revealed he noticed that his father had been declining steadily since mid January, 2014. The son voiced his concerns repeatedly to the UM. He stated that the Certified Nursing Assistants (CNAs) also shared with him their concerns with his father's decreased activity levels and increased lethargy. He stated he spoke to the UM on 2/5/14 regarding his father's continued weight loss, poor appetite, and incoherence. The UM's response was that the resident had given up. She suggested a DNR (Do Not Resuscitate) order and hospice for the resident. The UM presented the DNR paperwork to the son, which he signed, and hospice came in that evening to admit the resident to their service. The son stated he was still concerned about his father's level of consciousness, and asked the nurse on duty to call the physician. Record review revealed that the Advanced Registered Nurse Practitioner (ARNP) responding to the nurse's call ordered labs for the resident, including a urinalysis and CBC (complete blood count). The urinalysis report of 2/7/14 showed numerous bacteria indicating a urinary tract infection, and treatment was ordered. On 2/8/14 the resident's Dilantin level was discovered to be at a critical level of 55.4mcg/mL (normal range 10-20mcg/mL). The physician was notified of the result, and placed the Dilantin on hold until further notice. Review of the consultant pharmacist (CP) monthly reports for January and February, 2014 revealed the pharmacist found no issues with Resident #1's medication review performed on 1/13/14. There was no documentation in the medication review regarding the increased Dilantin dose (double the previously ordered dose). There was no mention of monitoring Dilantin levels. The February review conducted on 2/14/14 addressed a concern related to anemia. There was no mention of the resident's decline related to excessive Dilantin dosing. An interview was conducted at 11:20 a.m on 3/7/14 with the Medical Director, the resident's physician. When asked about the resident's Dilantin dose he stated, "The pharmacy should have questioned this; 300mg to 600mg is a big jump." He went on to say that a Dilantin dose increase is never made at an interval that large. He stated that the Dilantin level on 1/8/14 was low. He asked staff if the resident was receiving Dilantin. "They told me 'Yes', so I increased the Dilantin to 300mg twice daily." He stated the Dilantin was changed from 300mg to 600mg in the liquid form; "that is when the mistake happened." He explained that the family went to the supervisor (UM) about the changes in the resident, and she recommended hospice due to his decline. The Medical Director stated that the supervisor should have let him know about the change in the resident's condition sooner; my ARNP or I would have looked at the resident. He said the nurse saw some changes in the resident in February. The nurse notified the Medical Director's ARNP, and requested an order for [REDACTED]. He said once the resident ' s critical Dilantin level was discovered, his Dilantin levels were monitored until he was back to baseline. The Medical Director stated that the resident is now on Dilantin 200 mg twice a day. He explained that the maximum Dilantin dose is 400 mg three times a day, and in this case the maximum dose was erroneously given. Interview with the acting Director of Nursing on 3/11/14 at 11:30 am revealed that the consultant pharmacist was replaced in March, 2014, prior to this complaint investigation. A phone interview was conducted on 3/10/14 at 1:30 p.m. with the Registered Pharmacist for the dispensing pharmacy. She stated the 1/8/14 Dilantin order faxed from the facility had the number of tabs scratched out, and 600mg bid (twice a day) written on it. When asked if there was a pharmacy policy regarding a medication order received with scratch outs written on it, she said the pharmacy did not have a policy to clarify scratch outs. She stated that according to the pharmacy records, on 1/10/14 the resident ' s order was changed to Dilantin 125mg/5ml give 24 ml = 600 mg bid. On 1/15/14 there was an order entered for 600mg in the morning and 400mg at 5:00 pm. When asked if the pharmacist should question such an increase in dosage of medication (300mg bid to 600mg twice a day) she stated, "Yes." She stated that the pharmacy computer system alerts them to maximum and minimum dosages. " Dilantin is one of the drugs that would trigger an alert to clarify dosage. " When asked what the pharmacy protocol was if the dose of a medication requested is double the previous dose she stated, "We would call the facility to clarify with the physician." When asked who was responsible for ensuring accuracy of changing medications from tablet form to liquid she said, "The pharmacist would make conversions of medication dosage and double check to make sure things are correct." When asked if the alert system was in place when Resident #1's Dilantin was ordered on [DATE] she stated, "Yes." A phone interview was conducted at 1:51 p.m. on 3/10/14 with the Director of Pharmacy. He confirmed that Dilantin 600mg twice a day was a high dose. He stated the computer has an alert system in place to make the pharmacist aware of maximum doses of medications. When asked if an alert occurred when dispensing the Dilantin dose for Resident #1 he stated there was an alert, however the system allows the pharmacist to use their discretion when filling an order. When asked why the pharmacist did not contact the facility for clarification, he stated the pharmacist was comfortable with the dose and didn't need clarification. Package insert INFATABS? Dilantin? (Phenytoin Chewable Tablets, USP) Pfizer Parke-Davis, Revised September 2013. DOSAGE AND ADMINISTRATION: Dilantin? Kapseals? is formulated with the sodium salt of phenytoin. The free acid form of phenytoin is used in Dilantin-125 Suspension and Dilantin Infatabs. Because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa.Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. Adult Dosage: Patients who have received no previous treatment may be started on two Infatabs three times daily, and the dose is then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be six to eight Infatabs daily. PRECAUTIONS: If early signs of dose-related CNS toxicity develop, plasma levels should be checked immediately. OVERDOSAGE: The initial symptoms are [DIAGNOSES REDACTED], ataxia, and dysarthria. Other signs are tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting. The patient may become comatose and hypotensive. [DIAGNOSES REDACTED] on lateral gaze usually appears at 20 mcg/mL, ataxia at 30 mcg/mL, dysarthria and lethargy appear when the plasma concentration is over 40 mcg/mL, but as high a concentration as 50 mcg/mL has been reported without evidence of toxicity.

Based on record review and staff interviews the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to sudden decline in status due to medication transcription error and excessive [MEDICATION NAME] administration for 1 resident (Resident #1), out of 17 sampled residents. The findings include: Review of records for Resident #1 revealed an [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was documented as alert with [MEDICAL CONDITION] (unable to speak), required extensive assist with bathing, dressing, transfers and mobility due to [MEDICAL CONDITION] (paralysis on one side). He was incontinent of bowel and bladder. Resident #1 was able to propel his own wheelchair and needed supervision with eating. Further record review revealed the resident was prescribed [MEDICATION NAME] for [MEDICAL CONDITION]. A [MEDICATION NAME] level was ordered on [DATE]. Results showed a [MEDICATION NAME] level of 1.8mcg/mL (normal range 10-20mcg/mL). The physician increased the [MEDICATION NAME] to 200mg twice a day to obtain an optimum therapeutic level of the medication. The [MEDICATION NAME] level was repeated on 1/8/14. Results showed a level of less than 1mcg/mL. The physician was notified and he increased the dose to 300mg twice a day. The [MEDICATION NAME] order on the electronic Medication Administration Records (MAR) was transcribed as [MEDICATION NAME] 50mg [MEDICATION NAME] give 6 tablets to equal 600mg twice a day (double the dose ordered). An interview was conducted at 10:12 a.m. on 3/11/14 with Licensed Practical Nurse (LPN) #2. She stated that Resident #1 was originally on [MEDICATION NAME] capsules 200 mg twice daily, which the physician changed to 300 mg twice daily. She stated the original order to change the dose read "[MEDICATION NAME] 50 mg give 6 tabs po bid (twice daily)." She stated the order did not have "equal to" to account for the total milligrams per dose. She stated she couldn't find the original order, so she didn't follow the facility " matchback " protocol to verify accurate transcription of the order. She alerted the Unit Manager (UM) that she couldn't verify transcription of the order. The UM found the order and said it was 300 mg. It was end of shift; I put the order in the electronic MAR and I didn't read the order. I put = 600mg. I did not re-fax the order to pharmacy due to the previous nurse already sending the order. The order print out sheet was available and the original order for 50 mg 6 tabs was in the chart, and I wrote in equals 300 there. I am not sure why the capsules were changed to [MEDICATION NAME]. The medication was then changed to a liquid. The order was supposed to be verified at the morning meeting by the unit manager." Interview with the medical records nurse on 3/10/14 at 10:00 am revealed that she reviewed the 1/8/14 [MEDICATION NAME] order and questioned the increase in dose at the morning meeting per the facility protocol. She stated the UM said she would take care of clarifying the order. Review of the Medication Administration Records (MAR) for January and February, 2014 revealed Resident #1 received [MEDICATION NAME] 600mg twice daily (double the dose ordered) from 1/9/14 thru 1/22/14. A review of laboratory reports revealed the [MEDICATION NAME] level on 1/22/14 was 22mcg/mL (normal range 10-20mcg/mL). Record review revealed the Advanced Registered Nurse Practitioner (ARNP) reduced the pm dose of [MEDICATION NAME] from 600mg to 400mg at that time. An interview conducted on 3/11/14 at 11:00 am with Licensed Practical Nurse (LPN) #1 revealed Resident #1 had a routine he followed everyday like clockwork. He liked to be up early, wheeled himself to the medication cart to see the nurse, went to the dining room for meals, wheeled himself up and down the corridors, and went outside on the patio. He was always on the move. When asked if there had been a change in condition for Resident #1 she stated she had observed changes in the resident at the end of January, 2014. His appetite had decreased and he often refused to eat. He experienced weight loss, was not as active, and was often lethargic. She stated he had a urinary tract infection and was treated, however his condition did not improve. When asked if she reported the changes she noted in January to the physician, she stated she reported the changes to the UM. She stated the UM referred the resident to hospice, but she did not know why. On 2/8/14, LPN #1 recognized the change in the resident ' s condition could be related to his [MEDICATION NAME]. LPN #1 called the physician to request a [MEDICATION NAME] level. An interview with the resident's son on 3/7/14 at 8:20 am revealed he noticed that his father had been declining steadily since mid January, 2014. The son voiced his concerns repeatedly to the UM. He stated that the Certified Nursing Assistants (CNAs) also shared with him their concerns with his father's decreased activity levels and increased lethargy. He stated he spoke to the UM on 2/5/14 regarding his father's continued weight loss, poor appetite, and incoherence. The UM's response was that the resident had given up. She suggested a DNR (Do Not Resuscitate) order and hospice for the resident. The UM presented the DNR paperwork to the son, which he signed, and hospice came in that evening to admit the resident to their service. The son stated he was still concerned about his father's level of consciousness, and asked the nurse on duty to call the physician. Review of the nursing notes for January and February, 2014 revealed a decrease in appetite. The significant changes in condition reported to the UM by nursing staff and the resident's son (weight loss, and changes in level of consciousness or activity) were not documented. The notes did not reflect any changes that would indicate a need for DNR or hospice services. Record review revealed that the Advanced Registered Nurse Practitioner (ARNP) responding to the nurse ' s call ordered labs for the resident, including a urinalysis and CBC (complete blood count). The urinalysis report of 2/7/14 showed numerous bacteria indicating a urinary tract infection, and treatment was ordered. On 2/8/14 the resident ' s [MEDICATION NAME] level was discovered to be at a critical level of 55.4mcg/mL (normal range 10-20mcg/mL). The physician was notified of the result, and placed the [MEDICATION NAME] on hold until further notice. An interview was conducted at 11:20 a.m on 3/7/14 with the Medical Director, the resident's physician. When asked about the resident ' s [MEDICATION NAME] dose he stated, "The pharmacy should have questioned this; 300mg to 600mg is a big jump." He went on to say that a [MEDICATION NAME] dose increase is never made at an interval that large. He stated that the [MEDICATION NAME] level on 1/8/14 was low. He asked staff if the resident was receiving [MEDICATION NAME]. "They told me 'Yes', so I increased the [MEDICATION NAME] to 300mg twice daily." He stated the [MEDICATION NAME] was changed from 300mg to 600mg in the liquid form; " that is when the mistake happened. " He explained that the family went to the supervisor (UM) about the changes in the resident, and she recommended hospice due to his decline. The Medical Director stated that the supervisor should have let him know about the change in the resident's condition sooner; my ARNP or I would have looked at the resident. He said the nurse saw some changes in the resident in February. The nurse notified the Medical Director's ARNP, and requested an order for [REDACTED]. He said once the resident ' s critical [MEDICATION NAME] level was discovered, his [MEDICATION NAME] levels were monitored until he was back to baseline. The Medical Director stated that the resident is now on [MEDICATION NAME] 200 mg twice a day. He explained that the maximum [MEDICATION NAME] dose is 400 mg three times a day, and in this case the maximum dose was erroneously given. Review of the facility policy entitled "Matchback protocol" included the following: This process to be completed nightly and be given to the unit manager to present at the morning meeting for auditing. 1. The most current physician orders are compared with the original medication order if this order has been transcribed from another source document. The orders are then compared to the medication administration record (MAR), and then the medication on the cart. 2. The process requires pulling the chart and comparing the orders to the MAR to verify they match. 3. If the chart and MAR match, the medications should be pulled and compared to ensure all three match. (Medication name, strength, dosage form and directions for use). An interview was conducted on 3/11/14 at 9:30 am with the acting Director of Nursing (DON). She confirmed that the [MEDICATION NAME] transcription error went undetected by the facility until 2/8/14. When asked if the matchback protocol was still being utilized by the facility she stated, "Yes." She confirmed that the former UM and DON were not following up and auditing orders per the facility policy. Prior to the surveyors ' entrance to the facility on [DATE], the nurse who transcribed the [MEDICATION NAME] order was retrained on the matchback procedure (confirmed by sign-in sheet). The facility also checked residents' MARs for accurate transcription of all [MEDICATION NAME] and [MEDICATION NAME] orders. The facility rechecked all residents' records for medication indicated labs, and continues to do this on a weekly basis. The DON and Administrator were terminated on 2/24/14. The UM was suspended on 2/24/14, and terminated on 3/11/14. Package insert [MEDICATION NAME]? [MEDICATION NAME]? ([MEDICATION NAME] Chewable Tablets, USP) Pfizer Parke-Davis, Revised September 2013. DOSAGE AND ADMINISTRATION: [MEDICATION NAME]? [MEDICATION NAME]? is formulated with the sodium salt of [MEDICATION NAME]. The free acid form of [MEDICATION NAME] is used in [MEDICATION NAME]-125 Suspension and [MEDICATION NAME]. Because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa.Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. Adult Dosage: Patients who have received no previous treatment may be started on two [MEDICATION NAME] three times daily, and the dose is then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be six to eight [MEDICATION NAME] daily. PRECAUTIONS: If early signs of dose-related CNS toxicity develop, plasma levels should be checked immediately. OVERDOSAGE: The initial symptoms are [DIAGNOSES REDACTED], ataxia, and dysarthria. Other signs are tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting. The patient may become comatose and hypotensive. [DIAGNOSES REDACTED] on lateral gaze usually appears at 20 mcg/mL, ataxia at 30 mcg/mL, dysarthria and lethargy appear when the plasma concentration is over 40 mcg/mL, but as high a concentration as 50 mcg/mL has been reported without evidence of toxicity. .

Based on record review and staff interviews the facility failed to ensure that residents were free of excessive dose of medication in the presence of adverse consequences for 1 resident (Resident #1) related to anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]), out of 17 sampled residents. The findings include: Record review of Resident #1 revealed an [AGE] year old male with the following diagnoses; Stroke, difficulty swallowing, diabetes, high blood pressure, [MEDICAL CONDITION], convulsions, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Resident #1 was documented as alert with [MEDICAL CONDITION] (unable to speak), required extensive assist with bathing, dressing, transfers and mobility due to [MEDICAL CONDITION] (paralysis on one side). He was incontinent of bowel and bladder. Resident #1 was able to propel his own wheelchair and needed supervision with eating. Further record review revealed the resident was prescribed [MEDICATION NAME] for [MEDICAL CONDITION]. A [MEDICATION NAME] level was ordered on [DATE]. Results showed a [MEDICATION NAME] level of 1.8mcg/mL (normal range 10-20mcg/mL). The physician increased the [MEDICATION NAME] to 200mg twice a day to obtain an optimum therapeutic level of the medication. The [MEDICATION NAME] level was repeated on 1/8/14. Results showed a level of less than 1mcg/mL. The physician was notified and he increased the dose to 300mg twice a day. The [MEDICATION NAME] order on the electronic Medication Administration Records (MAR) was transcribed as [MEDICATION NAME] 50mg [MEDICATION NAME] give 6 tablets to equal 600mg twice a day (double the dose ordered). An interview was conducted at 10:12 a.m. on 3/11/14 with Licensed Practical Nurse (LPN) #2. She stated that Resident #1 was originally on [MEDICATION NAME] capsules 200 mg twice daily, which the physician changed to 300 mg twice daily. She stated the original order to increase the dose to 300mg (twice daily) read "[MEDICATION NAME] 50 mg give 6 tabs po." She stated the order did not have "equal to" to account for the total milligrams per dose. She stated she couldn't find the original order, so she didn't follow the facility "matchback" protocol to verify accurate transcription of the order. She alerted the Unit Manager (UM) that she couldn't verify transcription of the order. "The Unit Manager found the order and said it was 300 mg. It was end of shift; I put the order in the computer and I didn't read the order. I put equals 600mg. I did not re-fax the order to pharmacy due to the previous nurse already sending the order. The order print out sheet was available, and the original order was in the chart for 50 mg 6 tabs, and I wrote in equals 300mg there. I am not sure why the capsules were changed to [MEDICATION NAME]. The medication was later changed to a liquid. The order was supposed to be verified at the morning meeting by the unit manager." Interview with the medical records nurse on 3/10/14 at 10:00 am revealed that she reviewed the 1/8/14 [MEDICATION NAME] order and questioned the increase in dose at the morning meeting per the facility matchback protocol. She stated the UM said she would take care of clarifying the order. Review of the Medication Administration Records (MAR) for January and February, 2014 revealed Resident #1 received [MEDICATION NAME] 600mg twice daily (double the dose ordered) from 1/9/14 thru 1/22/14. A review of laboratory reports revealed the [MEDICATION NAME] level on 1/22/14 was 22mcg/mL (normal range 10-20mcg/mL). Record review revealed the Advanced Registered Nurse Practitioner (ARNP) reduced the pm dose of [MEDICATION NAME] from 600mg to 400mg at that time. An interview conducted on 3/11/14 at 11:00 am with LPN #1 revealed Resident #1 had a routine he followed everyday like clockwork. He liked to be up early, wheeled himself to the medication cart to see the nurse, went to the dining room for meals, wheeled himself up and down the corridors, and went outside on the patio. He was always on the move. When asked if there had been a change in condition for Resident #1 she stated she had observed changes in the resident at the end of January, 2014. His appetite had decreased and he often refused to eat. He experienced weight loss, was not as active, and was often lethargic. She stated he had a urinary tract infection and was treated, however his condition did not improve. When asked if she reported the changes she noted in January to the physician, she stated she reported the changes to the UM. She stated the UM referred the resident to hospice, but she did not know why. On 2/8/14, LPN #1 recognized the change in the resident's condition could be related to his [MEDICATION NAME]. LPN #1 called the physician to request a [MEDICATION NAME] level. An interview with the resident's son on 3/7/14 at 8:20 am revealed he noticed that his father had been declining steadily since mid January, 2014. The son voiced his concerns repeatedly to the UM. He stated that the Certified Nursing Assistants (CNAs) also shared with him their concerns with his father's decreased activity levels and increased lethargy. He stated he spoke to the UM on 2/5/14 regarding his father's continued weight loss, poor appetite, and incoherence. The UM's response was that the resident had given up. She suggested a DNR (Do Not Resuscitate) order and hospice for the resident. The UM presented the DNR paperwork to the son, which he signed, and hospice came in that evening to admit the resident to their service. The son stated he was still concerned about his father's level of consciousness, and asked the nurse on duty to call the physician. Record review revealed that the Advanced Registered Nurse Practitioner (ARNP) responding to the nurse's call ordered labs for the resident, including a urinalysis and CBC (complete blood count). The urinalysis report of 2/7/14 showed numerous bacteria indicating a urinary tract infection, and treatment was ordered. On 2/8/14 the resident ' s [MEDICATION NAME] level was discovered to be at a critical level of 55.4mcg/mL (normal range 10-20mcg/mL). The physician was notified of the result, and placed the [MEDICATION NAME] on hold until further notice. An interview was conducted at 11:20 a.m on 3/7/14 with the Medical Director, the resident's physician. When asked about the resident ' s [MEDICATION NAME] dose he stated, "The pharmacy should have questioned this; 300mg to 600mg is a big jump." He went on to say that a [MEDICATION NAME] dose increase is never made at an interval that large. He stated that the [MEDICATION NAME] level on 1/8/14 was low. He asked staff if the resident was receiving [MEDICATION NAME]. "They told me 'Yes', so I increased the [MEDICATION NAME] to 300mg twice daily." He stated the [MEDICATION NAME] was changed from 300mg to 600mg in the liquid form; " that is when the mistake happened. " He explained that the family went to the supervisor (UM) about the changes in the resident, and she recommended hospice due to his decline. The Medical Director stated that the supervisor should have let him know about the change in the resident's condition sooner; my ARNP or I would have looked at the resident. He said the nurse saw some changes in the resident in February. The nurse notified the Medical Director's ARNP, and requested an order for [REDACTED]. The Medical Director stated that the resident is now on [MEDICATION NAME] 200 mg twice a day. He explained that the maximum [MEDICATION NAME] dose is 400 mg three times a day, and in this case the maximum dose was erroneously given. Review of the facility policy entitled "Matchback protocol" included the following: This process to be completed nightly and be given to the unit manager to present at the morning meeting for auditing. 1. The most current physician orders are compared with the original medication order if this order has been transcribed from another source document. The orders are then compared to the Medication Administration Record [REDACTED]. 2. The process requires pulling the chart and comparing the orders to the MAR indicated [REDACTED] 3. If the chart and MAR match, the medications should be pulled and compared to ensure all three match. (Medication name, strength, dosage form and directions for use). An interview was conducted on 3/11/14 at 9:30 am with the acting Director of Nursing (DON). She confirmed that the [MEDICATION NAME] transcription error went undetected by the facility until 2/8/14. When asked if the matchback protocol was still being utilized by the facility she stated, "Yes." She confirmed that the former UM and DON were not following up and auditing orders per the facility policy. Prior to the surveyors ' entrance to the facility on [DATE], the nurse who transcribed the [MEDICATION NAME] order was retrained on the matchback procedure (confirmed by sign-in sheet). The facility also checked residents' MARs for accurate transcription of all [MEDICATION NAME] and [MEDICATION NAME] orders. The facility rechecked all residents' records for medication indicated labs, and continues to do this on a weekly basis. The DON and Administrator were terminated on 2/24/14. The UM was suspended on 2/24/14, and terminated on 3/11/14. Package insert [MEDICATION NAME]? [MEDICATION NAME]? ([MEDICATION NAME] Chewable Tablets, USP) Pfizer Parke-Davis, Revised September 2013. DOSAGE AND ADMINISTRATION: [MEDICATION NAME]? [MEDICATION NAME]? is formulated with the sodium salt of [MEDICATION NAME]. The free acid form of [MEDICATION NAME] is used in [MEDICATION NAME]-125 Suspension and [MEDICATION NAME]. Because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa.Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. Adult Dosage: Patients who have received no previous treatment may be started on two [MEDICATION NAME] three times daily, and the dose is then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be six to eight [MEDICATION NAME] daily. PRECAUTIONS: If early signs of dose-related CNS toxicity develop, plasma levels should be checked immediately. OVERDOSAGE: The initial symptoms are [DIAGNOSES REDACTED], ataxia, and dysarthria. Other signs are tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting. The patient may become comatose and hypotensive. [DIAGNOSES REDACTED] on lateral gaze usually appears at 20 mcg/mL, ataxia at 30 mcg/mL, dysarthria and lethargy appear when the plasma concentration is over 40 mcg/mL, but as high a concentration as 50 mcg/mL has been reported without evidence of toxicity. .

Based on observation and staff interviews the facility failed to provide pharmacy services to assure accurate transcribing, acquiring, dispensing, and administering of anti-seizure medication (Dilantin) for 1 resident (Resident #1) who experienced medication related adverse consequences, out of 6 residents reviewed for anti-seizure medication. The findings include: Record review of Resident #1 revealed an [AGE] year old male with the following diagnoses; Stroke, difficulty swallowing, diabetes, high blood pressure, anemia, convulsions, vascular dementia, and glaucoma. Resident #1 was documented as alert with aphasia (unable to speak), required extensive assist with bathing, dressing, transfers and mobility due to [DIAGNOSES REDACTED] (paralysis on one side). He was incontinent of bowel and bladder. Resident #1 was able to propel his own wheelchair and needed supervision with eating. Further record review revealed the resident was prescribed Dilantin for seizures. A Dilantin level was ordered on [DATE]. Results showed a Dilantin level of 1.8mcg/mL (normal range 10-20mcg/mL). The physician increased the Dilantin to 200mg twice a day to obtain an optimum therapeutic level of the medication. The Dilantin level was repeated on 1/8/14. Results showed a level of less than 1mcg/mL. The physician was notified and he increased the dose to 300mg twice a day. The Dilantin order on the electronic Medication Administration Records (MAR) was transcribed as Dilantin 50mg infatabs give 6 tablets to equal 600mg twice a day (double the dose ordered). An interview was conducted at 10:12 a.m. on 3/11/14 with the 11-7 shift Licensed Practical Nurse (LPN) #2. She stated that Resident #1 was originally on Dilantin capsules 200 mg twice daily, which the physician changed to 300 mg twice daily. She stated the original order to change the dose read "Dilantin 50 mg give 6 tabs po." She stated the order did not have "equal to" to account for the total dose. She stated she couldn't find the original order, so she didn't do the facility matchback protocol to verify accurate transcription of the order. She alerted the Unit Manager (UM) that she couldn't verify the order transcription. "The Unit Manager found the order and said it was 300 mg. It was end of shift and I put the order in the electronic MAR and I didn't read the order. I put = 600mg. I did not re-fax the order to pharmacy due to the previous nurse already sending the order. The print out sheet was available and the original order was in the chart 50 mg 6 tabs, and I wrote in = 300 there. I am not sure why the capsules were changed to infatabs. The medication was later changed to a liquid." Review of the Medication Administration Records (MAR) for January and February, 2014 revealed Resident #1 received Dilantin 600mg twice daily (double the dose ordered) from 1/9/14 thru 1/22/14. A review of laboratory reports revealed the Dilantin level on 1/22/14 was 22mcg/mL (normal range 10-20mcg/mL). Record review revealed the Advanced Registered Nurse Practitioner (ARNP) reduced the pm dose of Dilantin from 600mg to 400mg at that time. A phone interview was conducted on 3/10/14 at 1:30 p.m. with the Registered Pharmacist for the dispensing pharmacy. She stated the 1/8/14 Dilantin order faxed from the facility had the number of tabs scratched out, and 600mg bid (twice a day) written on it. When asked if there was a pharmacy policy regarding a medication order received with scratch outs written on it, she said the pharmacy did not have a policy to clarify scratch outs. She stated that according to the pharmacy records, on 1/10/14 the resident's order was changed to Dilantin 125mg/5ml give 24 ml = 600 mg bid. On 1/15/14 there was an order entered for 600mg in the morning and 400mg at 5:00 pm. When asked if the pharmacist should question such an increase in dosage of medication (300mg bid to 600mg twice a day) she stated, "Yes." She stated that the pharmacy computer system alerts them to maximum and minimum dosages. "Dilantin is one of the drugs that would trigger an alert to clarify dosage." When asked what the pharmacy protocol was if the dose of a medication requested is double the previous dose she stated, "We would call the facility to clarify with the physician." When asked who was responsible for ensuring accuracy of changing medications from tablet form to liquid she said, "The pharmacist would make conversions of medication dosage and double check to make sure things are correct." When asked if the alert system was in place when Resident #1's Dilantin was ordered on [DATE] she stated, "Yes." A phone interview was conducted at 1:51 p.m. on 3/10/14 with the Director of Pharmacy. He confirmed that Dilantin 600mg twice a day was a high dose. He stated the computer has an alert system in place to make the pharmacist aware of maximum doses of medications. When asked if an alert occurred when dispensing the Dilantin dose for Resident #1 he stated there was an alert, however the system allows the pharmacist to use their discretion when filling an order. When asked why the pharmacist did not contact the facility for clarification, he stated the pharmacist was comfortable about the dose and didn't need clarification. Record review revealed no documentation of pharmacy clarifying the Dilantin dose increase, or monitoring transcription of the order to ensure that it was administered in the correct dose. An interview conducted on 3/11/14 at 11:00 am with Licensed Practical Nurse (LPN) #1 revealed Resident #1 had a routine he followed everyday like clockwork. He liked to be up early, wheeled himself to the medication cart to see the nurse, went to the dining room for meals, wheeled himself up and down the corridors, and went outside on the patio. He was always on the move. When asked if there had been a change in condition for Resident #1 she stated she had observed changes in the resident at the end of January, 2014. His appetite had decreased and he often refused to eat. He experienced weight loss, was not as active, and was often lethargic. She stated he had a urinary tract infection and was treated, however his condition did not improve. When asked if she reported the changes she noted in January to the physician, she stated she reported the changes to the UM. She stated the UM referred the resident to hospice, but she did not know why. On 2/8/14, LPN #1 recognized the change in the resident's condition could be related to his Dilantin. LPN #1 called the physician to request a Dilantin level. An interview with the resident's son on 3/7/14 at 8:20 am revealed he noticed that his father had been declining steadily since mid January, 2014. The son voiced his concerns repeatedly to the UM. He stated that the Certified Nursing Assistants (CNAs) also shared with him their concerns with his father's decreased activity levels and increased lethargy. He stated he spoke to the UM on 2/5/14 regarding his father's continued weight loss, poor appetite, and incoherence. The UM's response was that the resident had given up. She suggested a DNR (Do Not Resuscitate) order and hospice for the resident. The UM presented the DNR paperwork to the son, which he signed, and hospice came in that evening to admit the resident to their service. The son stated he was still concerned about his father's level of consciousness, and asked the nurse on duty to call the physician. Record review revealed that the Advance Registered Nurse Practitioner (ARNP) responding to the nurse's call ordered labs for the resident, including a urinalysis and CBC (complete blood count). The urinalysis report of 2/7/14 showed numerous bacteria indicating a urinary tract infection, and treatment was ordered. On 2/8/14 the resident ' s Dilantin level was discovered to be at a critical level of 55.4mcg/mL (normal range 10-20mcg/mL). The physician was notified of the result, and placed the Dilantin on hold until further notice. An interview was conducted at 11:20 a.m on 3/7/14 with the Medical Director, the resident's physician. When asked about the resident's Dilantin dose he stated, "The pharmacy should have questioned this; 300mg to 600mg is a big jump." He went on to say that a Dilantin dose increase is never made at an interval that large. He stated that the Dilantin level on 1/8/14 was low. He asked staff if the resident was receiving Dilantin. "They told me 'Yes', so I increased the Dilantin to 300mg twice daily." He stated the Dilantin was changed from 300mg to 600mg in the liquid form; " that is when the mistake happened." He explained that the family went to the supervisor (UM) about the changes in the resident, and she recommended hospice due to his decline. The Medical Director stated that the supervisor should have let him know about the change in the resident's condition sooner; my ARNP or I would have looked at the resident. He said the nurse saw some changes in the resident in February. The nurse notified the Medical Director's ARNP, and requested an order for [REDACTED]. He said once the resident ' s critical Dilantin level was discovered, his Dilantin levels were monitored until he was back to baseline. The Medical Director stated that the resident is now on Dilantin 200 mg twice a day. He explained that the maximum Dilantin dose is 400 mg three times a day, and in this case the maximum dose was erroneously given. An interview was conducted on 3/11/14 at 9:30 am with the acting Director of Nursing (DON). She confirmed that the resident's Dilantin transcription error went undetected by the facility until 2/8/14. She stated that the consultant pharmacist was replaced in March, 2014, prior to this complaint investigation. The pharmacy also in-serviced facility nursing staff on dosing and monitoring of high risk medications, including Dilantin (confirmed by sign-in sheets). After the surveyors inquired about a corrective action plan for the pharmacy's failure to monitor excessive dosing of the resident's Dilantin, the pharmacy retrained their own staff on 3/11/14 on monitoring high risk medications. The pharmacy also initiated a policy to respond to all medication dosing alerts. Package insert for INFATABS? Dilantin? (Phenytoin Chewable Tablets, USP) Pfizer Parke-Davis, Revised September 2013. DOSAGE AND ADMINISTRATION: Dilantin? Kapseals? is formulated with the sodium salt of phenytoin. The free acid form of phenytoin is used in Dilantin-125 Suspension and Dilantin Infatabs. Because there is approximately an 8% increase in drug content with the free acid form over that of the sodium salt, dosage adjustments and serum level monitoring may be necessary when switching from a product formulated with the free acid to a product formulated with the sodium salt and vice versa.Dosage should be individualized to provide maximum benefit. In some cases, serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. Adult Dosage: Patients who have received no previous treatment may be started on two Infatabs three times daily, and the dose is then adjusted to suit individual requirements. For most adults, the satisfactory maintenance dosage will be six to eight Infatabs daily. PRECAUTIONS: If early signs of dose-related CNS toxicity develop, plasma levels should be checked immediately. OVERDOSAGE: The initial symptoms are [DIAGNOSES REDACTED], ataxia, and dysarthria. Other signs are tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting. The patient may become comatose and hypotensive. [DIAGNOSES REDACTED] on lateral gaze usually appears at 20 mcg/mL, ataxia at 30 mcg/mL, dysarthria and lethargy appear when the plasma concentration is over 40 mcg/mL, but as high a concentration as 50 mcg/mL has been reported without evidence of toxicity. .

Based on staff interview, record review and review of facility policy and procedures, the facility's Quality Assessment and Assurance committee failed to identify quality of care issues related to recognition of a medication dosing discrepancy for a blood pressure medication, created by erroneous entry of a medication order into the electronic system, and follow-up of pharmacy recommendations for 1 of 5 residents (Resident #119) reviewed for medications. These findings resulted in Immediate Jeopardy for Resident #119 that occurred on 2/1/13 and remained ongoing at the time of exit on 11/22/13, for failure to discern and correct the quality deficiencies, placing all 140 residents residing in the facility at risk for medication errors and adverse consequences that would be likely to result in serious harm, impairment, or death to residents. Resident #119 was receiving [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. An Allegation of Compliance (AOC) was received by the State Agency on 11/27/13. The AOC was amended by the facility and accepted by the State Agency and CMS Regional Office on 12/11/13. The AOC revealed action items related to the recertification survey conducted on 11/22/13 identifying IJ on 2/1/13 and ongoing at F520 scope and severity (S/S) J, under 483.75(o)(1) Qaa Committee-Members/meet Quarterly/plans. On 12/13/16 an abbreviated follow-up survey was conducted to determine the status of the ongoing IJ identified at F520. The facility was found to have implemented the action items in the AOC in order to identify quality of care issues related to recognition of medication dosing discrepancies, created by erroneous entry of a medication order into the electronic system, and follow-up of pharmacy recommendations, and monitoring was ongoing. The IJ at F520 was removed as of 12/13/13. At the time of exit on 12/13/13, F520 remained out of compliance at S/S of D. The facility is not in compliance with the regulations at 42 CFR, Part 483 subpart B Requirements for Long Term Care Facilities. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed [MEDICATION NAME] 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for [MEDICATION NAME] 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's Medication Administration Record (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "[MEDICATION NAME] 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month ' s MAR for the resident's [MEDICATION NAME] 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received [MEDICATION NAME] 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated [MEDICATION NAME] 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13 the administration time for Resident #119 ' s medication order for [MEDICATION NAME] 25mg tab give 1 tablet QD was changed to 9:00 AM only. A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- [MEDICATION NAME] being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, " receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report dated 10/14/13 revealed that the pharmacist stated, "[MEDICATION NAME] daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, " Continue to receive as ordered. Will review. " Further review of the pharmacy consultation reports found that on 11/14/13 the pharmacy consultant made a recommendation that read, "[MEDICATION NAME] daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, " changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January 2013 through November 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's [MEDICATION NAME] 25mg was ordered on the physician order [REDACTED]. In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received [MEDICATION NAME] 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated [MEDICATION NAME] 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the [MEDICATION NAME] coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's [MEDICATION NAME] dosing until September, 2013. She reported that the facility did not clarify Resident #119's [MEDICATION NAME] dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. A review of the facility's policy titled "Documentation and communication of consultant pharmacist recommendations, " with an effective date of 3/2011, revealed that "comments and recommendations concerning drug therapy are communicated and acted on by the facility in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review." The policy also states that the "consultant pharmacist documents potential or actual medication therapy problems and other medication regimen review findings appropriate for prescriber and/or nursing review." A review of the facility's policy titled, "Monthly physician's orders [REDACTED]. The policy read that the LPN compares the prior month's orders, including all telephone, verbal and facsimile orders received during the past month, against the computer generated POS, and makes any needed revisions. The policy also read that the physician should review, revise as warranted, sign and date monthly orders during routine visits to the facility. In an interview on 11/22/2013 at 11:15 AM with Nurse Unit Manager I, she reported that on the last day of each month medical records prints out all of the POSs and brings them to each unit. The third shift nurse compares the medications on the printed POS to the MAR in the computer to see if they match, and signs and dates the POS. If the POS and MAR do not match, the nurse investigates what is wrong. She stated that the POS and MAR always match. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's [MEDICATION NAME]. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/21/2013 at 2:50 pm with the Administrator, she stated the Quality Assessment Assurance (QAA) Committee meets monthly. The facility looks for trends related to weight loss, abuse, and adverse incidents for QAA focus. The monthly QAA meetings cover wounds, weights, incidents and accidents, restraints, pain management, and restorative care. The grievance book and resident council to identify QAA issues. She has an open door policy for staff to report any issues or file a grievance. Incidents and accidents are tracked by pulling information off of the computer. There are no facility audits for the accuracy of physician medication orders, but the facility looks at statistics of medication dose reductions. The Administrator stated that the MARs are printed at the end of each month. The charge nurses compare the POS to the MAR monthly. The physician signs off on the POS. She stated that this has not been a recent QAA issue. She stated the pharmacy consultant attends the meetings, and the Administrator confirmed that the consulting pharmacist attended the QAA meeting on 11/14/2013. The Administrator stated that the consulting pharmacist works from a report off the POS system. Recommendations from the consulting pharmacist go to the Director of Nursing. She stated they have not identified a concern for QAA related to the consulting pharmacist's recommendations. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119 ' s medication order for [MEDICATION NAME] 25 mg PO once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013 the medication was not corrected and I spoke with the DON. In November, 2013 the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is [MEDICATION NAME] 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." An interview on 11/22/13 at 2:30PM with the facility ' s Medical Director revealed that when asked if the facility had informed him of the Immediate Jeopardy, he stated that the administrator had informed him about an hour ago of the following: A resident (Resident #119) had an order for [REDACTED]. The [MEDICATION NAME] order was not clarified by the facility, and remained on the MARs every month from January, 2013 to November, 2013 as twice daily dosing. The consultant pharmacist recognized and reported the dosing discrepancy via written recommendations to the facility in September, October, and November, 2013. The facility did not act upon the pharmacist ' s recommendations to clarify the [MEDICATION NAME] dose. The Medical Director stated that the consultant pharmacist attends the facility ' s monthly Quality Assurance Committee meetings. He further stated that the pharmacist did not bring any concerns to the committee related to facility recognition of dosing discrepancies, failure of nurses to respond to the monthly medication regimen recommendations, or any concerns related to Resident #119. The medical director expressed his concerns regarding systems problems in the facility related to errors in the entry of orders into the electronic records, communication issues between nursing and pharmacy, and the process of reconciling the monthly physician orders. He stated he would work with the facility and review the plan of corrective action to correct the immediate jeopardy. (Cross reference to F329 and F428.)

Based on clinical and facility record review and staff interviews, the facility failed to ensure that 1 out of 2 residents (Resident #119) on blood pressure medication, out of 5 residents reviewed for unnecessary medications, received medication management at readmission from the hospital and ongoing related to the dosing of a blood pressure medication. It was discovered that Resident #119 received a medication for high blood pressure twice daily from January, 2013 to November, 2013 (a total of 313 days), when the physician's orders [REDACTED]. It was found that the facility did not have an effective system in place to identify the dosing error in the electronic Medication Administration Record. The facility also failed to clarify the dosing with the physician, according to recommendations from the consulting pharmacist from September, 2013 to November, 2013. These findings resulted in Immediate Jeopardy (IJ) that occurred on 2/1/13 and remained ongoing at the time of exit on 11/22/13, for failure to have a system in place to enure that residents were free from unnecessary medications and excessive dosing, and placed all 140 residents residing in the facility at risk for receiving unnecessary medications and experiencing adverse consequences. All of the residents in the facility were receiving medications. Resident #119 was receiving [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. An Allegation of Compliance (AOC) was received by the State Agency on 11/27/13. The AOC was amended by the facility and accepted by the State Agency and CMS Regional Office on 12/11/13. The AOC revealed action items related to the recertification survey conducted on 11/22/13 identifying IJ on 2/1/13 and ongoing at F-329 scope and severity (S/S) J, under 483.25(l) Drug Regimen Is Free From Unnecessary Drugs. On 12/13/16 an abbreviated follow-up survey was conducted to determine the status of the ongoing IJ identified at F-329. The facility was found to have implemented the action items in the AOC in order to have a system in place to enure that residents were free from unnecessary medications and excessive dosing, and monitoring was ongoing. The IJ at F-329 was removed as of 12/13/13. At the time of exit on 12/13/13, F-329 remained out of compliance at S/S of D. The facility is not in compliance with the regulations at 42 CFR, Part 483 subpart B Requirements for Long Term Care Facilities. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed [MEDICATION NAME] 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for [MEDICATION NAME] 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- [MEDICATION NAME] being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, "receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report dated 10/14/13 revealed that the pharmacist stated, "[MEDICATION NAME] daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, "continue to receive as ordered. Will review." Further review of the pharmacy consultation reports found that on 11/14/13 the pharmacy consultant made a recommendation that read, "[MEDICATION NAME] daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, "changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January 2013 through November 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's [MEDICATION NAME] 25mg was ordered on the physician order [REDACTED]. A review of Resident #119's Medication Administration Records (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "[MEDICATION NAME] 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month ' s MAR for the resident's [MEDICATION NAME] 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received [MEDICATION NAME] 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated [MEDICATION NAME] 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13 the administration time for Resident #119's medication order for [MEDICATION NAME] 25mg tab give 1 tablet QD was changed to 9:00 AM only. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119's medication order for [MEDICATION NAME] 25 mg PO (by mouth) once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013, the medication was not corrected and I spoke with the DON. In November, 2013, the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is [MEDICATION NAME] 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received [MEDICATION NAME] 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated [MEDICATION NAME] 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the [MEDICATION NAME] coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's [MEDICATION NAME] dosing until September, 2013. She reported that the facility did not clarify Resident #119's [MEDICATION NAME] dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. Review of the facility medication error report filed on 11/18/13 at 10:00 AM for Resident # 119 revealed that a medication order was written in the electronic order text every day. However, the order interval (dosing time) was coded as twice a day per the medication card from the pharmacy. The physician and family were notified of the error on 11/18/13. The DON was notified on 11/19/13. Review of the post incident immediate action revealed that orders will be rechecked once by an interdisciplinary team. Review of the medication error policies and procedures revealed the facility followed the protocol. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. A review of the facility's policy titled "Documentation and communication of consultant pharmacist recommendations," with an effective date of 3/2011, revealed that "comments and recommendations concerning drug therapy are communicated and acted on by the facility in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review." The policy also states that the "consultant pharmacist documents potential or actual medication therapy problems and other medication regimen review findings appropriate for prescriber and/or nursing review." In an interview on 11/22/2013 at 11:15 AM with Nurse Unit Manager I, she reported that on the last day of each month medical records prints out all of the POSs and brings them to each unit. The third shift nurse compares the medications on the printed POS to the MAR in the computer to see if they match, and signs and dates the POS. If the POS and MAR do not match, the nurse investigates what is wrong. She stated that the POS and MAR always match. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's [MEDICATION NAME]. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/21/13 at 7:26 PM with Licensed Practical Nurse (LPN) N, she reported that she worked on the South wing 4 times a week on the 3:00 PM to 11:00 PM shift. She reported that Resident #119 received Metroprolol 25mg at 5:00 PM until it was discontinued on 11/18/13. An observation of Resident #119's [MEDICATION NAME] medication punch card found that the card read, "[MEDICATION NAME] 25 mg BID (twice daily)." An interview on 11/21/13 at 7:45 PM with the dispensing pharmacy revealed that the prescription on file for Resident #119 read, "[MEDICATION NAME] 25 mg 1 tablet BID (twice daily)." A review of the facility's policy titled, "Monthly physician's orders [REDACTED]. The policy read that the LPN compares the prior month's orders, including all telephone, verbal and facsimile orders received during the past month, against the computer generated POS, and makes any needed revisions. The policy also read that the physician should review, revise as warranted, sign and date monthly orders during routine visits to the facility. In a telephone interview on 11/22/13 at 11:40 AM with the prescribing physician for Resident #119, he reported that he reviewed Resident #119's medications monthly. He reported that every month he signed a POS that was used as a doctor's order for up to 45 days. He reported that each month, when he signed the new physician order [REDACTED]. When asked what the correct dose of [MEDICATION NAME] was for Resident #119 (BID or QD), the physician stated that he would not answer the question because he didn't have the chart in front of him (this was a telephone interview). When asked will you be coming into the facility he said, "No, not today." The interviewer gave the physician her contact information so that he could let her know what the correct dose of [MEDICATION NAME] was for the resident, but he never contacted the surveyor. An interview on 11/22/13 at 2:30PM with the facility's Medical Director revealed that when asked if the facility had informed him of the Immediate Jeopardy, he stated that the administrator had informed him about an hour ago of the following: A resident (Resident #119) had an order for [REDACTED]. The [MEDICATION NAME] order was not clarified by the facility, and remained on the MARs every month from January, 2013 to November, 2013 as twice daily dosing. The consultant pharmacist recognized and reported the dosing discrepancy via written recommendations to the facility in September, October, and November, 2013. The facility did not act upon the pharmacist's recommendations to clarify the [MEDICATION NAME] dose. The Medical Director stated that the consultant pharmacist attends the facility's monthly Quality Assurance Committee meetings. He further stated that the pharmacist did not bring any concerns to the committee related to facility recognition of dosing discrepancies, failure of nurses to respond to the monthly medication regimen recommendations, or any concerns related to Resident #119. The medical director expressed his concerns regarding systems problems in the facility related to errors in the entry of orders into the electronic records, communication issues between nursing and pharmacy, and the process of reconciling the monthly physician orders. He stated he would work with the facility and review the plan of corrective action to correct the immediate jeopardy. (Cross reference to F428.) .

Based on interview and record review, the consultant pharmacist failed to timely identify a dosing discrepancy related to a blood pressure medication, failed to identify irregularities in the transmission of orders by nursing staff, and failed to communicate to those with authority when her recommendation to clarify the dosing discrepancy was not resolved by staff for 1 of 5 residents (Resident #119) reviewed for unnecessary medications. These findings resulted in Immediate Jeopardy that is ongoing, for failure to have systems in place to identify medication dosing discrepancies and ensure that they are communicated to the physician, placing all 140 residents residing in the facility at risk for medication dosing errors and adverse consequences that would be likely to result in serious harm, impairment, or death to residents. Resident #119 was receiving Lopressor (Metoprolol Tartrate) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on Lopressor (Metoprolol Tartrate) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed Metoprolol Tartrate 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for Metoprolol 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's Medication Administration Record (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "Metoprolol Tartrate 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month's MAR for the resident's Metoprolol Tartrate 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received Metoprolol Tartrate 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated Metoprolol 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13, the administration time for Resident #119's medication order for Metoprolol 25mg tab give 1 tablet QD was changed to 9:00 AM only. An interview on 11/21/13 at 7:40 p.m. with the dispensing pharmacist revealed that the prescription on file, dated 01/06/13, for Resident #119 read, "Metoprolol 25 mg bid (twice a day)." She stated, "We don't look at physician orders [REDACTED]. Refills are provided when the facility pulls off the label on the medication blister pack and faxes it to the pharmacy. The pharmacy looks at original physician orders [REDACTED]. A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- Metoprolol being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation, a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, "receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report, dated 10/14/13, revealed that the pharmacist stated, "Metoprolol daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, "continue to receive as ordered. Will review." Further review of the pharmacy consultation reports found that on 11/14/13, the pharmacy consultant made a recommendation that read, "Metoprolol daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, "changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January, 2013 through November, 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's Metoprolol 25mg was ordered on the physician order [REDACTED]. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119 ' s medication order for Metoprolol 25 mg PO once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013 the medication was not corrected and I spoke with the DON. In November, 2013 the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is Metoprolol 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received Metoprolol 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated Metoprolol 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the Metoprolol coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's Metoprolol dosing until September, 2013. She reported that the facility did not clarify Resident #119's Metoprolol dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's Metoprolol. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled, the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing, she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy, she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. In an interview on 11/21/13 at 7:26 PM with Licensed Practical Nurse (LPN) N, she reported that she worked on the South wing 4 times a week on the 3:00 PM to 11:00 PM shift. She reported that Resident #119 received Metroprolol 25mg at 5:00 PM until it was discontinued on 11/18/13. An observation of Resident #119's Metoprolol medication punch card found that the card read, "Metoprolol 25 mg BID (twice daily)." Review of the facility medication error report, filed on 11/18/13 at 10:00 AM for Resident # 119 revealed that a medication order was written in the electronic order text every day. However, the order interval (dosing time) was coded as twice a day per the medication card from the pharmacy. The physician and family were notified of the error on 11/18/13. The DON was notified on 11/19/13. Review of the post incident immediate action revealed that orders will be rechecked once by an interdisciplinary team. Review of the medication error policies and procedures revealed the facility followed the protocol. (Cross reference to F329.)

Based on interview and record review, the consultant pharmacist failed to timely identify a dosing discrepancy related to a blood pressure medication, failed to identify irregularities in the transmission of orders by nursing staff, and failed to communicate to those with authority when her recommendation to clarify the dosing discrepancy was not resolved by staff for 1 of 5 residents (Resident #119) reviewed for unnecessary medications. These findings resulted in Immediate Jeopardy that occurred on 2/1/13 and remained ongoing at the time of exit on 11/22/13, for failure to have systems in place to identify medication dosing discrepancies and ensure that they are communicated to the physician, placing all 140 residents residing in the facility at risk for medication dosing errors and adverse consequences that would be likely to result in serious harm, impairment, or death to residents. Resident #119 was receiving Lopressor (Metoprolol Tartrate) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. An Allegation of Compliance (AOC) was received by the State Agency on 11/27/13. The AOC was amended by the facility and accepted by the State Agency and CMS Regional Office on 12/11/13. The AOC revealed action items related to the recertification survey conducted on 11/22/13 identifying IJ on 2/1/13 and ongoing at F-428 scope and severity (S/S) J, under 483.60(c) Drug Regimen Review, Report Irregular, Act On. On 12/13/16 an abbreviated follow-up survey was conducted to determine the status of the ongoing IJ identified at F-428. The facility was found to have implemented the action items in the AOC in order to identify irregularities in the transmission of physician orders [REDACTED]. The IJ at F-428 was removed as of 12/13/13. At the time of exit on 12/13/13, F-428 remained out of compliance at S/S of D. The facility is not in compliance with the regulations at 42 CFR, Part 483 subpart B Requirements for Long Term Care Facilities. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on Lopressor (Metoprolol Tartrate) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed Metoprolol Tartrate 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for Metoprolol 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's Medication Administration Record (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "Metoprolol Tartrate 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month's MAR for the resident's Metoprolol Tartrate 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received Metoprolol Tartrate 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated Metoprolol 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13, the administration time for Resident #119's medication order for Metoprolol 25mg tab give 1 tablet QD was changed to 9:00 AM only. An interview on 11/21/13 at 7:40 p.m. with the dispensing pharmacist revealed that the prescription on file, dated 01/06/13, for Resident #119 read, "Metoprolol 25 mg bid (twice a day)." She stated, "We don't look at physician orders [REDACTED]. Refills are provided when the facility pulls off the label on the medication blister pack and faxes it to the pharmacy. The pharmacy looks at original physician orders [REDACTED]. A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- Metoprolol being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation, a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, "receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report, dated 10/14/13, revealed that the pharmacist stated, "Metoprolol daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, "continue to receive as ordered. Will review." Further review of the pharmacy consultation reports found that on 11/14/13, the pharmacy consultant made a recommendation that read, "Metoprolol daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, "changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January, 2013 through November, 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's Metoprolol 25mg was ordered on the physician order [REDACTED]. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119 ' s medication order for Metoprolol 25 mg PO once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013 the medication was not corrected and I spoke with the DON. In November, 2013 the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is Metoprolol 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received Metoprolol 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated Metoprolol 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the Metoprolol coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's Metoprolol dosing until September, 2013. She reported that the facility did not clarify Resident #119's Metoprolol dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's Metoprolol. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled, the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing, she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy, she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. In an interview on 11/21/13 at 7:26 PM with Licensed Practical Nurse (LPN) N, she reported that she worked on the South wing 4 times a week on the 3:00 PM to 11:00 PM shift. She reported that Resident #119 received Metroprolol 25mg at 5:00 PM until it was discontinued on 11/18/13. An observation of Resident #119's Metoprolol medication punch card found that the card read, "Metoprolol 25 mg BID (twice daily)." Review of the facility medication error report, filed on 11/18/13 at 10:00 AM for Resident # 119 revealed that a medication order was written in the electronic order text every day. However, the order interval (dosing time) was coded as twice a day per the medication card from the pharmacy. The physician and family were notified of the error on 11/18/13. The DON was notified on 11/19/13. Review of the post incident immediate action revealed that orders will be rechecked once by an interdisciplinary team. Review of the medication error policies and procedures revealed the facility followed the protocol. (Cross reference to F329.)

Based on staff interview, record review and review of facility policy and procedures, the facility's Quality Assessment and Assurance committee failed to identify quality of care issues related to recognition of a medication dosing discrepancy for a blood pressure medication, created by erroneous entry of a medication order into the electronic system, and follow-up of pharmacy recommendations for 1 of 5 residents (Resident #119) reviewed for medications. These findings resulted in Immediate Jeopardy for Resident #119 that is ongoing for failure to discern and correct the quality deficiencies, placing all 140 residents residing in the facility at risk for medication errors and adverse consequences that would be likely to result in serious harm, impairment, or death to residents. Resident #119 was receiving [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed [MEDICATION NAME] 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for [MEDICATION NAME] 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's Medication Administration Record (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "[MEDICATION NAME] 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month ' s MAR for the resident's [MEDICATION NAME] 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received [MEDICATION NAME] 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated [MEDICATION NAME] 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13 the administration time for Resident #119 ' s medication order for [MEDICATION NAME] 25mg tab give 1 tablet QD was changed to 9:00 AM only. A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- [MEDICATION NAME] being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, " receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report dated 10/14/13 revealed that the pharmacist stated, "[MEDICATION NAME] daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, " Continue to receive as ordered. Will review. " Further review of the pharmacy consultation reports found that on 11/14/13 the pharmacy consultant made a recommendation that read, "[MEDICATION NAME] daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, " changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January 2013 through November 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's [MEDICATION NAME] 25mg was ordered on the physician order [REDACTED]. In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received [MEDICATION NAME] 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated [MEDICATION NAME] 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the [MEDICATION NAME] coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's [MEDICATION NAME] dosing until September, 2013. She reported that the facility did not clarify Resident #119's [MEDICATION NAME] dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. A review of the facility's policy titled "Documentation and communication of consultant pharmacist recommendations, " with an effective date of 3/2011, revealed that "comments and recommendations concerning drug therapy are communicated and acted on by the facility in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review." The policy also states that the "consultant pharmacist documents potential or actual medication therapy problems and other medication regimen review findings appropriate for prescriber and/or nursing review." A review of the facility's policy titled, "Monthly physician's orders [REDACTED]. The policy read that the LPN compares the prior month's orders, including all telephone, verbal and facsimile orders received during the past month, against the computer generated POS, and makes any needed revisions. The policy also read that the physician should review, revise as warranted, sign and date monthly orders during routine visits to the facility. In an interview on 11/22/2013 at 11:15 AM with Nurse Unit Manager I, she reported that on the last day of each month medical records prints out all of the POSs and brings them to each unit. The third shift nurse compares the medications on the printed POS to the MAR in the computer to see if they match, and signs and dates the POS. If the POS and MAR do not match, the nurse investigates what is wrong. She stated that the POS and MAR always match. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's [MEDICATION NAME]. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/21/2013 at 2:50 pm with the Administrator, she stated the Quality Assessment Assurance (QAA) Committee meets monthly. The facility looks for trends related to weight loss, abuse, and adverse incidents for QAA focus. The monthly QAA meetings cover wounds, weights, incidents and accidents, restraints, pain management, and restorative care. The grievance book and resident council to identify QAA issues. She has an open door policy for staff to report any issues or file a grievance. Incidents and accidents are tracked by pulling information off of the computer. There are no facility audits for the accuracy of physician medication orders, but the facility looks at statistics of medication dose reductions. The Administrator stated that the MARs are printed at the end of each month. The charge nurses compare the POS to the MAR monthly. The physician signs off on the POS. She stated that this has not been a recent QAA issue. She stated the pharmacy consultant attends the meetings, and the Administrator confirmed that the consulting pharmacist attended the QAA meeting on 11/14/2013. The Administrator stated that the consulting pharmacist works from a report off the POS system. Recommendations from the consulting pharmacist go to the Director of Nursing. She stated they have not identified a concern for QAA related to the consulting pharmacist's recommendations. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119 ' s medication order for [MEDICATION NAME] 25 mg PO once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013 the medication was not corrected and I spoke with the DON. In November, 2013 the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is [MEDICATION NAME] 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." An interview on 11/22/13 at 2:30PM with the facility ' s Medical Director revealed that when asked if the facility had informed him of the Immediate Jeopardy, he stated that the administrator had informed him about an hour ago of the following: A resident (Resident #119) had an order for [REDACTED]. The [MEDICATION NAME] order was not clarified by the facility, and remained on the MARs every month from January, 2013 to November, 2013 as twice daily dosing. The consultant pharmacist recognized and reported the dosing discrepancy via written recommendations to the facility in September, October, and November, 2013. The facility did not act upon the pharmacist ' s recommendations to clarify the [MEDICATION NAME] dose. The Medical Director stated that the consultant pharmacist attends the facility ' s monthly Quality Assurance Committee meetings. He further stated that the pharmacist did not bring any concerns to the committee related to facility recognition of dosing discrepancies, failure of nurses to respond to the monthly medication regimen recommendations, or any concerns related to Resident #119. The medical director expressed his concerns regarding systems problems in the facility related to errors in the entry of orders into the electronic records, communication issues between nursing and pharmacy, and the process of reconciling the monthly physician orders. He stated he would work with the facility and review the plan of corrective action to correct the immediate jeopardy. (Cross reference to F329 and F428.)

Based on clinical and facility record review and staff interviews, the facility failed to ensure that 1 out of 2 residents (Resident #119) on blood pressure medication, out of 5 residents reviewed for unnecessary medications, received medication management at readmission from the hospital and ongoing related to the dosing of a blood pressure medication. It was discovered that Resident #119 received a medication for high blood pressure twice daily from January, 2013 to November, 2013 (a total of 313 days), when the physician's orders [REDACTED]. It was found that the facility did not have an effective system in place to identify the dosing error in the electronic Medication Administration Record. The facility also failed to clarify the dosing with the physician, according to recommendations from the consulting pharmacist from September, 2013 to November, 2013. These findings resulted in Immediate Jeopardy and is ongoing for failure to have systems in place to ensure that residents were free from unnecessary medications and excessive dosing, and placed all 140 residents residing in the facility at risk for receiving unnecessary medications and experiencing adverse consequences. All of the residents in the facility were receiving medications. Resident #119 was receiving [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. This beta blocker medication (a medication that blocks nerve receptors and thereby controls heart rate and blood pressure) has a Food and Drug Administration "Black Box" warning indicating that it can cause serious heart problems, particularly if abruptly withdrawn. Resident #119 had identified kidney disease. For individuals with kidney disease, inappropriate medication dosing can cause toxicity or ineffective therapy. The nursing home administrator was notified of Immediate Jeopardy on November 21, 2013 at 7:30 p.m. The findings include: A review of Resident #119's record revealed that he was readmitted to the facility on [DATE] from an acute care hospital, with [DIAGNOSES REDACTED]. Review of discharge orders from the hospital revealed that the resident was discharged on [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram (mg) orally twice daily. Review of an order dated 1/7/13 revealed [MEDICATION NAME] 25mg QD (daily). Review of physician orders [REDACTED].#119's physician signed orders monthly (except August and October, 2013) for [MEDICATION NAME] 25mg daily. The monthly physician orders [REDACTED]." A review of Resident #119's pharmacy consultation report dated 9/12/13 revealed the following recommendation to nursing: "nurse- [MEDICATION NAME] being given BID (twice daily). Order is for QD (once daily)." Next to the pharmacy recommendation a handwritten note dated 9/12/13 and signed by Nurse Unit Manager D read, "receiving BID (twice daily) per order." Review of the resident's pharmacy consultation report dated 10/14/13 revealed that the pharmacist stated, "[MEDICATION NAME] daily being given BID (twice daily) - please correct." Nurse Unit manager D made a handwritten notation next to the pharmacy recommendation that read, "continue to receive as ordered. Will review." Further review of the pharmacy consultation reports found that on 11/14/13 the pharmacy consultant made a recommendation that read, "[MEDICATION NAME] daily being given BID (twice daily)." An unknown writer made a handwritten notation next to the pharmacy recommendation that read, "changed 11/18/13." The pharmacy consultant reviewed Resident #119's medication regimen monthly from January 2013 through November 2013. The pharmacy consultant recognized in September, 2013 that Resident #119's [MEDICATION NAME] 25mg was ordered on the physician order [REDACTED]. A review of Resident #119's Medication Administration Records (MAR) from January, 2013 to November, 2013 revealed that the medication order in the left hand column of the form read, "[MEDICATION NAME] 25 mg tablet (tab) give one tablet QD (daily)" each month. The administration times on each month ' s MAR for the resident's [MEDICATION NAME] 25mg tablet were 9:00 AM and 5:00 PM. Further review of the MARs revealed that, with the exception of one day in January, Resident #119 received [MEDICATION NAME] 25mg tablet at both 9:00 AM and 5:00 PM from January 7, 2013 through November 17, 2013, a total 313 days in 2013, when the POSs for that time period stated [MEDICATION NAME] 25mg 1 tablet daily. The MAR for November, 2013 revealed that on 11/18/13 the administration time for Resident #119's medication order for [MEDICATION NAME] 25mg tab give 1 tablet QD was changed to 9:00 AM only. An interview on 1/22/13 at 11:50 AM with the consultant pharmacist revealed that when she reviews medications she compares the electronic MAR to the physician orders. The pharmacist reviews the medication dosage and interactions with other medications. The pharmacist's recommendations are entered into an electronic MAR and given to the DON. The DON follows up on the recommendations. On her next visit to the facility the pharmacist checks for actions taken by the facility, based on her recommendations. She stated, "After a second visit and recommendation isn't acted upon, I follow up with the DON. I speak to the DON and recommend she channel the recommendation to the appropriate person. I exit with the DON after each visit to the facility and discuss anything that is pressing. I reviewed Resident #119's medication order for [MEDICATION NAME] 25 mg PO (by mouth) once a day in September, 2013, and observed it was given two times a day. I put in the nursing section of my recommendation to correct the time. In October, 2013, the medication was not corrected and I spoke with the DON. In November, 2013, the recommendation was still not followed-up on, so I spoke to the DON and put the recommendation to the physician's attention. The DON said she would follow up on the recommendation. Maybe I should have brought this to the physician's attention sooner, but I saw this as a medication error. The order in the pharmacy system is [MEDICATION NAME] 25 mg two times a day and the direction from the physician was once a day. I felt it was an issue with directions." In an interview on 11/21/13 at 11:50 AM with the Director of Nursing (DON), she confirmed that Resident #119 received [MEDICATION NAME] 25mg twice daily from January 7, 2013 through November 17, 2013. She confirmed that the monthly POS and MAR stated [MEDICATION NAME] 25mg once daily. She reported that there was a coding problem with the electronic MAR, and the nurse that entered the order for the [MEDICATION NAME] coded the medication as twice daily dosing. She confirmed that the consulting pharmacist did not find the discrepancy in Resident #119's [MEDICATION NAME] dosing until September, 2013. She reported that the facility did not clarify Resident #119's [MEDICATION NAME] dosing with the physician, as recommended by the pharmacist, in September, 2013 and October, 2013 because the recommendations for those months were on a nursing recommendation sheet rather than a physician recommendation sheet. The pharmacist's recommendation for dosing clarification in November, 2013 was on a physician recommendation sheet. The DON stated that she does not review the pharmacy recommendations on a monthly basis. She reported that she hands the pharmacy recommendations to the Nurse Unit Managers for review, and she does not follow up on the recommendations. In an interview on 11/22/2013 at 2:53 PM with the DON, she stated that medical records personnel print the order sheets for the facility each month. The order sheets are given to the nurses on each wing, who check the residents' newly printed order sheet against the order sheet from the previous month. She stated the nurses also check the telephone orders from the chart. She stated that all new telephone orders show up on the physician orders [REDACTED]. At the meeting a print out of orders from the last 24 hours is reviewed. She stated that everyone is looking at the POS and making sure the orders are entered correctly. She stated that no one in the facility looks at the MAR to ensure it is correct. She stated the MAR comes from the physician orders [REDACTED]. Nursing does not print out the complete MAR for review. The pharmacist does that. She stated that when the pharmacist completes her monthly medication reviews, she leaves a folder of recommendations for the DON. She stated that she distributes the recommendations to the units. She makes a copy of the physician recommendations for her file, and later checks to see that they have come back after being reviewed. She stated she does not look to see if the recommendations are made. She stated that the Nurse Unit Managers keeps the nursing recommendations; they are not returned to the DON, and she does not look to see if the nursing recommendations are acted upon. Review of the facility medication error report filed on 11/18/13 at 10:00 AM for Resident # 119 revealed that a medication order was written in the electronic order text every day. However, the order interval (dosing time) was coded as twice a day per the medication card from the pharmacy. The physician and family were notified of the error on 11/18/13. The DON was notified on 11/19/13. Review of the post incident immediate action revealed that orders will be rechecked once by an interdisciplinary team. Review of the medication error policies and procedures revealed the facility followed the protocol. In an interview on 11/22/2013 at 12:10 PM with the South Wing Nurse Unit Manager, she stated that medical records personnel print out the POSs around the 28th or 29th of each month. The 11:00 PM to 7:00 AM nurse reviews and signs the order sheets after comparing the newly printed order sheets to the order sheets in the computer. When asked if anyone compares the residents' MARs to the POSs, she stated that she did not know. When asked how the pharmacy recommendations are handled the South Wing Nurse Unit Manager stated that the DON receives the recommendations and brings them to the Nurse Unit Managers. When asked what she does with the pharmacy recommendations to nursing she stated, "Sometimes I do not look at them and sometimes I do." She stated that she files the pharmacy recommendations in a book under each month. If she is not busy she may be able to file them right away, and sometimes she may not get to them until the end of the month. She stated she is the only staff person on her unit that handles the pharmacy recommendations. A review of the facility's policy titled "Documentation and communication of consultant pharmacist recommendations," with an effective date of 3/2011, revealed that "comments and recommendations concerning drug therapy are communicated and acted on by the facility in a timely fashion. The timing of these recommendations should enable a response prior to the next medication regimen review." The policy also states that the "consultant pharmacist documents potential or actual medication therapy problems and other medication regimen review findings appropriate for prescriber and/or nursing review." In an interview on 11/22/2013 at 11:15 AM with Nurse Unit Manager I, she reported that on the last day of each month medical records prints out all of the POSs and brings them to each unit. The third shift nurse compares the medications on the printed POS to the MAR in the computer to see if they match, and signs and dates the POS. If the POS and MAR do not match, the nurse investigates what is wrong. She stated that the POS and MAR always match. In an interview on 11/21/13 at 7:20 PM with the Assistant Director of Nursing (ADON), he reported that the administration times on the MAR are reviewed by the clinical team. He reported that new orders are reviewed once by the clinical team on the next day after they are entered into the electronic MAR. He reported that the clinical team checks to ensure that the physician orders [REDACTED]. He reported that the clinical team "missed" the difference in dosing for Resident #119's [MEDICATION NAME]. He confirmed that the administration times were coded as twice daily, when the doctor's order stated once daily. He reported that the pharmacy refills medication orders when the facility turns in the medication label from the punch card in which the medication was dispensed. In an interview on 11/21/13 at 7:26 PM with Licensed Practical Nurse (LPN) N, she reported that she worked on the South wing 4 times a week on the 3:00 PM to 11:00 PM shift. She reported that Resident #119 received Metroprolol 25mg at 5:00 PM until it was discontinued on 11/18/13. An observation of Resident #119's [MEDICATION NAME] medication punch card found that the card read, "[MEDICATION NAME] 25 mg BID (twice daily)." An interview on 11/21/13 at 7:45 PM with the dispensing pharmacy revealed that the prescription on file for Resident #119 read, "[MEDICATION NAME] 25 mg 1 tablet BID (twice daily)." A review of the facility's policy titled, "Monthly physician's orders [REDACTED]. The policy read that the LPN compares the prior month's orders, including all telephone, verbal and facsimile orders received during the past month, against the computer generated POS, and makes any needed revisions. The policy also read that the physician should review, revise as warranted, sign and date monthly orders during routine visits to the facility. In a telephone interview on 11/22/13 at 11:40 AM with the prescribing physician for Resident #119, he reported that he reviewed Resident #119's medications monthly. He reported that every month he signed a POS that was used as a doctor's order for up to 45 days. He reported that each month, when he signed the new physician order [REDACTED]. When asked what the correct dose of [MEDICATION NAME] was for Resident #119 (BID or QD), the physician stated that he would not answer the question because he didn't have the chart in front of him (this was a telephone interview). When asked will you be coming into the facility he said, "No, not today." The interviewer gave the physician her contact information so that he could let her know what the correct dose of [MEDICATION NAME] was for the resident, but he never contacted the surveyor. An interview on 11/22/13 at 2:30PM with the facility's Medical Director revealed that when asked if the facility had informed him of the Immediate Jeopardy, he stated that the administrator had informed him about an hour ago of the following: A resident (Resident #119) had an order for [REDACTED]. The [MEDICATION NAME] order was not clarified by the facility, and remained on the MARs every month from January, 2013 to November, 2013 as twice daily dosing. The consultant pharmacist recognized and reported the dosing discrepancy via written recommendations to the facility in September, October, and November, 2013. The facility did not act upon the pharmacist's recommendations to clarify the [MEDICATION NAME] dose. The Medical Director stated that the consultant pharmacist attends the facility's monthly Quality Assurance Committee meetings. He further stated that the pharmacist did not bring any concerns to the committee related to facility recognition of dosing discrepancies, failure of nurses to respond to the monthly medication regimen recommendations, or any concerns related to Resident #119. The medical director expressed his concerns regarding systems problems in the facility related to errors in the entry of orders into the electronic records, communication issues between nursing and pharmacy, and the process of reconciling the monthly physician orders. He stated he would work with the facility and review the plan of corrective action to correct the immediate jeopardy. (Cross reference to F428.) .