Every finding on record at Diversicare of Southaven

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure timely assessment and management of pain for one (1) of 16 residents residing on the rehabilitation unit (Resident #144), resulting in a delay of greater than three hours in treatment, prolonged unrelieved pain at a level ten (10), inability to eat, and unnecessary physical suffering. Findings include:Review of the facility policy titled Pain Management revealed under, Purpose: To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life .An observation and interview with Resident #144 on 4/20/26 at 11:15 AM revealed she was lying in bed with facial frowning and rubbing her right knee, which had gross edema and was propped up on a pillow. The resident stated she was hurting in her right knee down to her foot, which she described as aching and throbbing, and verbalized her pain score as a level 10 (ten) on a pain scale from 0 (zero) to 10, with 10 being the most severe. The resident stated she had been asking for pain medication since 8:00 AM that morning, pushing the call light multiple times, and stated, They come in here and tell me they will have to tell the nurse, and no one ever comes back. The resident revealed she was unable to eat breakfast because she was hurting so badly.An interview with Certified Nurse Aide (CNA) #1 on 4/20/26 at 11:20 AM revealed she had responded to Resident #144's call light twice that morning since her shift began at 7:00 AM. She explained that the resident reported pain and requested pain medication both times and stated she notified Registered Nurse (RN) #1, who was working the medication cart. CNA #1 confirmed the resident did not eat breakfast and stated the resident verbalized she could not eat due to pain.An interview with RN #1 on 4/20/26 at 11:22 AM revealed she came on shift at 8:45 AM. She stated that the Nurse Practitioner (NP) had told her approximately 30 minutes earlier that Resident #144 needed pain medication; however, she had not yet administered it. RN #1 stated that no one other than the NP had reported to her that the resident needed pain medication. She revealed the resident had Tylenol and Tramadol as needed for pain.During an observation on 4/20/26 at 11:25 AM, RN #1 assessed Resident #144's pain. The resident reported a pain score of 10 to her right knee and leg. Despite CNA #1 reporting the resident's pain to RN #1 on two occasions, RN #1 reported she had not been notified, indicating a breakdown in communication and failure to act upon reported pain. At the time of observation, Resident #144 had not received pain medication despite requesting it since approximately 8:00 AM.Record review of Resident #144's Medication Administration Record (MAR) revealed an order dated 4/13/26, Monitor for pain every shift. Pain scale 0-10. Notify physician for unrelieved pain. Observe for nonverbal s/s (signs/symptoms) of pain every shift for pain monitoring. The resident's pain scale on 4/20/26 was documented as 10.Record review of Resident #144's MAR revealed orders dated 4/13/26, Tylenol (pain) 325 MG (milligrams) take 2 (two) tablet by mouth every 4 (four) hours as needed for mild pain (1-3); Tramadol (pain) HCL (hydrochloride) oral tablet 50 MG (milligrams) give 1 (one) tablet by mouth every 6 (six) hours as needed for pain related to lymphedema, pain unspecified. Further review revealed the most recent administration time for Tramadol was on 4/19/26 at 8:28 AM with a documented pain scale of 10. Tylenol was last administered on 4/18/26 at 2219 (10:19 PM) with a documented pain score of 4.An interview on 4/20/26 at 11:40 AM with the NP revealed Resident #144 has a deep vein thrombosis (blood clot) in her right leg. She revealed she visited the resident this morning and the resident reported pain. The NP stated she reported to RN #1 that the resident needed pain medication. She explained that Tramadol was effective for the resident's pain management and acknowledged it should be administered timely for optimal pain control.Record review of Resident #144's Progress Notes dated 4/20/26 revealed the resident was visited by the NP with the following documented entry, Resident complains of right lower extremity pain rated 10 out of 10 at time of complaint.An interview with the Occupational Therapist (OT) on 4/22/26 at 11:20 AM revealed Resident #144 was at the facility for rehabilitation and was on the OT caseload. He revealed the resident reports pain daily and that he notifies the nurse on duty.Record review of Resident #144's Occupational Therapy Treatment Encounter Notes dated 4/14/26 revealed under, Pain: Pain level determined based upon behaviors exhibited by patient; Behaviors Exhibited: yelling, wincing, grimacing; Does pain limit patient's functional activities? Yes; Pain limits the following functional activities: bed mobility, rolling, scooting, standing, etc (etcetera).An interview with RN #1 on 4/22/26 at 11:55 AM confirmed Resident #144's pain medication was not administered timely, acknowledging this caused the resident unnecessary discomfort.An interview with the Director of Nursing (DON) on 4/22/26 at 2:48 PM confirmed that Resident #144 not receiving pain medication timely was a big concern. She stated that her expectation was that if a resident was on the call light requesting pain medication, the nurse should stop and administer it. The DON stated, As soon as you're aware of it, it's your priority.Record review of the admission Record revealed the facility admitted Resident #144 on 4/10/26 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Distal Lower Extremity, Lymphedema, and Pain.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/16/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated Resident #144 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure the Activities of Daily Living (ADL) care plan was implemented for personal hygiene and grooming (Resident #101 and Resident #119) and failed to implement a pain care plan (Resident #144) for three (3) of 31 care plans reviewed. Resident #101, #119, and #144.Findings Include: Record review of the facility policy titled Care Plans revealed under, Guideline: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #101 Record review of Resident #101's Activity of Daily Living (ADL) care plan revealed, Self-care performance deficit related to Hemiplegia Provide bathing/showering: provide hair care, shave facial hair daily on bath days and as necessary. During an observation on 4/20/2026 at 10:55 AM, Resident #101 was observed in his room with approximately 1/4-1/2-inch facial hair and long hair extending to the top of his shoulders. During interview, Resident #101 stated he wanted bath and to be shaved and have his hair cut. He reported the aide assisting him does not shave or cut hair. Resident #101 stated he did not want his hair to be that long and reported it looks like a woman's hair. He further stated he had to be placed on a list for a haircut; however, he is bedbound and unable to speak with staff regarding placement on the list. During an interview on 4/22/2026 at 12:23 PM, with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed it is the expectation for residents to be bathed on their scheduled bath days and to have their hair washed. On 4/22/2026 at 3:00 PM, interview with the Minimum Data Set (MDS) Coordinator #1 confirmed Resident #101 required assistance with bathing and shaving. The MDS Coordinator stated the resident's care plan directs staff on how to properly care for the resident and meet individualized needs. The MDS Coordinator further confirmed the care plan was not implemented if the resident was not bathed and his hair was not shampooed. The resident's scheduled bath days were Tuesdays, Thursdays, and Saturdays. Record review of Resident #101 admission Record revealed the resident was admitted [DATE] with a medical diagnosis that includes Hemiplegia. Record review of Resident #101 Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 3/21/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #101 is cognitively intact. Resident #119 Record review of Resident #119's Activity of Daily Living (ADL) care plan revealed, Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Revised 11/10/2025. On 4/20/2026 at 10:29 AM during an observation and interview, Resident #119 was observed with visibly oily hair. The resident stated she received two (2) baths the previous week; however, she reported it had been approximately three (3) weeks prior to that and another three (3) weeks before that between baths. On 4/22/2026 at 10:00 AM, during an interview the ADON confirmed Resident #119 is cognitively intact. She stated, We try to accommodate the residents as best we can. She further stated residents should receive showers three (3) times per week unless they decline. During an interview on 4/22/2026 at 3:07 PM with the Registered Nurse Assessment Coordinator (RNAC) and the MDS Coordinator, the RNAC reviewed Resident #119's ADL care plan and confirmed that it did not specify the frequency or schedule for showers. The MDS Coordinator stated baths and showers are provided according to a shower schedule located at the nursing station and explained the schedule is organized by room number rather than by resident, as room changes could affect the schedule. She stated that when a Certified Nursing Assistant (CNA) provides a bath or shower, the CNA completes a CNA Bath & Shower Report and submits it to the nurse. The nurse is responsible for verifying the resident received the bath or shower and signing the form, and if the resident refuses, the CNA reports the refusal to the nurse, who then verifies the refusal with the resident and signs the form. Further interview with the RNAC revealed the task frequency for bathing and showering was documented as every shift. The RNAC stated the care plan was not being followed by nursing staff and needed to be reviewed and revised to reflect an accurate bathing schedule. Review of the admission Record indicated that the facility admitted Resident #119 on 8/16/2024 with medical diagnoses that included Paraplegia, unspecified. A record review of the MDS with an ARD of 2/10/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #119 was cognitively intact. Resident #144 Record review of Resident #144's Care Plan Report revealed under, Focus: Resident has pain related to lymphedema. Also revealed under, Interventions: Administer analgesia per orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During an observation and interview with Resident #144 on 4/20/26 at 11:15 AM, she was lying in bed with facial frowning and rubbing her right knee, which had gross edema and was propped up on a pillow. The resident stated she was hurting in her right knee down to her [NAME], which she described as aching and throbbing, and verbalized her pain score as a level 10 (ten) on a pain scale from 0 (zero) to 10, with 10 being the most severe. The resident stated she had been asking for pain medication since 8:00 AM that morning, pushing the call light multiple times, and stated, They come in here and tell me they will have to tell the nurse, and no one ever comes back. The resident revealed she was unable to eat breakfast because she was hurting so badly. At the time of observation, Resident #144 had not received pain medication despite requesting it since approximately 8:00 AM. On 4/20/26 at 11:20 AM An interview with Certified Nurse Aide (CNA) #1 revealed she had responded to Resident #144's call light twice that morning and confirmed she notified Registered Nurse (RN) #1 on both occasions that the resident requested pain medication. On 4/20/26 at 11:22 AM an interview with RN #1 revealed she came on shift at 8:45 AM. She stated that the Nurse Practitioner (NP) had told her approximately 30 minutes earlier that Resident #144 needed pain medication; however, she had not yet administered it. RN #1 stated that no one other than the NP had reported to her that the resident needed pain medication. On 4/20/26 at 11:25 AM, during an observation RN #1 assessed Resident #144's pain. The resident reported a pain score of 10 to her right knee and leg. Despite CNA #1 reporting the resident's pain to RN #1 on two occasions, RN #1 reported she had not been notified, indicating a breakdown in communication and failure to follow the resident's care plan. Record review of Resident #144's Medication Administration Record (MAR) revealed orders dated 4/13/26, Tylenol (pain) 325 MG (milligrams) take 2 (two) tablet by mouth every 4 (four) hours as needed for mild pain (1-3); Tramadol (pain) HCL (hydrochloride) oral tablet 50 MG (milligrams) give 1 (one) tablet by mouth every 6 (six) hours as needed for pain related to lymphedema, pain unspecified. Further review revealed the most recent administration time for Tramadol was on 4/19/26 at 8:28 AM and Tylenol was last administered on 4/18/26 at 2219 (10:19 PM). An interview with RN #1 on 4/22/26 at 11:55 AM confirmed Resident #144's pain care plan was not followed as medication was not administered timely. An interview with the DON on 4/22/26 at 2:48 PM revealed the purpose of the care plan was to ensure that staff knew what care to provide for the residents. She confirmed that Resident #144's pain care plan was not followed. Record review of the admission Record revealed the facility admitted Resident #144 on 4/10/26 with medical diagnoses that included Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Distal Lower Extremity, Lymphedema, and Pain. Record review of the MDS with an ARD of 4/16/26 revealed under Section C, a BIMS summary score of 13, which indicated Resident #144 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to reasonably accommodate resident needs by not ensuring the call light was accessible (Resident #54) and by failing to timely address and replace an uncomfortable mattress (Resident #42) for two (2) of four (4) residents reviewed for accommodation of needs and preferences. Findings Include: Review of the facility policy titled Resident Rights & (and) Quality of Life Policy revealed under, Procedure: A patient or resident has the right: . To receive services in a center environment that is safe, clean, and comfortable. Review of facility policy titled Nurse Call System with effective date: 9/1/2014, revealed, .2. Each cord needs to be visible and reachable by the resident to which it operates for . Resident #42 An observation of Resident #42 on 4/20/26 at 11:45 AM revealed he was sitting in his wheelchair in his room. The resident stated his mattress was uncomfortable, dipped in the middle, and felt like a rod was poking him. He further stated he had asked multiple staff members, including Maintenance, to replace the mattress; however, it had not been replaced. Observation of the mattress revealed two pillows placed vertically across the mattress. The resident reported he slept on top of the pillows for additional support and cushioning, stating this issue had impacted his sleep. An interview with Maintenance on 4/20/26 at 4:24 PM confirmed he was aware Resident #42 had reported his mattress as uncomfortable a couple of weeks prior. Maintenance stated the mattress was not replaced at that time because the facility needed to order new mattresses. He acknowledged that the residents' comfort was of the utmost importance, as it affected his comfort and sleep. An interview with the Director of Nursing (DON) on 4/22/26 at 3:09 PM revealed Resident #42 should have a bed that was comfortable and confirmed that the mattress had not been replaced. Record review of the admission record revealed the facility admitted Resident #42 on 3/25/26 with a medical diagnosis that included Chronic Diastolic (Congestive) Heart Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/18/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated Resident #42 was moderately cognitively impaired. Resident #54 During an observation and interview on 4/20/2026 at 10:54 AM, Resident #54 was observed to be visibly uncomfortable, holding her stomach and stating she needed to use the bathroom and needed a bedpan. Resident #54's call light was observed wrapped around the grab bar attached to the bed, hanging down toward the floor, and was not within the resident's reach. During an observation and interview on 4/20/2026 at 10:56 AM, the Assistant Director of Nursing (ADON) confirmed the call light was wrapped around the grab bar. She unwrapped the cord and placed the call light within reach of the resident. She stated the call light should always be within the resident's reach, especially when the resident is in bed, and that the call light is the resident's means of communicating her needs. Record review of the admission Record indicated that the facility admitted Resident #54 on 2/24/2026 with medical diagnoses that included Chronic Diastolic (Congestive) Heart Failure, Pressure Ulcer of sacral region, stage 4, Osteomyelitis, unspecified, Unspecified severe protein-calorie malnutrition, Dysphagia, oropharyngeal phase, Other symptoms and signs concerning food and fluid intake. A record review of the MDS with an ARD of 4/15/26 revealed under section C, a BIMS summary score of 3 which indicated Resident #54 was severely cognitively impaired.

Based on observations, resident interviews, staff interviews, record review, and facility policy review, the facility failed to ensure residents were treated with dignity and respect by maintaining privacy and providing personal care in a manner that preserved resident dignity for four (4) of 31 residents reviewed (Residents #20, #101, #111, #119). Findings Include: Review of facility policy, Resident Rights & Quality of Life Policy with an effective date of March 13, 2020, revealed, .all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center . Resident #20 On 4/20/2026 at 10:32 AM, Resident #20 was observed in his room with a urinary catheter bag containing yellow urine. The resident's room door was open, and the catheter bag was visible from the hallway, with no privacy cover in place. During an interview, Resident #20 stated he had returned from the hospital approximately one week prior and reported that no privacy bag had been placed over the catheter bag. A second observation was made on 4/21/2026 at 3:00 PM, observed catheter bag from the doorway with yellow urine visible. Upon entering the room, approximately 600 milliliters (mL) of yellow urine was observed in the catheter bag, which remained uncovered. On 4/21/2026 at 3:35 PM, interview with Licensed Practical Nurse (LPN) #1, revealed the catheter bag should have had a privacy bag in place for dignity. During an interview on 4/22/2026 at 12:20 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed it is the facility's expectation for all catheter bags to have a privacy cover in place. Record review of the admission Record revealed that the facility admitted Resident #20 on 8/27/2024 with a medical diagnosis that included Paraplegia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/2026 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15, which indicated Resident #20 was cognitively intact. Resident #101 On 4/20/2026 at 10:55 AM, Resident #101 was observed in his room with approximately 1/4-inch to 1/2-inch facial hair and long hair extending to the top of his shoulders. During the interview, Resident #101 stated he wanted to be shaved and his hair cut. He reported the aide who assisted him does not shave or cut hair. The resident stated he did not want his hair to be that long and reported it looks like a woman's hair. He further stated he was told there is a list he must be placed on to receive a haircut; however, he is bedbound and unable to go speak with staff about being placed on the list. The resident stated he had asked several aides about it, but they did not provide an answer. On 4/22/26 at 9:00 AM, the Assistant Director of Nursing (ADON) confirmed the resident's hair was long and that the resident had previously requested a haircut. Record review of Resident #101 admission Record revealed the resident was admitted [DATE] with a medical diagnosis that included Hemiplegia. Record review of Resident #101 MDS, Section C, with an ARD of 3/21/2026, revealed a BIMS score of 15, indicating Resident #101 is cognitively intact. Resident #111 On 4/20/2026 at 10:15 AM, Resident #111 was sitting in the dayroom/dining area on the East/West halls along with other residents and staff. It was observed that an unidentified staff member was shaving her face in the common area with other residents present. During an interview with Resident #111 on 4/20/2026 at 10:30 AM, she stated someone did shave her face, but couldn't remember the staff member's name. During an interview on 4/22/2026 at 9:53 AM with the Director of Nursing (DON), she stated that no resident should ever be shaved in the common area/dining area. It is not the expectation of the facility to provide care in that manner. Record review of Resident #111 admission Record revealed the resident was admitted [DATE] with medical diagnosis that included Cognitive Communication Deficit. Record review of Resident #111 MDS, Section C, with an ARD of 3/11/2026, revealed a BIMS score of 6, indicating Resident #111 had severe cognitive impairment. Resident #119 During an observation on 4/20/2026 at 10:29 AM, Resident #119's catheter bag was hanging on the bedside with no privacy cover, and the bag was filled with urine and was visible from the doorway. During an interview on 4/21/2026 at 3:40 PM, LPN #6 stated that privacy bags should always be placed on catheter bags to protect the dignity of the residents. Record review of the admission Record indicated that the facility admitted Resident #119 on 8/16/2024 with medical diagnoses that included Paraplegia, unspecified. A record review of the MDS with an ARD of 2/10/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #119 was cognitively intact.

Based on observation, interview, record review, and facility policy review the facility failed to ensure nursing services were provided in accordance with professional standards of practice and physician orders for one (1) of seven (7) resident care observations (Resident #5).Findings Include: Review of the facility's Standards of Practice typed on letterhead revealed, The expectation set forth by (Proper Name) management is that nurses comply with current standards of practice by following physician orders for providing to peg site care. An observation on 04/21/26 at 2:55 PM of Resident #5's Percutaneous Endoscopic Gastrostomy (PEG) tube site revealed no dressing in place and there was a yellowish-brown substance beneath the external skin disk and extended out about one-fourth of an inch to surrounding skin. An observation and interview on 04/21/26 at 3:00 PM in Resident #5's room, revealed Licensed Practical Nurse (LPN) #5, enter and she stated that she came in to change Resident #5's PEG tube site dressing. She stated she didn't know what the orders were on Resident #5's Medication Administration Record (MAR) and LPN #5 proceeded with the care. An observation revealed that LPN #5 cleaned Resident #5's PEG tube site with an adult cleansing cloth, she patted it dry and applied a dressing. LPN #5 confirmed that there was no dressing intact to Resident #5's PEG tube site when she assessed the site prior to performing care. An interview on 04/22/26 at 8:27 AM with LPN #5, revealed that sometimes she used soap and water and sometimes she used the wipes (adult cleansing cloths) to clean the dried drainage surrounding the PEG site depending on where it was on the skin. LPN #5 reviewed the physician orders and confirmed that the order on Resident #5's MAR was to clean the peg tube site with normal saline, pat dry, and apply a dry drain dressing to avoid skin breakdown. LPN #5 revealed that it was nearing the end of her shift yesterday when observed, and she did not follow the physician orders. She also confirmed that by not following the physician orders, she could have caused skin irritation. An interview on 04/22/26 at 10:27 AM with Assistant Director of Nursing (ADON), revealed that her expectation was for nurses to follow the physician orders when providing resident care. She revealed that PEG tube sites should be cleaned every day and should be cleaned with soap and water or normal saline, and if there was an order for a dressing to be applied, it should be done. She revealed that by cleaning Resident #5's PEG tube site with an adult wipe, she could have caused skin irritation or burning. She also revealed that this was unacceptable practice. An interview on 04/22/26 at 10:33 AM with Registered Nurse (RN) #1, Infection Preventionist, revealed that they expected nurses to assess PEG tube sites daily and clean around the stomas with soap and water or normal saline. She revealed that she also expected nurses to review physician orders and provide the care accordingly. RN #1 revealed that failure to clean the PEG tube sites as ordered could result in skin irritation, burning of the skin, or infection. Record review of Resident #5's admission Record revealed an original admission date of 08/07/20 and that she had diagnoses that included Alzheimer's Disease, Unspecified, Functional Quadriplegia, and Gastrostomy Status. Record review of Resident #5's Medication Administration Record with order date of 09/10/2025, revealed Enteral Feed Order every day shift Cleanse peg tube stoma site with normal saline, pat dry. Apply dry drain dressing to avoid skin breakdown. Record review of Resident #5's Order Summary Report revealed an order with effective date of 09/10/25 documented, Enteral Feed Order every day shift Cleanse peg tube stoma site with normal saline, pat dry. Apply dry drain dressing to avoid skin breakdown.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to maintain a shower room in a safe manner to prevent potential hazards to residents and staff as evidenced by an obstructed floor drain resulting in water accumulation and flooding, for one (1) of three (3) shower rooms observed. East wing Findings Include:Review of the facility policy titled Resident Rights & (and) Quality of Life Policy revealed under, Procedure: A patient or resident had the right: . To receive services in a center environment that is safe, clean, and comfortable.An interview with Resident #138 on 4/21/26 at 3:01 PM revealed she received a shower the previous night on E hall. She stated the shower room drain was stopped up, causing water to stand on the floor. The resident reported the water accumulated to the point that she was afraid she might fall. She further revealed on a previous night , she witnessed water overflowing out of the shower room into the hallway and in front of the nurse's station, at which time staff placed towels on the floor to absorb the overflow.An interview with Licensed Practical Nurse (LPN) #1 on 4/21/26 at 3:08 PM revealed she had observed water overflow into the hallway from the east shower room on multiple occasions and confirmed she had not reported the issue to anyone.An observation and interview with Maintenance on 4/21/26 at 3:15 PM revealed the facility utilized TELS (electronic work order repair system) for staff to report maintenance concerns. During observation, after running the right shower stall for approximately five minutes, water was noted to accumulate on the floor and failed to drain. Maintenance confirmed the drain was backed up and acknowledged this condition could create a slip and fall risk for residents and staff. Maintenance further denied prior awareness of the issue.An interview with Resident #57 on 4/21/26 at 4:43 PM revealed the clogged shower drain had been an ongoing issue for several months. The resident stated he had continued to shower despite the drain being clogged and reported that even when staff attempted to unclog it, the drain would clog up again the following day. He further stated the shower room had flooded on several occasions.An interview with the Director of Nursing (DON) on 4/22/26 at 3:09 PM revealed that a couple of weeks prior, the facility had to call an outside company to assess the problem with the shower drain due to flooding in the shower room. She acknowledged that pooling water on the floor presents a safety risk to both residents and staff.Record review of the admission Record revealed the facility admitted Resident #57 on 7/12/25 with medical diagnoses that included Hereditary and Idiopathic Neuropathy, Muscle Weakness, and Repeated Falls.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #57 was cognitively intact.Record review of the admission Record revealed the facility admitted Resident #138 on 11/14/25 with medical diagnoses that included Chronic Obstructive Pulmonary Disease, Muscle Weakness, and Repeated Falls.Record review of the MDS with an ARD of 2/20/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #138 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement infection control practices to prevent the spread of infection by not maintaining aseptic technique and not providing dressing changes during 3 (three) of 7 (seven) care area observations. Resident #5, Resident #23, Resident #54. Findings Include: Review of the facility policy, Infection Control with effective date of 11/01/2017 revealed, This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Review of the facility policy titled Clean Dressing Change, dated February 2026, revealed, It is the policy of this center to provide wound care in a manner to decrease potential for infection and/or cross-contamination.9. Loosen the tape and remove the existing dressing.10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. Review of the facility Peri-Care Audit Tool, undated, revealed, .Removes soiled brief, washes front to back, changes side of cloth or disposable wipe with each swipe. STOP! Removes gloves, washes/sanitizes hands and re-gloves. RESIDENT #5 An observation on 04/21/2026 at 2:55 PM revealed Resident #5's Percutaneous Endoscopic Gastrostomy (PEG) tube site with no dressing in place and there was a yellowish-brown substance beneath and surrounding the external skin disk and extending approximately one-fourth inch to surrounding skin. Certified Nursing Assistant (CNA) #2 was present in Resident #5's room and confirmed the absence of a dressing, she confirmed the yellowish-brown substance and stated her PEG tube site looked like this often. At 3:00 PM, Licensed Practical Nurse (LPN) #5 entered Resident #5's room and confirmed that there was no dressing in place to Resident #5's PEG tube site and confirmed the presence of yellowish-brown drainage to the site. LPN #5 revealed that PEG tube site care should be completed every day and as needed for increased drainage. She also revealed that since there was no dressing to her PEG tube site and due to the amount of drainage observed to the site, there was no way to tell when the last time it was cleaned. LPN #5 confirmed that failure to keep the PEG tube site clean and dry could lead to skin irritation and infection. An interview on 04/22/26 at 10:27 AM with Assistant Director of Nursing (ADON), revealed that her expectation was for nurses to follow the physician orders when providing resident care. She revealed that PEG tube sites should be cleaned every day and should be cleaned with soap and water or normal saline, and if there was an order for a dressing to be applied, it should be done. ADON agreed that failure to perform daily dressing changes as ordered by the physician, along with allowing drainage to accumulate around the PEG tube sites could result in infection. An interview on 04/22/26 at 10:33 AM with Registered Nurse (RN) #1, Infection Preventionist, revealed that they expected nurses to assess PEG tube sites daily and clean around the stomas with soap and water or normal saline. She revealed that she also expected nurses to review physician orders and provide the care accordingly. RN #1 revealed that failure to clean the PEG tube sites as ordered could result in skin irritation, burning of the skin, or infection. Record review of Resident #5's admission Record revealed an original admission date of 08/07/20 and that she had diagnoses that included Alzheimer's Disease, Unspecified, Functional Quadriplegia, and Gastrostomy Status. Record review of Resident #5's Medication Administration Record with order date of 09/10/2025, revealed Enteral Feed Order every day shift Cleanse peg tube stoma site with normal saline, pat dry. Apply dry drain dressing to avoid skin breakdown. Record review of Resident #5's Order Summary Report revealed an order with effective date of 09/10/25 documented, Enteral Feed Order every day shift Cleanse peg tube stoma site with normal saline, pat dry. Apply dry drain dressing to avoid skin breakdown. RESIDENT #23 An observation and interview on 04/20/26 at 12:32 PM revealed Resident #23 lying in bed and he stated that he needed some help. He pulled his shirt up and exposed his PEG tube site which had a thick brown, crusted substance beneath the external skin disk which extended approximately one-half to three fourths of an inch to the surrounding area. Resident #23 revealed that the site had not been cleaned in approximately three days and stated, Look at this, it's nasty and I want it out. Follow-up observations on 04/21/2026 at 8:30 AM and 3:08 PM confirmed that Resident #23's PEG tube site remained unclean with visible drainage. During an interview at 3:08 PM, Resident #23 stated, I may have to clean it myself. During an observation and interview on 04/21/2026 at 3:10 PM with Licensed Practical Nurse (LPN) #5, she confirmed the presence of thick, brown drainage and stated the site had not been cleaned in several days. LPN #5 revealed that PEG tube care should be performed daily and as needed to prevent infection and skin breakdown and stated she would take care of it now. During an observation and interview on 04/21/26 at 3:25 PM with Director of Nursing, she viewed Resident #23's PEG tube site and confirmed the dry crusty brown drainage and stated that this had not been cleaned in a while. She revealed that his PEG tube site should be cleaned every day and as needed. DON also revealed that not cleaning the site daily could cause skin irritation and possible infection. She revealed that she would get the treatment nurse to look at the site and they would take care of the issue. Record review of Resident #23's Order Summary Report revealed an order dated 09/10/25, every day shift Cleanse peg tube stoma with soap and water rinse with clean water pat dry and leave open to air. Can apply dry dressing if drainage is present. Record review of Resident #23's admission Record revealed an admission date 08/14/25 with diagnoses that included Unspecified Severe Protein-Calorie Malnutrition and Gastrostomy Status. Record review of Resident #23's MDS with ARD of 01/30/2026 under Section C indicated a BIMS score of 10, reflecting moderate cognitive impairment. Resident #54 During an observation of wound care to a Stage IV pressure injury to the sacrum on 4/22/2026 at 11:10 AM with the Treatment Nurse and CNA #3, when CNA #3 opened Resident #54's brief, the presence of stool was observed. CNA #3 obtained a clean brief and wipes and provided peri-care to clean the resident prior to wound care. Immediately after completing peri-care, CNA #3 removed the existing wound dressing and assisted with repositioning the resident by rolling her so her back faced the Treatment Nurse. The Treatment Nurse then performed wound care while CNA #3 assisted in holding the resident in position using the same gloves worn during peri-care. CNA #3 did not perform hand hygiene or change gloves between peri-care and wound care. During an interview on 4/22/2026 following wound care, CNA #3 stated she should have performed hand hygiene and changed gloves after providing peri-care and prior to assisting with wound care. She stated, I just didn't bring extra gloves with me. During an interview on 4/22/2026 at 11:24 AM, the Treatment Nurse stated that CNA #3 should have performed hand hygiene after providing peri-care and confirmed that this could put the resident at risk for an infection. During an interview on 4/22/2026 at 12:14 PM, the DON and ADON confirmed hand hygiene should be performed after providing care and that CNA #3 should not have assisted with wound care without first performing hand hygiene and changing gloves. The DON stated this was an infection control concern. Record review of the admission Record indicated that the facility admitted Resident #54 on 2/24/2026 with medical diagnoses that included Chronic Diastolic (Congestive) Heart Failure and Pressure Ulcer of sacral region, stage 4. A record review of the MDS with an ARD of 4/15/26 revealed under section C, a BIMS summary score of 3 which indicated Resident #54 was severely cognitively impaired.

Based on observation, record review, staff interview and facility policy review, the facility failed to ensure physician-ordered oxygen therapy for one (1) of four (4) residents requiring oxygen. Resident #145 Findings Include:Review of the facility policy titled Oxygen Guideline revealed under, Policy: Medical oxygen is classified by the Food and Drug Administration as a drug; therefore, it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice .On 4/21/2026 at 8:30 AM, observation of Resident #145 revealed the resident was sitting in a wheelchair in her room with an oxygen nasal cannula in place, with the concentrator set at two (2) liters.Record review of the Clinical Health Status Evaluation dated 4/14/26 revealed Resident #145 was on continuous oxygen. Record review of Resident #145's Order Listing revealed no physician order for oxygen.An interview on 4/22/2026 at 11:08 AM with Licensed Practical Nurse (LPN) #4 revealed Resident #145 was on continuous oxygen at 2 liters per minute for Chronic Obstructive Pulmonary Disease (COPD). LPN #4 confirmed the resident did not have a physician order for oxygen and stated that an order should have been in place.On 4/22/2026 at 2:48 PM, an interview with the Director of Nursing (DON) confirmed there should be a physician order for oxygen. She revealed the nurse admitting the resident was responsible for ensuring an order was in place.Review of the admission Record revealed the facility admitted Resident #145 on 4/14/2026 with a medical diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #145 was severely cognitively impaired.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure percutaneous endoscopic gastrostomy (PEG) feedings were administered in a manner to prevent complications for two (2) of five (5) PEG feedings observed. (Residents #54 and #121) Findings include:Review of facility Performance Checklist Skill 31-4 Administering Enteral Nutrition: Nasoenteric, Gastrostomy or Jejunostomy Tube with no date revealed, .labeled bag properly.During an observation on 4/20/2026 at 10:54 AM, Resident #54's tube feeding bottle of Jevity 1.5 was observed without proper labeling, including date, time, and nurse initials.During an observation on 4/20/2026 at 11:01 AM, Resident #121's tube feeding bottle of Jevity 1.5 was observed without proper labeling, including date, time, and nurse initials.During an interview on 4/20/2026 at 11:05 AM, the Assistant Director of Nursing (ADON) confirmed the feeding bottles were not dated, timed, or initialed by nursing staff. She stated, This should be done every time a new bottle of feeding is hung. Now we have no way of knowing how long these bottles have been running.Record review of the admission Record indicated that the facility admitted Resident #54 on 2/24/2026 with medical diagnoses that included Chronic Diastolic (Congestive) Heart Failure, Pressure Ulcer of sacral region, stage 4, Osteomyelitis, unspecified, Unspecified severe protein-calorie malnutrition, Dysphagia, oropharyngeal phase, Other symptoms and signs concerning food and fluid intake. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3 which indicated Resident #54 was severely cognitively impaired.Record review of the admission Record indicated that the facility admitted Resident #121 on 2/12/2024 with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side. A record review of the MDS with an ARD of 1/31/26 for Resident #121 revealed under section C, a BIMS should not be conducted because the resident is rarely or never understood.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure assistance with activities of daily living (ADLs), including bathing and personal hygiene, was provided in accordance with resident needs and preferences for two (2) of thirty-one (31) residents sampled. (Residents #101 and #119) Findings include: Review of facility policy titled Activities of Daily Living (ADL's) with effective date August 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences . Resident #101 On 4/20/2026 at 10:55 AM, Resident #101 was observed in his room with approximately 1/4-1/2-inch facial hair and oily long hair extending to the top of his shoulders. Interview with the resident stated he had not had a bath for more than one week and he couldn't remember how long it had been since his hair was shampooed or cut. On 4/22/2026 at 12:23 PM, interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed it is the expectation for residents to be bathed on their scheduled bath days and to have their hair washed. Record review of Resident #101 admission Record revealed the resident was admitted [DATE] with a medical diagnosis that includes Hemiplegia. Record review of Resident #101 Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 3/21/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #101 is cognitively intact. Resident #119 During an observation and interview on 4/20/2026 at 10:29 AM, Resident #119 was observed with visibly oily hair. The resident stated she received two (2) baths the previous week; however, she reported it had been approximately three (3) weeks prior to that and another three (3) weeks before that between baths. During an interview on 4/22/2026 at 10:00 AM, the ADON confirmed Resident #119 is cognitively intact. She stated, We try to accommodate the residents as best we can. She further stated residents should receive showers 3 times per week unless they decline. Record review of the admission Record indicated that the facility admitted Resident #119 on 8/16/2024 with medical diagnoses that included Paraplegia, unspecified. A record review of the MDS with an ARD of 2/10/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #119 was cognitively intact.

Based on staff and resident interviews, record reviews, the facility's investigation, and the facility clinical care system guidelines review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed for accident hazards (Resident #1). The facility's failure to provide supervision resulted in Resident #1 exiting the facility unnoticed and unsupervised. She was determined to have exited the facility on 2/14/26, at approximately 1:08 PM and was located by staff 0.4 miles from the facility at 1:33 PM. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 2/14/26, and existed at 42 CFR: 483.25(d)(1)(2) - Free of Accident Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement in a situation likely to cause serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 2/18/26, at 4:08 PM and provided the Administrator with the IJ template. The facility provided an acceptable Removal Plan on 2/19/26 in which they alleged all corrective actions to remove the IJ were completed on 2/18/26 and the IJ removed on 2/19/26. The SA validated the Removal Plan on 2/20/26 and determined the IJ and SQC was removed on 2/19/26, prior to exit, and the scope and severity for F689 was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings Include: A review of the facility's clinical care system guidelines, Elopement, revealed, Purpose to establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process: On admission, newly admitted or re-admitted residents are assessed for elopement risk. If an elopement risk is determined, an individualized plan is established, and intervention is initiated to mitigate that risk. When the nurse identifies the intervention, it is documented on the care plan and on the caregiver guide. A photograph of the resident is taken to assist with identification if necessary. There is a central system (i.e., nurse's station, reception area) where information, including a photograph regarding all those identified at risk is located.Door Alarm Protocol: Team members know how to respond to all door/exit alarms. Once door/exit alarms are activated, a resident search is completed ensuring there is no missing resident . A record review of the facility's investigation revealed that around 1:00 PM on 2/14/26, staff noticed that Resident #1 was no longer on the unit. Upon checking Resident #1's room, it was noted that she was not present. The nurse called a missing resident code. Another resident informed staff that she had seen a lady in pink walking outside her window. Staff went outside, located the resident, and brought her back into the facility. Record review of the Clinical Health Status Evaluation, Elopement Risk, dated 2/14/26, at 12:41 AM, for Resident #1 revealed, Based on Risk Assessment, is resident at risk? Yes. Narrative: Resident has a wander guard in place. Record review of Assessment Outcomes, the Brief Interview for Mental Status (BIMS) score on 2/14/26, was zero (0), indicating that Resident #1 was severely cognitively impaired. Record review of the admission Record revealed that the facility admitted Resident #1 on 2/13/26, with diagnoses that included UNSPECIFIED DEMENTIA, MODERATE, WITH OTHER BEHAVIORAL DISTURBANCE, and WANDERING IN DISEASES. During an interview with Licensed Practical Nurse (LPN) #2 on 2/18/26, at 9:15 AM, she stated she was assigned to Resident #1 on 2/14/26. She verified that she was aware the resident wandered and was at risk for elopement. She stated the resident had a wander guard in place and confirmed she had last seen the resident right after lunch walking up and down the halls. LPN #2 further stated that at approximately 1:00 PM, she noticed Resident #1 was no longer in the hallway. She asked the Certified Nursing Assistants (CNA) to check the resident's room, and when she was not there, she called a missing resident code. LPN #2 stated another resident told staff that they had seen a lady in pink walking outside her window. Staff went outside and brought the resident back inside. Interview and observation with Resident #1 on 2/18/26, at 10:30 AM, she stated that she did go outside on 2/14/26. She stated she had been sitting at a table with others, and when they left, they did not tell her where they were going. She stated she did not want to be left alone, so she followed them out. Interview with CNA #1 on 2/18/26, at 11:00 AM, she stated she had last seen the resident right after lunch walking the halls. While picking up lunch trays at approximately 1:00 PM, the nurse asked if she had seen Resident #1 recently and asked her to check the resident's room. When the resident was not present, the nurse called a missing resident code. She and another CNA went outside, and the resident was located in the neighboring subdivision. She confirmed that they brought the resident back to the facility. Telephone interview with Receptionist #1 on 2/18/26, at 1:23 PM, stated that on 2/14/26, around 1:00 PM, a visitor was leaving and a lady in pink was with her. She stated she let the visitor out, and the lady in pink followed her outside. She stated she was not aware the lady was a resident. Receptionist #1 stated that they have an elopement book at the desk, and when the facility admits a resident who wanders or is at risk for elopement, nursing staff notify her and provide a picture and information to add to the book so she will know who is at risk and prevent them from exiting. She stated she was not notified that Resident #1 was at risk for wandering or elopement and that there was no information in the elopement book. She stated the door alarm did not sound when she let the resident out. She stated she later learned the individual was a resident when staff asked her if she had seen Resident #1. She also stated the alarm had been activating intermittently throughout the day with no residents being present, and the alarm company had contacted the facility, and she referred them to Maintenance. Interview with Maintenance on 2/18/26, at 3:02 PM, he stated he came to the building on 2/14/26, after the incident, and checked all door alarms and found no malfunction. He stated he reviewed video footage showing Receptionist #1 turned the alarm off after the visitor and Resident #1 exited the building. Interview with the Administrator on 2/18/26, at 3:15 PM, she stated the video was no longer available due to automatic overwriting; however, she verified that her review of the video from 2/14/26 showed Receptionist #1 turned the alarm off after the visitor and Resident #1 exited. She also verified the elopement book did not contain a picture or information regarding Resident #1 being at risk for elopement at the time of exit. The facility submitted an acceptable Removal Plan on 2/18/26, and the IJ was removed on 2/19/26. On 2/14/2026, LPN #1 identified Resident #1 was no longer in the hallway and began searching for her on 2/14/2026, at approximately 1:00 PM. Staff members implemented the elopement guideline immediately on 2/14/26, at approximately 1:10 PM. Staff members immediately completed a room-to-room audit of all residents to assure all were safe on 2/14/26, beginning at 1:10 PM. On 2/14/2026, at approximately 1:33 PM, Resident #1 was returned safely to her room by LPN #1. No distress was noted. Resident #1 was wearing a wander guard upon return and was checked for functionality upon return to the building on 2/14/26, at approximately 1:33 PM by LPN #1. It was functioning as designed. A full body audit of Resident #1 was performed immediately upon her return by LPN #1 on 2/14/2026, at approximately 1:35 PM. There were no negative findings identified. Resident #1 was immediately placed on 1:1 supervision on 2/14/2026, at approximately 1:35 PM and a request for psychiatric consultation was placed by the Director of Nursing Services (DNS). Resident #1 was to remain on 1:1 supervision pending psychiatric consultation. Following removal of 1:1 supervision, the facility will ensure visual observations every thirty minutes for twenty-four hours and continued as needed. The DNS reviewed Resident #1's plan of care to ensure reflection of elopement risk and updated it on 2/14/26, at approximately 3:00 PM. All doors were checked for proper function and operation immediately on 2/14/26, at 3:05 PM by Maintenance. All doors were functioning properly. The facility determined that Resident #1 followed a visitor and exited at the front entrance on 2/14/2026, at 1:08 PM. The door alarm system functioned appropriately. The Medical Director was notified by the DNS on 2/14/26, at approximately 2:00 PM. Resident Representative of Resident #1 was notified by LPN #1 on 2/14/26, at approximately 2:00 PM. On 2/14/2026, a 100% audit of all residents identified for elopement risk was completed by the DNS to ensure placement and functioning of the wander guard system. An audit of elopement books located on all units and reception was completed by the DNS on 2/14/2026, to ensure pictures and care plans were present for all at-risk residents. Elopement drills were completed on all shifts on 2/14/26, by Maintenance. The Receptionist was educated on elopement guidance with emphasis on prompt response and investigation of alarm activation on 2/14/2026, by the DNS. The Receptionist was placed on administrative leave on 2/14/2026. The DNS and Assistant Director of Nursing Services immediately initiated an in-service on 2/14/2026, with nursing staff regarding elopement guidelines, including completion of risk assessments, care plan updates, and elopement book updates. The DNS and Assistant Director of Nursing Services initiated additional staff education on elopement guidelines and abuse and neglect on 2/14/2026. Education was provided to Social Services on 2/16/2026, by the Director of Clinical Operations on elopement guideline oversight. On 2/15/26, the DNS returned to the facility to educate staff and monitor effectiveness. On 2/16/2026, the DNS returned to educate staff and monitor effectiveness. On 2/18/2026, the DNS educated House Supervisors and Managers on Duty regarding elopement book accuracy. No staff member will be permitted to work without completing education. On 2/14/2026, facility leadership conducted a QAPI (Quality Assurance and Performance Improvement) meeting to address root cause and corrective action. All corrective actions were completed on 2/18/26, and the facility alleged the IJ was removed on 2/19/26. Validation: The State Agency validated the Removal Plan on-site during Complaint Investigation (CI) #2744403 and CI #2744399 through record review and interviews on 2/20/26. The SA determined all corrective actions were completed on 2/18/26, and the IJ was removed on 2/19/26.

Based on record review and staff interview, the facility failed to ensure medications were available and administered as ordered for one (1) of three (3) resident reviewed for significant medication errors. (Resident #4). Findings Include:Record review of the facility Medication Availability form, identified by the Nurse Consultant as the facility protocol for missing medications, revealed, If medication is not available at administration time: Check E Kit (Emergency Medication Kit), call the pharmacy, obtain estimated time of delivery, notify supervisor. If greater than four (4) hours, call Medical Doctor (MD) to inform and obtain plan to address. Record review of the January 2026 Electronic Medication Administration Record (eMAR) for Resident #4 revealed that on the night of admission, 1/9/26, Resident #4 had physician orders for Terazosin Hydrochloride (HCL) oral capsule 1 milligram (MG), give one (1) capsule by mouth one (1) time a day related to Essential Hypertension, scheduled at hour of sleep (HS); Dabigatran Etexilate Mesylate oral capsule 150 mg, give one (1) capsule by mouth two (2) times a day related to Paroxysmal Atrial Fibrillation, scheduled at HS; and Morphine Sulfate oral tablet 30 mg, give one (1) tablet by mouth two (2) times a day for pain related to Rheumatoid Arthritis. Administration of all three (3) medications was documented as code seven (7), which indicates Other/See Progress Notes, indicating the medications were not administered as ordered. Record review of Progress Notes, dated 1/9/26, and timed 11:48 PM, for Resident #4 revealed documentation stating, awaiting medications, with no further documentation to indicate the medications were obtained or administered in accordance with facility protocol. Interview with Licensed Practical Nurse (LPN) #2 on 2/19/26 at 11:40 AM revealed that when a new resident is admitted , medication orders are transmitted to the pharmacy for dispensing and delivery. She stated that if a medication is not available, staff may obtain medications from the Emergency Medication Kit (E Kit). She further stated that if the medication is not available in the E Kit, staff may contact the pharmacy, including the backup or emergency pharmacy for after-hours needs, to obtain the medication. LPN #2 stated that failure to administer Resident #4's prescribed medications could result in adverse outcomes including elevated blood pressure, cardiac complications, or unmanaged pain. Record review of the January 2026 eMAR for Resident #4 and interview with the Director of Nursing (DON) on 2/19/26 at 11:53 AM confirmed that the three (3) prescribed medications had not been administered as ordered. The DON further stated that facility staff did not follow the facility protocol for obtaining unavailable medications and that it was her expectation that the medications would have been obtained and administered in accordance with physician orders and facility protocol. Record review of the facility admission Record revealed that Resident #4 was admitted to the facility on [DATE] with diagnoses that included Essential Hypertension, Paroxysmal Atrial Fibrillation, and Rheumatoid Arthritis, which required ongoing physician-ordered medication management.

Revised 6/4/25 After quality review by the Centers for Medicare and Medicaid Services Regional Office, the deficiency originally cited at F 600 has been moved to F 689. Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards when the facility staff failed to refer to the kiosk Kardex to ensure staff transferred the resident with the required number of staff members and failed to use the proper assistive device for one (1) of three (3) residents reviewed. Resident #1 Findings Include: Record review of the facility policy titled, Lift 4 Care-Safe 4 All revealed Purpose: To provide team members guidance with assisting patients and residents to safely reposition or transfer . 7. In order to maintain patients' and residents' safety , patients and residents should be lifted or transferred by the lift and sling, which is deemed appropriate after the lift evaluation is completed. Record review of the facility Kardex Guidelines revealed Purpose: to ensure optimal communication and connection between our caregivers and residents resulting in enhanced quality of care and life . The Kardex will be reviewed daily in clinical startups and updated with any changes in a resident condition. Team members providing care will view the Kardex through the POC (Plan of Care) portal. A record review of the facility investigation revealed that on 3/14/25, while Resident #1 was being transferred to bed by Certified Nursing Assistant (CNA) #1, the resident stated, ow, and CNA #1 eased the resident to the floor. CNA #1 immediately notified the nurse. Upon evaluation, no injury or complaint of pain was noted. After assessing the resident, the Registered Nurse (RN) assisted her back to bed, identifying no apparent injury, bruising, or swelling. However, within 48 hours, swelling was observed above the right knee. An intervention was provided for comfort, and the physician was notified of the change in conditions. An X-ray revealed a fracture above the previous joint replacement device. The Nurse Practitioner (NP) and the Responsible Party were notified, and Resident #1 was transferred to the local emergency room for further evaluation and treatment. A record review of the Computed Tomography (CT) scan of Resident #1's right knee from the local hospital, dated 3/20/25, revealed an acute comminuted periprosthetic fracture of the distal femoral metaphysis. A record review of the Lift Transfer Evaluation, dated 4/7/24, revealed that Resident #1 required a total lift with a medium yellow sling for transfers. A record review of a printout of the Kiosk Kardex for Resident #1 revealed the following: Safety .Two members will assist with transfers with each episode .Lift 4 Care: type of lift, sling size, etc. total lift with medium yellow sling. During an interview with the Administrator on 3/26/25 at 9:15 AM, she verified that the facility investigation confirmed that on the evening of 3/14/25, CNA #1 transferred Resident #1 to bed using a stand-pivot transfer method instead of a lift and had to lower the resident to the ground. During the transfer, the resident said, ow, but upon assessment by the RN, no injury was noted. She stated that within 48 hours, Resident #1 was moaning during care. Upon assessment by the nurse, the resident's right knee was swollen and tender to touch. The resident was assessed by the NP, who noted swelling but no other signs of trauma. A right knee X-ray was ordered on 3/19/25, and results received on 3/20/25 revealed a fracture of the femoral shaft. The NP was notified, and orders were given to transfer the resident to the hospital. A record review of the Progress Notes from 3/14/25 through 3/20/25 confirmed that on 3/16/25, the resident was moaning during care, prompting the nurse to be notified. The resident was observed to have swelling in the right knee with tenderness to touch. The leg was elevated for comfort, and the NP was notified. On 3/17/25, the resident was assessed by the NP, who noted swelling in the right knee without redness, tenderness, warmth, or pain. The resident was diagnosed with right knee effusion, and the current treatment with diuretics was continued. On 3/19/25, the NP saw the resident again, observing no change in the knee's condition. An X-ray of the right knee was ordered. On 3/20/25, the NP noted that the resident continued to have knee swelling without pain. The X-ray results showed a femur fracture, and the NP ordered the resident's transfer to the emergency room for further evaluation and treatment. During a telephone interview with CNA #1 on 3/26/25 at 11:32 AM, she confirmed that on the evening of 3/14/25, she transferred Resident #1 from the chair to the bed by standing the resident up and pivoting her to bed. She explained that while the resident was standing in front of the bed, the resident's knees buckled, and she lowered her to the floor. She called the nurse, and they assisted the resident back into bed. CNA #1 stated that the resident moaned at some point during the transfer. She added that she had always transferred the resident in this manner because that was how she had been taught when hired. She acknowledged being aware that the Kardex on the kiosk provided information on the resident's care needs and transfer status. She also confirmed that, during her orientation, she was instructed to check the Kardex at the beginning of each shift for any changes in the resident's needs or transfer requirements. CNA #1 admitted that she did not realize Resident #1 required a total lift for transfers because she had not checked the Kardex. She agreed that failing to follow the Kardex instructions could result in resident injury. Record review of the Admission Record revealed the facility admitted Resident #1 on 4/10/18 with diagnosis that include dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/25 revealed that Resident #1 has impaired range of motion (ROM) of lower extremities on both sides and maximal assistance for transfers.

Based on staff interview, record review, and facility policy review the facility failed to implement a resident's care plan when Resident #1 was transferred without the required number of staff members and the use of the proper assistive devices for one (1) of three (3) residents care plans reviewed. Resident #1 Findings Include: Record review of the facility policy titled, Comprehensive Care Plans revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . A record review of the facility investigation revealed that on 3/14/25, while Resident #1 was being transferred to bed by Certified Nursing Assistant (CNA) #1, the resident stated, ow, and CNA #1 eased the resident to the floor. CNA #1 immediately notified the nurse. Upon evaluation, no injury or complaint of pain was noted. After assessing the resident, the Registered Nurse (RN) assisted her back to bed, identifying no apparent injury, bruising, or swelling. However, within 48 hours, swelling was observed above the right knee. An intervention was provided for comfort, and the physician was notified of the change in conditions. An X-ray revealed a fracture above the previous joint replacement device. The Nurse Practitioner (NP) and the Responsible Party were notified, and Resident #1 was transferred to the local emergency room for further evaluation and treatment. Record review of the Comprehensive Care plan for Resident #1 revealed, under Focus I have a physical functioning deficit with transfers and require assistance from team members and an (proper lift name) total lift. Under Interventions : (proper lift name) total lift with medium yellow sling .Two (2) members will assist with transfers with each episode On 3/26/25 at 9:15 AM, during an interview with the Administrator she verified that on the evening of 3/14/25, CNA #1 transferred Resident #1 to bed using a stand-pivot transfer method instead of a lift and had to lower the resident to the ground. During the transfer, the resident said, ow, but upon assessment by the RN, no injury was noted. She stated that within 48 hours, Resident #1 was moaning during care and an x-ray was ordered that showed the resident had a right femoral shaft fracture. A record review of a printout of the Kiosk Kardex for Resident #1 revealed the following: Safety .Two members will assist with transfers with each episode .Lift 4 Care: type of lift, sling size, etc. total lift with medium yellow sling. During an interview with CNA #2, CNA #3, and CNA #4 on 3/26/25 at 10:00 AM confirmed that the residents Kardex informed them of what the residents' care plans were and should be checked at the beginning of each shift. CNA #2, CNA #3, and CNA #4 all agreed that the Kardex would show how many staff were needed for a resident transfer and what type of lift to use based on the resident's care plan. On 3/26/25 at 11:32 AM, during a telephone interview with CNA #1 she confirmed that on the evening of 3/14/25 she transferred Resident #1 from the chair to the bed using the wrong type of lift method. She admitted that she did not look at or follow the residents' Kardex or care plan but used the stand pivot method of transfer instead of a total lift. She confirmed that when she stood the resident up and pivoted her to the bed, the resident's knees buckled, and she lowered her to the floor. During a follow-up interview with the Administrator on 3/26/25 at 12:00 PM, she stated that the care plan interventions for the total lift automatically pull to the Kardex kiosk for the CNAs to follow. She confirmed that it was her expectation that CNAs check the Kardex at the beginning of each shift and follow the care plan interventions. Record review of the Admission Record revealed the facility admitted Resident #1 on 4/10/18 with diagnoses that included dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/25 revealed that Resident #1 has impaired range of motion (ROM) of lower extremities on both sides and maximal assistance for transfers.

Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system for one (1) of four (4) quarters reviewed. First Quarter 2025 (October-December 2024) Findings Include: Review of the facility policy titled Payroll Based Journal Entry Submission unrevised, revealed under, Policy: CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered too. Record review of the PBJ Staffing Data Report revealed the facility submitted excessively low weekend staffing data for the 1st quarter 2025 (October 1-December 31). An interview with the Regional Human Resource on 3/18/25 at 11:30 AM revealed the facility's payroll system handled late clock-ins and shifts that crossed midnight as counting toward the next shift. He revealed if a staff member clocked in late, it would automatically transfer over to the next shift because of the federal overtime laws in place. He revealed he was unsure if the department heads that worked the weekend were captured on the payroll-based journal (PBJ). An interview with Human Resources on 3/19/25 at 9:00 AM, she revealed the facility's corporate office submitted the payroll-based journal (PBJ). She confirmed that with the payroll system that they use, if someone clocks in late, the hours will automatically transfer over to the next shift. She confirmed that she did not manually correct the employee hours in the system. An interview with the Administrator (ADM) on 3/19/25 at 10:37 AM revealed every morning she went over the PPD (Patient Per Day) and looked at call ins from the day before to ensure the PPD was accurate. She revealed they had not had any low staffing. She revealed that on the weekends, they have an on-call person, and they come in and work as a CNA or nurse or whatever was needed to ensure that they met that PPD. Furthermore, she explained that they had the current payroll system for about a year and had not worked out all the kinks yet. She confirmed that no one manually corrected payroll. She revealed that she had compared the workforce manager's schedule with the human resources report and saw for herself that the hours were not captured correctly. The ADM revealed that if someone came in 2 hours late, their hours would not be captured that shift. She confirmed this could cause a discrepancy with the hours submitted in the payroll-based journal.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for resident's dependent on staff assistance for three (3) of five (5) residents reviewed for ADL's. (Residents #12, #111, and #118). Findings include: Review of the facility policy titled ADLs, effective August 2021, revealed the following: Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choice and preferences. Resident #12 An observation on 3/17/25 at 12:05 PM and again on 3/18/25 at 9:20 AM revealed that Resident #12's upper and lower teeth were covered in a thick white substance that adhered to the upper and lower gum lines. During an interview and observation on 3/18/25 at 11:00 AM, Certified Nurse Aide (CNA) #6 confirmed Resident #12's teeth were bad and had a bunch of gunk on them. She revealed she honestly thought they looked like it had been quite some time since his mouth had been tended to. During an interview on 03/18/25 at 2:10 PM, Registered Nurse (RN) #3 revealed that Resident #12 has a hospice aide that comes twice a week and provides personal hygiene but admits that it is all of their responsibility to make sure the residents oral care is taken care of. She stated that there is no excuse for a residents' daily oral care to not be completed. During an interview on 3/18/25 at 3:26 PM, the Director of Nurses (DON) revealed that all residents are to be adequately groomed, including oral care. A record review of Resident #12's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side. Resident #111 An observation and interview on 3/17/25 at 10:54 AM revealed Resident #111's fingernails to be one and one-half (1.5) inches long past the tip of the fingers, jagged in appearance with a brown substance under the nail beds. Resident #111 stated, I am a diabetic, and the nurse has to cut them. They are sharp, and I don't like them this long. I'm not sure when the last time they were cut and cleaned. An observation and interview on 3/18/25 at 9:05 AM with Resident #111 revealed she got cleaned up last night by the bath girl but admitted that she didn't get her fingernails cut. Her fingernails remain long and jagged. She revealed the girl who gave her a bath couldn't cut her fingernails because she is diabetic, and the nurse had to cut them. She stated, I don't know when I will get my fingernails trimmed, but they need them. An interview and observation on 3/18/25 at 11:10 AM CNA #5 revealed she was assigned to the resident today and confirmed that the resident's nails were long and jagged. She revealed that she couldn't cut them since the resident is diabetic, but we are supposed to notify the nurses when we notice the fingernails are long and need to be cut. She revealed she had not reported it to the nurse. During an interview and observation on 3/18/25 at 11:15 AM, Licensed Practical Nurse (LPN) #3 confirmed that the resident is diabetic, and the nurses are responsible for trimming the resident's fingernails. She confirmed Resident #111's nails were long and jagged and needed to be trimmed. Resident #111 stated, I would like my fingernails cut. During an interview on 03/18/25 at 2:00 PM, the DON confirmed that Resident #111 should receive assistance with their ADLs, including proper nail care. A record review of the Admission Record for Resident #111 revealed she was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus and Parkinson's Disease. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/13/25 revealed Resident #111 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. 47157 Resident #118 An observation of Resident #118 on 3/17/2025 at 10:15 AM revealed the resident had jagged fingernails approximately one-half (1/2) inch in length with a dark brown substance present underneath the nail beds. During an interview conducted at the time of the observation, Resident #118 verbalized he did not like his fingernails to be long and could not recall the last time they had been trimmed. A subsequent observation and interview on 3/18/2025 at 10:48 AM was conducted with RN #1, she confirmed that Resident #118's fingernails were long, jagged, and visibly soiled with a dark brown substance under the nail beds. RN #1 further acknowledged the nails appeared untrimmed for a prolonged period and required attention. RN #1 expressed concern that the resident could potentially scratch himself, increasing the risk of skin breakdown or infection due to the dirty nails. During an interview with the DON on 3/18/2025 at 11:10 AM he confirmed that Resident #118 was dependent on staff assistance for personal care and should have already received nail care. A record review of the Admission Record for Resident #118 revealed he was admitted on [DATE], with diagnoses including A Need for Assistance with Personal Care. Record review of the MDS with an ARD of 1/28/25 revealed Resident #118 had a BIMS score of 09, indicating the resident had moderate cognitive impairment.

Based on observation, staff interview, Safety Data Sheet review, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on two (2) of three (3) housekeeping carts observed during survey. Findings include: Review of facility policy titled Environmental Services Chemical Use/Dilution and Hazards revealed Overview of proper chemical use .6. Each housekeeping cart has a lockbox. All chemicals are to be stored in the lock box. Do not leave your cart unattended . An observation and interview on 3/17/25 at 10:50 AM revealed an unattended housekeeping cart on the west hall that was unlocked. An interview at this time with Housekeeper #5 confirmed that the housekeeping cart was not locked. She then stated that the door on the side of the cart and the roll cabinet on the top of the cart did not lock. Further observation of the cart with Housekeeper #5 revealed that the following chemicals were stored on the cart: Crew Bathroom Disinfectant Cleaner, Virex Plus One-step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #5 stated that she was not sure how long the lock had not worked and at one point someone had used tape to keep the door shut, but they really needed new ones. She stated that the cart is supposed to be locked to keep the chemicals away from the residents because they are dangerous and could hurt them if they drank it or got it on them. An observation and interview on 3/17/25 at 11:00 AM with Housekeeper #4 revealed that the rehabilitation hall housekeeping cart was locked but the following chemicals were stored outside the cart, within resident reach: Crew Bathroom Disinfectant Cleaner, Virex Plus One step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner. Housekeeper #4 stated that he stored the chemicals there because he did not have a key to unlock the cart. He stated that he has worked at the facility for about a month. He stated that the cart is supposed to be locked to keep the chemicals away from the residents because they are dangerous and could hurt them if they drank it or got it on them. An interview with the Housekeeping Supervisor on 3/18/25 at 9:07 AM, he stated that he was not aware that the west housekeeping cart was not locking. He stated he knew that there had been a previous issue with it not locking but stated that he had used it about a month ago and it was locking with no issue. He further stated that Housekeeper #4 had just recently started using the rehabilitation housekeeping cart and he had forgotten to tell him to come and get his key. He confirmed that it was important to keep the cleaning chemicals secure because they were caustic and could cause injury if the residents got them on them or drank them. An interview with the Administrator on 3/18/25 at 2:45 PM, she stated she was not aware of the issues with the housekeeping cart and that it was her expectation that she would have been notified if the housekeeping cart was not locking or if an extra key was needed. Record review of the Safety Data Sheets (SDS) review for Crew Bathroom Disinfectant Cleaner, Virex Plus One step disinfectant cleaner & deodorant, and Crew clinging Toilet bowl cleaner revealed: Crew Bathroom Disinfectant Cleaner, Hazard Statement: None .4. First Aid Measures, Eyes: Rinse with plenty of water, if irritation occurs or persists, get medical attention . Virex Plus One step disinfectant cleaner & deodorant: Hazard Statement: combustible liquid. Causes severe skin burns and serious eye damage. Harmful if swallowed. May cause damage to organs through prolonged or repeated exposure First Aid Measures, Eyes: If in eyes rinse cautiously with water for several minutes .Continue rinsing for at least 15 minutes. Crew clinging Toilet bowl cleaner: Hazard Statement: Causes severe skin burns and serious eye damage First Aid Measures, Eyes: If in eyes rinse cautiously with water for several minutes .Continue rinsing for at least 15 minutes .

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure that resident call lights were within reach, which limited a resident's ability to request assistance as needed for two (2) of 134 residents observed on survey. Resident #32 and Resident #42 Findings include: Review of the facility policy with a revision date of October 2022 titled Call Lights: Accessibility and Timely Response revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance . 5. Staff will ensure the call light is within reach of residents and secured, as needed .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room . Resident # 32 An observation and interview on 3/17/25 at 10:30 AM revealed Resident #32 in bed with the call light wrapped around the side rail on the right side of the bed and hanging out of the resident's reach. When asked how he called the staff for assistance, he stated I use the call light if I can find it, you can't push what you can't find. An observation of Resident #32's room and interview with Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #2 on 3/17/25 at 10:32 AM, they verified that the call light was wrapped around the side rail on the right side of the bed and hanging out of the resident's reach. CNA #2 stated that is on me, I just left to throw something away and forgot to put it where he could reach it, I was coming back. RN #2 confirmed that the call light should be kept in the resident's reach because if there was a problem or emergency the resident would not be able to call for assistance. Record review of the Admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with diagnoses that included Blindness Right Eye and End Stage Renal Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 12/22/24 for Resident #32 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. 46013 Resident #42 An observation on 3/17/25 at 10:25 AM revealed Resident #42 lying in bed asleep; the resident's call light was positioned inside the closed drawer of his nightstand, making it inaccessible. An observation on 3/17/25 at 1:20 PM and again at 3:45 PM revealed the call light hanging down on the left side of the nightstand and was not within reach of the resident. An observation on 3/18/25 at 8:30 AM revealed that Resident #42 was lying in bed; his call light was hanging down from the wall and positioned to the right of the nightstand on the floor, and out of reach of the resident. During an interview and observation on 3/18/25 at 11:16 AM of Resident #42's call light position, CNA #4 confirmed the call light was hanging down from the wall and positioned to the right of the nightstand on the floor and was inaccessible to the resident and had not been accessible all morning. She revealed his call light should always be within reach so we can be notified if he needs anything. An interview on 03/18/25 at 2:15 PM, the Director of Nurses (DON) confirmed that staff are expected to ensure call lights are always within residents' reach. The DON stated, Residents should always have access to their call lights to request assistance. This is a critical aspect of resident safety and care. A record review of Resident #42's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide a safe, clean, and homelike environment for nine (9) of 134 residents residing in the facility. (Residents #14, # 17, #32, # 70,, #71, #79, #87, #93, and #95). Findings include: Review of the facility policy titled, Room Audit, with an effective date of September 1, 2014, revealed, Purpose: To assess resident rooms to identify items that should be repaired, replaced, or addressed to ensure a home-like standard that meets acceptable standards .General Room Appearance - Housekeeping issues should be noted and reported to housekeeping. Damaged drywall, furniture, or non-functioning equipment should be noted, a work order created and addressed accordingly to priority . Resident #14 During an observation of Resident #14's room and interview with the resident on 3/17/25 at 11:10 AM revealed the headboard of the resident's bed was broken on both sides, exposing jagged wood edges. Pieces of the broken headboard were observed lying on the floor behind the bed. He stated the headboard had been broken for a while and confirmed he reported it to staff. A follow-up observation of Resident #14's room on 3/18/25 at 8:58 AM revealed the headboard remained broken with jagged edges exposed. An observation conducted with Registered Nurse (RN) #1 on 3/18/25 at 10:45 AM confirmed the headboard was broken in half on both sides, with jagged edges of wood exposed. She stated that the jagged edges could potentially injure the resident. During an interview with the Administrator on 3/18/25 at 10:55 AM confirmed the broken headboard should have already been identified and repaired. She acknowledged the condition could cause concerns for the resident's safety. During an interview on 3/18/25 at 11:10 AM the Maintenance Supervisor revealed he was unaware of the broken headboard in Resident #14's room. He confirmed staff should have reported the issue and entered a work order. He acknowledged the jagged edges of the headboard could be dangerous. Record review of Resident #14's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included Type II Diabetes Mellitus. Record review of Resident #14's Minimum Data Set (MDS), Section C with an Assessment Reference Date (ARD) of 1/24/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #70 During an interview with Resident #70 on 3/17/25 at 3:08 PM, the resident stated her husband noticed mice droppings inside her dresser drawers while helping her retrieve clothing. Resident #70 stated she reported the mouse droppings to staff. An observation of Resident #70's dresser drawers conducted with Certified Nurse Assistant (CNA) #10 on 3/17/25 at 3:10 PM revealed numerous amounts of black substances approximately the size of rice in the second, third, and fourth drawers. CNA #10 confirmed the presence of the black substances and revealed it appeared to be mice droppings and expressed concern that mice carry diseases. During an interview with RN #1 on 3/18/25 at 10:45 AM confirmed the presence of what appeared to be mice droppings in Resident #70's dresser drawers. RN #1 stated the resident's clothing would be contaminated with feces and bacteria. During an interview with the Administrator on 3/18/25 at 10:50 AM confirmed the substance that appeared to be mice droppings should have been cleaned immediately upon discovery to prevent health concerns. During an interview with the Maintenance Supervisor on 3/18/25 at 11:10 AM it was revealed that mice droppings in Resident #70's dresser drawers were reported to him on 3/15/25. He confirmed staff should have cleaned the droppings at the time they were discovered to avoid potential health concerns. Record review of Resident #70's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included Occlusion and Stenosis of an Unspecified Vertebral Artery. Record review of Resident #70's MDS, Section C with an ARD of 2/22/25, revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #79 An observation of Resident #79's room on 3/17/25 at 11:00 AM revealed a hole in the wall beside the resident's bed, with a metal vent cover hanging out of the hole. An observation of Resident #79's room conducted with RN #1 on 3/18/25 at 10:41 AM confirmed there was a hole in the wall and the vent cover was hanging out. She stated the condition posed a potential hazard because the resident could injure himself on the vent cover or stick his arm into the hole. During an interview on 3/18/25 at 10:54 AM the Administrator confirmed the hole in Resident #79's wall was a hazard and should have been identified and addressed. During an interview on 3/18/25 at 11:04 AM the Maintenance Supervisor revealed he was unaware of the hole in Resident #79's wall until today. He measured the hole as approximately four by six inches in diameter and confirmed staff should have identified the damage and submitted a work order. He stated he makes weekly rounds to check for maintenance concerns but did not have documentation of the rounds conducted. Record review of Resident #79's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included Obstructive Hydrocephalus. 46013 Resident #17 An observation and interview on 3/17/25 at 11:30 AM revealed three white bath towels lying on the floor in front of the air conditioner unit in Resident #17's room. Resident #17 revealed that staff change those towels out but was not sure why they were there. Resident #17 stated that the towels may be for the air conditioner but admitted they looked messy. During this observation a thick black substance was noted covering the entire bottom base of the resident's overbed table. On 3/18/25 at 8:44 AM, an observation revealed no changes in Resident #17's overbed table and the three white bath towels remained lying on the floor in front of the air conditioner unit. During an interview on 3/18/25 at 2:37 PM, Housekeeper #2 revealed that the air conditioner in Resident #17's room leaks, and they change out the towels every day and sometimes two times a day. She revealed it had been reported to the previous administrator. During an observation and interview on 3/18/25 at 2:50 PM, the Director of Nurses (DON) confirmed towels were lying on the floor in front of the air conditioner unit, and the overbed table had a thick black substance over the metal base. During this observation, it was noted that the resident's window had a white towel stuck in the side, and there was a gap of approximately three (3) inches to the remaining top of the window, which exposed the outside elements. There was no screen in the window. Resident #17 revealed they put that towel in there but didn't stop the whole gap. He revealed the window didn't close. The DON confirmed that the window had a gap of approximately 3 inches with a towel positioned in it and was open to the outside elements. He revealed Resident #17 should have a clean, functional room that is free of outside elements. He revealed this is just not acceptable. During an interview on 3/18/25 at 3:00 PM, the Maintenance Supervisor revealed he wasn't aware of the air conditioner unit leaking and didn't have a work order for it and, therefore, wasn't aware of the towels on the floor under the unit. He revealed he was aware of the gap in the window and that he used to have a helper, and he thought that the helper had repaired the window. A record review of Resident #17's Admission Record revealed the resident was admitted on [DATE] with diagnoses that included Unspecified Dementia and Anxiety Disorder. A record review of Resident #17's MDS, Section C, with an ARD of 2/7/25, revealed a BIMS score of 5, indicating severe cognitive impairment. 47158 Resident # 32 An observation of Resident #32's bed on 3/17/25 at 10:34 AM, revealed Resident #32 in bed with the bed remote control wrapped around the side rail on the right side of the bed with two (2) inches of wire exposed on the cord. An observation of Resident #32's bed and interview with RN #2 on 3/17/25 at 10:34 AM ,she verified that the wires on the bed remote control were exposed and that they could be a safety hazard because the exposed wires could cause a shock. During an interview on 3/18/25 at 2:00 PM the Maintenance Director stated that he was not notified prior to 3/17/25 that the resident's remote had exposed wires. He confirmed that the wires were exposed and agreed that it could have caused a risk of shock. He revealed that staff were supposed to notify him of maintenance issues by putting in a work order. Record review of the Admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with diagnoses that included End Stage Renal Disease. Record review of the MDS with an ARD of 12/22/24 for Resident #32 revealed a BIMS score of 15, indicating that the resident is cognitively intact. Resident # 71 An observation of Resident #71's room on 3/17/25 at 11:31 AM with CNA #2 revealed the mattress was noted to have a 12 by 12 inch area of sagging to the middle portion of the mattress, as well as a 36 by 12 inch, irregular shaped area in which the top layer of the mattress was peeling off exposing the under layer. The bed was electric, but staff could not raise or lower the head, foot or height of the bed. CNA #2 verified that the mattress was in disrepair and the bed was not working. She stated they had gotten the resident out of bed because of this. She stated she was unsure of how long the mattress had been in disrepair or how long the bed wasn't working stating We report these things all the time and we can never get anyone to fix them. She stated that they put in a work order to notify maintenance. She agreed that the bed being in disrepair could negatively affect the resident's comfort and positioning. An interview on 3/18/25 at 2:02 PM the Maintenance Director confirmed that staff were to notify him via work order if something needs to be fixed. He stated that he was not notified prior to 3/17/25 that the resident's mattress and bed was in disrepair. He verified that the mattress and the remote control on the bed had to be replaced. He agreed that the bed being in disrepair could negatively affect the resident's comfort and positioning. Record review of the Admission Record revealed that the facility admitted Resident #71 on 3/27/23 with diagnoses that included Systolic Congestive Heart Failure. 52240 Resident #87 On 3/17/25, at 10:30 AM, and again on 3/18/25, at 11:10 AM, an observation of Resident #87's room revealed multiple large brown spots on the window curtains and four boxes stacked on the floor containing tube feeding supplies. Further observation revealed a broken left bed rail, and an oxygen concentrator covered in a gray and white powdery substance. The wall behind the oxygen concentrator had a dried yellow substance. During an interview with RN #1 on 3/18/25 at 11:12 AM, she confirmed the presence of the boxes on Resident #87's floor and revealed that she was informed by central supply that the boxes were to be stored in the resident's room. She mentioned that the boxes were previously kept in central supply but was unsure why they were no longer stored there. RN #1 acknowledged that the boxes on the floor posed a potential hazard for staff and visitors. She also revealed that she reported any broken equipment to maintenance but was unaware of Resident #87's broken bed rail. An interview with the Maintenance Director on 3/18/25 at 2:26 PM revealed that he did not conduct routine room rounds, as department heads completed Embrace rounds. He explained that any necessary repairs were documented in the computer work-order system or reported directly by staff. He revealed he was unaware of Resident #87's broken bed rail. Record review of the Admission Record revealed the facility admitted Resident # 87 on 01/04/2025 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. 47874 Resident #93 An observation and interview on 3/17/2025 at 10:20 AM and again on 3/18/2025 at 11:00 AM revealed Resident #93 lying in bed with his overbed light on. He revealed that his overbed light had been broken for some time and that he had informed the staff about it. This observation revealed that the overhead light lacked a pull string, preventing him from turning it off. An observation and interview with RN #1 on 3/18/2025 at 11:12 AM confirmed that Resident #93's light was broken. She explained that staff members were responsible for reporting broken items to maintenance for repairs. During an interview with the Administrator on 3/18/2025 at 11:50 AM, she confirmed that staff members were responsible for reporting necessary repairs to maintenance, while maintenance was responsible for fixing them. She also acknowledged that Resident #93 should have had functioning equipment in his room. Record review of the Admission Record revealed Resident #93 had been admitted to the facility on [DATE] with a medical diagnosis that included Aphasia following Cerebral Infarction. Record review of the MDS with an ARD of 12/24/2024, indicated that under section C, the BIMS score was 6, which indicated that Resident #93 was severely cognitively impaired. Resident #95 An observation of Resident #95's room on 3/18/2025 at 10:37 AM revealed that the curtains over the windows were stained with large, dark brown marks. Additionally, 10 brown boxes containing various enteral feeding supplies were stacked on the floor. During an interview with RN #1 on 3/18/2025 at 11:12 AM, she confirmed that Resident #95's curtains were dirty and needed to be washed. She also acknowledged that the boxes on the floor had created clutter and posed a fall risk. RN #1 confirmed that the resident should have a clean and clutter-free environment. An interview with the Administrator on 3/18/2025 at 11:50 AM, she confirmed that Resident #95 should have a clean and safe living environment. Record review of the Admission Record revealed Resident #95 was admitted to the facility on [DATE] with a medical diagnosis that included Dysphagia following Cerebral Infarction.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement an activities of daily living (ADL) care plan for resident's dependent on staff assistance (Residents #12, #111, and #118) and failed to implement a care plan related to fluid restriction for (Resident #32) for four (4) of 45 resident care plans reviewed. Findings include: Review of the facility policy titled, MDS (Minimum Data Set) and Care Plans, with an effective date of August 2019, revealed, Policy: Care plans will be developed per the RAI (Resident Assessment Instrument) guidelines. Resident #12 A record review of Resident #12's Care Plan revealed that he had a self-care deficit related to (Cerebral Vascular Accident) with left hemiplegia, impaired cognition, and immobility with interventions that included Nail, hair, shave and oral care daily and as needed. An observation on 3/17/25 at 12:05 PM and again on 3/18/25 at 9:20 AM of Resident #12's mouth and gums revealed a thick white substance that was adhered to the upper and lower gum lines. During an interview and observation on 3/18/25 at 11:00 AM, Certified Nurse Aide (CNA) # 6 confirmed that Resident #12's teeth were bed and had a lot of gunk on them. She admitted that it looked like it had been a long time since his teeth had been taken care of. During an interview on 3/18/25 at 3:26 PM, the Director of Nurses (DON) revealed that all residents are to be adequately groomed, including oral care. He revealed that his care plan was not followed if the resident was not provided with oral care as he should have been. A review of the Admission Record for Resident #12 revealed he was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting the Left Dominant Side. Resident #111 Record review of Resident #111's Care Plan revealed that she had an ADL self-care performance deficit related to Dementia, Parkinson's, abnormal gait and mobility with interventions that included Bathing/Showering: Check nail length and trim and clean .daily as needed on bath day and as necessary. Report any changes to the nurse. An observation and interview on 3/17/25 at 10:54 AM revealed Resident #111's fingernails were long, jagged and had a brown substance under each nail. Resident #111 stated that his nails were sharp and needed cut and cleaned. An observation and interview on 3/18/25 at 9:05 AM Resident #11 revealed no change in the appearance of her fingernails. She stated that she got cleaned up last night, but they did not do anything with her nails. During an interview on 03/18/25 at 2:00 PM, the DON confirmed that residents should receive assistance with their ADLs, including proper nail care. He revealed that if the resident's fingernails were not adequately groomed, their care plan was not being followed, and it should have been. A review of the Admission Record for Resident #111 revealed she was admitted to the facility on [DATE] for diagnoses which included Type 2 Diabetes Mellitus and Parkinson's Disease. A review of the MDS with an ARD of 3/13/25 revealed Resident #111 had a BIMS of 15, indicating the resident was cognitively intact. 47158 Resident #32 A record review of the Care Plan for Resident #32 revealed Focus: [Resident Proper Name] has alteration in Kidney Function Due to End Stage Renal Disease (ESRD), evidenced by hemodialysis, left nephrostomy tube. Goal: I will reduce short term complications associated with impaired renal function through review date. Interventions: one liter (1L) fluid restriction. Nursing to provide: 150 cc on 7-3 shift, 150 cc fluids on 3-11 shift, 100 cc fluids on 11-7 shift. Dietary to provide: 12 oz fluids on breakfast tray, 4 oz fluids on lunch tray, 4 oz fluids on dinner tray. A record review of Resident #32's Electronic Medication Administration Record (eMAR) documentation of fluid intake revealed the resident was on a 1-liter fluid restriction daily and there were 9 days out of the last two weeks that indicated fluid intake exceeded 1 liter within a 24-hour period. Those days were 3/3/25, 3/5/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, and 3/17/25. During an interview and record review of Resident #32's documented fluid intake with Licensed Practical Nurse (LPN) #1 on 3/18/25 at 8:47 AM, she stated that Resident #32 was on a 150-cc fluid restriction for the 7:00 AM-3:00 PM shift. She clarified that this did not include his fluid intake from breakfast or lunch, only the fluids administered by the nursing staff during her shift. She admitted that she did not check his meal trays to verify that dietary provided the ordered amount of fluid for breakfast and lunch, nor did she monitor or document his fluid intake from those meals. After record review, LPN #1 verified that it was hard to tell from the documentation how much the resident was actually getting but appeared that the resident may have went over the one liter limit a few day. On 3/18/25 at 8:50 AM, during an interview and record review with the DON, he admitted that Resident #32 may have exceeded the one liter daily limit for multiple days. During an interview on 3/20/25 at 9:30 AM, with the MDS Nurse stated that the care plan is formulated as a guideline for resident care based on their needs. She agreed that the interventions are to be followed by staff in order for the residents to reach their goals. She stated that the staff's failure to accurately monitor and document Resident 32's fluid restriction was a failure to implement his current care plan. A record review of the Admission Record revealed that the facility admitted Resident #32 on 01/31/2020 with a diagnosis of End-Stage Renal Disease. 47157 Resident #118 Review of the care plan for Resident #118 titled, I have ADL self-care performance deficit r/t (related to) weakness, impaired cognition, with a revision date of 2/24/2025 revealed interventions: Personal Hygiene: The resident requires limited assistance x (1) one staff with personal hygiene and oral care. An observation and interview with Resident #118 on 3/17/2025 at 10:15 AM revealed the residents' fingernails were long, jagged with a dark brown substance present underneath the nail beds. Resident #118 stated that he did not like his fingernails to be long and could not recall the last time they had been trimmed. An observation on 3/18/2025 at 10:48 AM was conducted with RN #1 who confirmed that Resident #118's fingernails needed cut and cleaned and looked like it had been a while since they were taken care of. During an interview with the DON on 3/18/2025 at 11:10 AM, he confirmed after review of the ADL care plan for Resident #118 that staff did not implement the care plan related to personal hygiene. He stated the purpose of the care plan is to direct staff on how to care for the residents. He also stated that concerns from staff not implementing care plans are that the residents may not receive the care they need. A review of the Admission Record for Resident #118 revealed he was admitted on [DATE], with diagnoses including a Need for Assistance with Personal Care and Urinary Tract Infection.

Based on staff and Resident Representative (RR) interview, record review and Administrator statement review the facility failed to ensure a resident received treatment and services in accordance with professional standards of practices as evidenced by failure to change the negative pressure wound therapy system dressing as ordered by the provider for one (1) of three (3) residents with wound care reviewed. Resident # 1 Findings include: Record review of a typed document, undated, on facility letterhead and signed by the Administrator revealed (Proper Name of Facility) utilizes Negative Pressure Wound Therapy System manufactures guidelines. Record review of the NEGATIVE PRESSURE WOUND THERAPY SYSTEM (NPWT) Instructions for Use revealed .The NPWT system should remain on and in use for the duration of the prescribed treatment . During a telephone interview on 5/8/24 at 10:00 AM, with Resident # 1's RR, she stated she notified the facility staff that Resident #1's wound vac dressing to the left abdominal wound needed to be changed. She stated she was told that the dressing is only changed if the suction broke. She stated that the facility did not remove Resident #1's abdominal dressing the week of 04/01/24 until 4/10/24 and at that time the foam from the dressing was adhered to the wound. Record review of the Order Summary Report with active orders as of 3/26/24 revealed an order dated 3/26/24 Treatment; Surgical wound to left lateral abdomen (#4) Clean with NS (normal saline), apply wound vac at 125 mmHg (millimeters of mercury) every Monday and Thursday PRN (as needed) for drainage/dislodgement . Record review of the April 2024 electronic treatment administration record (eTAR) for Resident #1 revealed there was no documentation that the wound vac dressing was changed on 4/1/2024, 4/4/2024 or 4/8/2024. Record review of General Notes for Resident #1, dated and timed 4/10/24 at 1:33 PM, revealed Wound vac dressing removed from left lat (lateral) abdomen .Lower wound remains open. Foam dressing adhered to wound bed . Record review of Progress Note Details for Resident #1 dated 4/11/2024, completed by Wound Care Nurse Practitioner (NP) revealed, .The wound vac was last changed on 3/25/24 and removed by the facility NP and DON (Director of Nursing) on 4/10/24 with sponge fragments remaining in the wound .The site was debrided today removing .fragments .Not all fragments were able to be removed .Recommend dressing changes .until evaluated by surgeon . In an interview with Registered Nurse #1 (RN) on 5/8/24 at 12:30 PM, she stated that the resident's RR notified her that the wound vac dressing needed to be changed, but she was unsure of the date she was notified. She stated that she observed the abdominal wound vac dressing at that time and it looked like it needed to be changed. She stated she did not recall the date on the dressing. RN #1 stated that the previous DON was responsible for wound care at that time, and she notified her that the dressing needed to be changed. RN #1 verified that the eTAR for April 2024 had no documentation that the wound vac dressing had been changed and that if there was no documentation, then it was not performed. Interview with NP #1 on 5/8/24 at 12:45 PM, she verified that she was informed by the previous DON on 4/10/24 that the foam from the wound vac dressing was adhered to the residents wound bed. She stated upon her assessment of the abdominal wound on 4/10/24 that the foam from the dressing was adhered to the wound bed and they were unable to remove it. She verified that failure to change the wound vac dressing as ordered could cause the foam to be adhered to the wound and prevent healing. In an interview with the Administrator on 5/8/24 at 2:00 PM, he agreed Resident #1's wound vac dressing should have been changed as ordered. Record review of the Admission Record revealed Resident #1 was admitted to the facility on [DATE] with a diagnoses that included Unspecified open wound of the abdominal wall.

Based on observation, staff and family interviews, record review and facility policy review the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. No facility staff saw resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 10:40 PM when they received a verbal report from a friend of a staff member that Resident #1 was at an apartment complex parking lot, off the facility grounds, talking to the police. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 10:50 PM on 03/31/24. The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/31/24 and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 03/31/24 through 04/01/24, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 04/02/24, prior to the SA's entrance on 04/05/24. Findings Include: Record review of a statement on facility letterhead, dated 4/5/2024 and signed by the Administrator revealed Supervision (Name of facility) provides supervision based on care plans, individual needs, and Resident Rights. The statement was signed by the facility administrator. Record review of the facility's undated policy titled Missing Resident/Elopement revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process . If an elopement risk is determined an individual plan is established and intervention is initiated to mitigate that risk. When the nurse identifies the intervention it is documented on the care plan and on the caregiver guide . An interview on 04/05/24 at 9:10 AM with the facility Administrator (ADM) revealed that Resident #1 was currently transferred to a Behavioral Health hospital for evaluation of his emotional and mental status as well as for his behaviors and medications. The ADM confirmed that on 03/31/24 after 10:30 PM Resident #1 left the facility without the knowledge of the staff. A visitor to the facility verbally reported that a male that appeared to be a facility Resident was seen at an apartment complex talking to the police. The facility staff immediately began searching for Resident #1 and ran to the apartment complex where the police were talking to a man. Upon arriving at the apartment complex it was determined that Resident #1 had walked to the parking lot of the apartment complex located below a hillside from the facility. The staff placed Resident #1 in a staff member's vehicle and brought Resident #1 back to the facility for evaluation. The staff began assessing Resident #1 at approximately 10:50 PM upon arrival back to the facility. Resident #1 was found not to be injured and in no distress. The Resident Representative (RR) and the Nurse Practitioner for Resident #1 were contacted and told of the elopement of Resident #1. The ADM confirmed that Resident #1 had been identified upon his admission as a wanderer and a wander guard alarm was placed on his ankle for security. The ADM stated that she observed on the facility security camera that Resident #1 had left out of the kitchen's back door that had not been properly closed shut and locked. Therefore, the wander guard alarm had not sounded and no staff saw Resident #1 leave the building because the kitchen had no wander guard alarm system and there was no staff assigned to that area that late at night. An observation and interview on 04/05/24 at 9:20 A.M. with Dietary Worker #1 revealed that a push pad lock and/or keypad lock was not on the kitchen doors on 3/31/24 when Resident #1 exited the facility. The Dietary Worker #1 confirmed that a keypad lock had been placed on the three (3) doors in the kitchen on 04/01/24. During an interview on 04/05/24 at 9:30 AM, with the Assistant Director of Nursing (ADON) who was the interim Director of Nurses (DON), revealed that she understood that the kitchen door was not properly shut which allowed Resident #1 to leave undetected out the back kitchen door on 03/31/24 after 10:30 P.M. The ADON confirmed that Resident #1 was identified and care planned as a wanderer and he wore a wander guard alarm on his ankle. During an interview on 04/08/24 at 3:15 PM with Certified Nursing Assistant (CNA) #3 revealed that she worked 3:00 PM - 11:00 PM on 03/31/24. She stated that as soon as she was told that Resident #1 was missing from the facility, she began to look inside and outside of the facility for Resident #1. She stated that a visitor reported that they thought they saw a Resident talking to the police in the parking lot of the apartment complex that was located down a hill from the facility. She immediately went outside and saw a man in a white T-shirt standing in the parking lot of the apartment complex talking to police. CNA #3 and two (2) other staff ran down the hill and found Resident #1. They told the police that he was a resident of the facility and the police released Resident #1. CNA #3 and CNA #4 along with the Registered Nurse (RN) Supervisor (RN #1) placed Resident #1 in their personal vehicle and returned him to the facility. Resident #1 remained calm and did not reveal any distress. Resident #1 told the facility staff that he would go where he wanted to and do what he wanted to because he was a grown man. CNA #3 stated that Resident #1 was a known wanderer and that he would often wander in and out of other Residents rooms and all about the facility hallways. CNA #3 stated that Resident #1 wore a wander guard alarm on his ankle since his admission to the facility. An interview on 04/08/24 at 3:30 PM with RN #1 Supervisor, revealed that she was told at approximately 10:40 PM that Resident #1 was missing from the facility and the staff had not seen Resident #1 since 10:30 PM. RN #1 stated that a friend of a staff member reported that he had seen a Resident in the parking lot of a nearby apartment complex talking to police. RN #1 and 2 other staff members took off running down the hill to the apartment complex to look for Resident #1. He was in the parking lot of the apartment complex talking to the police, and RN #1 told the police that he was a resident of the facility and that she would take him back to the facility for evaluation where she was the Nurse Supervisor. Resident #1 got into RN #1's vehicle and came back with her for evaluation without any incidents. RN #1 stated that Resident #1 was thoroughly assessed, and no injuries or distress were found. RN #1 stated that the Director of Maintenance found that the kitchen doors were not properly closed and had not been locked and Resident #1 had left the facility out the kitchen door. During an interview on 04/08/24 at 3:50 PM, with the Maintenance Director revealed he had been called to the facility at approximately 11:00 PM and immediately went to the facility and began assessing how Resident #1 left the facility without staff knowledge. The Maintenance Director stated he found that the door to the kitchen had not been properly shut and was not locked. He immediately reported his findings to the facility Administrator and to the RN Supervisor. He made sure the facility was secure, the wander guard alarm system was properly working and safe before he left the facility the night of 03/31/24. During an interview on 04/08/24 at 4:10 PM, CNA #4 revealed that he worked 3:00 PM - 11:00 PM on 3/31/24. He was assigned to the care of Resident #1. CNA #4 stated that he saw Resident #1 walking in the hallway at approximately 10:30 PM and had redirected him to his room. CNA #4 stated that walking and wandering about the facility was a regular occurrence for Resident #1. Resident #1 usually wandered about the facility, and he wore a wander guard alarm around his ankle because he had a tendency to wander. At approximately 10:40 PM, CNA #4 received word that Resident #1 was missing from the facility and the entire staff began looking for Resident #1. CNA #4 stated that he, CNA #3 and the RN Supervisor found Resident #1 approximately 200 yards off the facility grounds, down a hillside from the facility at an apartment complex. CNA #4 stated that Resident #1 told the staff that he would go where he pleased because he was a grown man and could take care of himself. Interview on 04/08/24 at 5:15 PM, with the Resident Representative (RR) of Resident #1 revealed Resident #1 had been living with family prior to his admission to the facility and he had made numerous attempts to elope and to wander away without supervision. The RR stated that the reason for Resident #1's admission to the facility was due to his wandering and resistance to care. He reported that the family was up-front with the facility about Resident #1's tendency to wander. He stated the family was unable to provide the level of supervision in their home that Resident #1 required. The RR stated that on 03/31/24 very late at night, a message had been left on his voicemail that Resident #1 had eloped. The RR stated that on 04/01/24 he came to the facility first thing in the morning to inquire as to what had happened and he agreed to have Resident #1 evaluated by the Behavioral Hospital unit. An interview on 04/09/24 at 10:00 AM with the ADM, revealed Resident #1 was admitted to a Behavioral Health facility for evaluation and that he would return to the facility. The ADM stated that on the night that Resident #1 eloped he was wearing a white T-shirt, tennis shoes, and gray sweatpants. The weather was clear and mild, and the temperature was in the low 60's. The elopement occurred on 3/31/24 at approximately 10:40 PM Observation on 04/09/24 at approximately 10:30 AM, by the SA revealed that the distance off the facility grounds to the apartment complex parking lot was approximately 200 yards from the facility and down a steep hillside. Record review of the Admission Record for Resident #1 revealed that he was admitted to the facility on [DATE] with diagnoses that included Senile Degeneration of the brain, Dementia, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait or Mobility, Lack of Coordination, and Cognitive Communication Deficit. Record review of the Elopement Risk Evaluation dated 02/14/2024 revealed that Resident #1 was an elopement risk and had a history of wandering or elopement prior to his admission to the facility. The Narrative revealed Patient is a new admission. Patient states he need to get out of here to go home. Record review of the Elopement Risk Evaluation dated 04/03/2024 revealed Narrative: Resident continues to walk from East to [NAME] in the center. He continues to talk about his vehicle and he needs to find it. Wander Guard in place. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/24 revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 8, which implicated that Resident #1 had moderate cognitive impairment. Record review of the Progress Note for Resident #1 written by the facility Nurse Practitioner (NP) dated 04/01/2024 at 22:59 (10:59 PM) revealed Patient is seen today for f/u (follow-up) on nurse report of elopement. He is laying in bed calm and cooperative with examination. No injuries noted. He denies having any pain. No grimacing noted during exam. He continue to be confused. Respond inappropriately to all orientation question except name. He is a/o x 1(alert and oriented times one). Staff is concurrently working to find appropriate facility for Resident. Family has been notified of current poc (plan of care). The facility implemented that following Corrective Action Plan prior to the State Agency (SA) entering the building on 04/05/24: On 03/31/24 at approximately 10:50 PM Resident #1 was assisted back to the facility via facility staff personal vehicle. Resident #1 was thoroughly assessed head to toe by RN #1 and no adverse injuries/incidents were found. RN #1 contacted the RR; the Medical Director (MD); the facility Administrator; the facility ADON; and placed Res #1 on one to one (1:1) close observation by facility staff. The elopement risk assessment was updated for Resident #1 and the care plan was revised. The elopement book kept at the nursing station was reviewed and updated. Facility staff conducted room to room audits of all residents in the building to ensure safety. The facility conducted a Quality Assurance (QA) meeting with the Medical Director (MD) in attendance via telephone on 04/01/24 at 8:00 A.M. An elopement drills were conducted on 3/31/24 and 4/01/24 and every day since the incident of 03/31/24 on all three (3) shifts. All residents with wander guard bracelets were checked for functionality and positioning on each shift. The ADM and the ADON began in-services on 04/01/24 of all staff on elopement protocol; wander guard monitoring; and Abuse and Neglect. All doors and windows were checked for for proper functioning and operation. ADM began an investigation to determine how Res #1 eloped. ADM called the incident in to the Mississippi State Department of Health (MSDH) office 04/01/2024 at 6:00 P.M. Resident #1 was placed on 1:1 close observation on 03/31/24 immediately upon his return to the facility at 10:50 PM on 03/31/24 and remained on 1:1 by staff until his transfer on 04/02/24 at 12:00 noon. There was a staff member placed at the front door to monitor the entrance and exits of the building and the staff would remain at the front door 24/7 until the new wander guard alarm system was installed on 04/01/24. No staff were allowed to work until they were in-serviced on elopements; Abuse/Neglect; and monitoring of wander guard systems. Immediate Actions: At 10:50 PM on 03/31/24 the RN#1 notified the ADM; the ADON; the Maintenance Director; the RR and the MD; and the Nurse Practitioner; via telephone of the elopement of Res #1. At 10:50 PM on 03/031/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. Upon return to the facility RN #1 assessed Res #1 from head to toe and found no injuries or incidents. Beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors. On 03/31/24 at 10:50 PM four (4) residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place. No negative findings were identified on 3/31/24. On 03/31/24 at 10:50 P.M. RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Res #1. On 03/31/24 at 10:30 PM staff In-services were begun by RN#1 and the ADM; and the ADON, to include all staff on Elopement Protocols, Wander Guard checks; and Abuse/Neglect with no staff allowed to work until in-services were completed. On 04/01/24 at 8:00 A.M. a QA meeting was held via telephone with the MD. The DON; the Maintenance Director; the Dietary Director; ADM; MDS/Care Plan Nurses x 3 were present; along with the Social Worker; and QA/Infection Control Nurse. All members of the QA committee were in attendance via telephone. On 03/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding. It was discovered that Resident #1 exited the facility through the kitchen doors, which had not been properly shut and did not contain an alarm, causing Resident #1 to leave the facility unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pads and alarms and locks to the kitchen doors x 3. The doors were also monitored by a staff member 24/7 until the wander guard system was installed on the kitchen doors. On 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. All corrective actions were completed on 04/01/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 4/02/24. Validation: The State Agency (SA) completed the validation for the facility's Past Non Compliance (PNC) Corrective Action Plan on 04/09/24. The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 RN #1 notified the ADM, the ADON, Maintenance Director, the RR and the MD via telephone of the elopement of Resident #1. The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. The SA validated through interviews and record reviews that upon return to the facility RN #1 assessed Resident #1 from head to toe and found no injuries or incidents. The SA validated through observations, record reviews, and interviews that beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning on all doors including the kitchen doors. The SA validated through observations, record reviews and interviews that on 03/31/24 at 10:50 PM four (4) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 03/31/24. The SA validated through record reviews and interviews that on 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements of the Elopement of Resident #1. The SA validated through interviews and record reviews that on 03/31/24 at 11:30 PM staff in-services were initiated by RN #1, the ADON and the ADM to include all staff on Elopement Protocols, Wander Guard checks and Abuse/Neglect with no staff allowed to work until in-services were completed. The SA validated through interviews and record reviews that on 04/01/24 at 8:00 AM a Quality Assurance (QA) meeting was held via telephone with the MD. The ADON, ADM, MDS/Care Plan Nurses x 3, Maintenance Director, Dietary Manager; Social Worker, and the QA/Infection Control Nurse were present. All members of the QA committee were in attendance via telephone. The SA validated through interviews, and record reviews, and review of vendor receipts that on 04/01/24 the Maintenance Director staff checked the functioning of the wander guard alarm system and found that there were three doors in the kitchen area that had not been properly shut and locked. It was discovered that the kitchen doors were not shut properly and the alarm did not sound when Resident #1 exited the facility through the kitchen unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pad locks to the kitchen doors. The doors were monitored by a staff 24/7 until the wander guard system was installed on the kitchen doors. The SA validated through interviews and record reviews that on 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 04/01/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 04/02/24.

Based on staff interview, facility policy review, facility statement review and record review, the facility failed to implement an elopement/wandering risk plan of care for Resident #1 who had worn a wander guard since his admission on February 12, 2024. Resident #1 had a documented history of wandering and elopement attempts prior to his admission to the facility. Resident #1 was one (1) of four (4) residents identified by the facility, who were at risk for elopement and that wore a wander guard. On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. No facility staff saw resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 10:40 PM when they received a verbal report from a friend of a staff member that Resident #1 was at an apartment complex parking lot, off the facility grounds, talking to the police. Resident #1 was returned to the facility via personal vehicle by a facility staff at approximately 10:50 PM on 03/31/24. The facility's failure to provide supervision resulted in Resident #1's elopement and has the likelihood to result in serious harm, serious injury, serious impairment, or death for Resident #1 and all other cognitively impaired residents who leave the facility unsupervised. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 3/31/24 and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 03/31/24 through 04/01/24, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 04/02/24, prior to the SA's entrance on 04/05/24. Findings Include: Record review of a statement on facility letterhead revealed Policy: Care Plans and MDS (Minimum Data Set) will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. The most recent effective date was August 2019. Record review of the facility's undated policy titled Missing Resident/Elopement revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements. Process . If an elopement risk is determined an individual plan is established and intervention is initiated to mitigate that risk. When the nurse identifies the intervention it is documented on the care plan and on the caregiver guide . Record review of the Care Plan for Resident #1 with an initiation date of 2/12/24 revealed Focus: At risk for elopement related to Wandering .Interventions: .Check Placement and function of Wander Guard to Left Ankle every shift .Redirect patient from doors . Record review of the March 2024 Medication Administration Record (MAR) revealed Check Placement of Wander Guard to Left Ankle every shift for Elopement Risk. The MAR documentation revealed there were 11 times on day shift, 10 times on evening shift and seven (7) times on night shift that N was documented, indicating No, that the wander guard for Resident #1 had not been checked. Interview on 04/05/24 at 9:10 AM, with the facility Administrator (ADM) confirmed that Resident #1 had been identified upon his admission as a wanderer and a wander guard alarm was placed on his ankle for security. Interview on 04/05/24 at 9:30 AM with the Assistant Director of Nursing (ADON) who was the interim Director of Nurses (DON), revealed that she understood that the kitchen door was not properly shut which allowed Resident #1 to leave undetected out the back kitchen door on 03/31/24 after 10:30 P.M. The ADON confirmed that Resident #1 was identified and care planned as a wanderer and he wore a wander guard alarm on his ankle. Interview and record review of Resident #1's care plan on 04/09/24 at 8:45 AM with the MDS/ Care Plan nurse (RN #2), revealed that she had completed the MDS and the Care Plan for Resident #1 upon his admission on 02/12/24 and had made care plan revisions on 04/01/24. RN #2 confirmed that she made elopement revisions to the care plan of Resident #1 on 04/01/24 after he had eloped on 03/31/24. Record review of the Admission Record for Resident #1 revealed that he was admitted to the facility on [DATE] with diagnoses that included Senile Degeneration of the brain, Dementia, Muscle Weakness, Unsteadiness on Feet, Abnormalities of Gait or Mobility, Lack of Coordination, and Cognitive Communication Deficit. The facility implemented that following Corrective Action Plan prior to the State Agency (SA) entering the facility on 04/05/24: On 03/31/24 at approximately 10:50 PM Resident #1 was assisted back to the facility via facility staff personal vehicle. Resident #1 was thoroughly assessed head to toe by RN #1 and no adverse injuries/incidents were found. RN #1 contacted the RR; the Medical Director (MD); the facility Administrator; the facility ADON; and placed Res #1 on one to one (1:1) close observation by facility staff. The elopement risk assessment was updated for Resident #1 and the care plan was revised. The elopement book kept at the nursing station was reviewed and updated. Facility staff conducted room to room audits of all residents in the building to ensure safety. The facility conducted a Quality Assurance (QA) meeting with the Medical Director (MD) in attendance via telephone on 04/01/24 at 8:00 A.M. An elopement drills were conducted on 3/31/24 and 4/01/24 and every day since the incident of 03/31/24 on all three (3) shifts. All residents with wander guard bracelets were checked for functionality and positioning on each shift. The ADM and the ADON began in-services on 04/01/24 of all staff on elopement protocol; wander guard monitoring; and Abuse and Neglect. All doors and windows were checked for for proper functioning and operation. ADM began an investigation to determine how Res #1 eloped. ADM called the incident in to the Mississippi State Department of Health (MSDH) office 04/01/2024 at 6:00 P.M. Resident #1 was placed on 1:1 close observation on 03/31/24 immediately upon his return to the facility at 10:50 PM on 03/31/24 and remained on 1:1 by staff until his transfer on 04/02/24 at 12:00 noon. There was a staff member placed at the front door to monitor the entrance and exits of the building and the staff would remain at the front door 24/7 until the new wander guard alarm system was installed on 04/01/24. No staff were allowed to work until they were in-serviced on elopements; Abuse/Neglect; and monitoring of wander guard systems. Immediate Actions: At 10:50 PM on 03/31/24 the RN#1 notified the ADM; the ADON; the Maintenance Director; the RR and the MD; and the Nurse Practitioner; via telephone of the elopement of Res #1. At 10:50 PM on 03/031/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. Upon return to the facility RN #1 assessed Res #1 from head to toe and found no injuries or incidents. Beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning and new punch pad systems were installed on the kitchen doors. On 03/31/24 at 10:50 PM four (4) residents with risks of elopement were reevaluated and updated to ensure all residents at risk for elopement had appropriate interventions in place. No negative findings were identified on 3/31/24. On 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements for the Elopement of Res #1. On 03/31/24 at 10:30 PM staff In-services were begun by RN#1 and the ADM; and the ADON, to include all staff on Elopement Protocols, Wander Guard checks; and Abuse/Neglect with no staff allowed to work until in-services were completed. On 04/01/24 at 8:00 AM a QA meeting was held via telephone with the MD. The DON; the Maintenance Director; the Dietary Director; ADM; MDS/Care Plan Nurses x 3 were present; along with the Social Worker; and QA/Infection Control Nurse. All members of the QA committee were in attendance via telephone. On 03/31/24 the Maintenance Director checked the functioning of the wander guard alarm/security system and found that the alarm was functioning properly and the alarm was sounding. It was discovered that Resident #1 exited the facility through the kitchen doors, which had not been properly shut and did not contain an alarm, causing Resident #1 to leave the facility unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pads and alarms and locks to the kitchen doors x 3. The doors were also monitored by a staff member 24/7 until the wander guard system was installed on the kitchen doors. On 04/01/24 at 6:00 PM the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. All corrective actions were completed on 04/01/24 and the facility alleged removal of the immediate Jeopardy (IJ) on 04/02/24. Validation: The State Agency (SA) completed the validation for the facility's Past Non Compliance (PNC) Corrective Action Plan on 04/09/24. The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 RN #1 notified the ADM, the ADON, Maintenance Director, the RR and the MD via telephone of the elopement of Resident #1. The SA validated through interviews and record reviews that at 10:50 PM on 03/31/24 the facility staff conducted a 100% head count of all residents to ensure they were all accounted for. All residents were found to be in the facility. The SA validated through interviews and record reviews that upon return to the facility RN #1 assessed Resident #1 from head to toe and found no injuries or incidents. The SA validated through observations, record reviews, and interviews that beginning at 10:50 PM on 03/31/24 all doors were monitored by staff 24/7 until the wander guard system was found fully functioning on all doors including the kitchen doors. The SA validated through observations, record reviews and interviews that on 03/31/24 at 10:50 PM four (4) residents with risks of elopement were re-evaluated and updated to ensure all residents for risk for elopement had appropriate interventions in place. No negative findings were identified on 03/31/24. The SA validated through record reviews and interviews that on 03/31/24 at 10:50 PM RN #1 and the ADM began officially investigating and obtaining statements of the Elopement of Resident #1. The SA validated through interviews and record reviews that on 03/31/24 at 11:30 PM staff in-services were initiated by RN #1, the ADON and the ADM to include all staff on Elopement Protocols, Wander Guard checks and Abuse/Neglect with no staff allowed to work until in-services were completed. The SA validated through interviews and record reviews that on 04/01/24 at 8:00 AM a Quality Assurance (QA) meeting was held via telephone with the MD. The ADON, ADM, MDS/Care Plan Nurses x 3, Maintenance Director, Dietary Manager; Social Worker, and the QA/Infection Control Nurse were present. All members of the QA committee were in attendance via telephone. The SA validated through interviews, and record reviews, and review of vendor receipts that on 04/01/24 the Maintenance Director staff checked the functioning of the wander guard alarm system and found that there were three doors in the kitchen area that had not been properly shut and locked. It was discovered that the kitchen doors were not shut properly and the alarm did not sound when Resident #1 exited the facility through the kitchen unsupervised and undetected. The vendor came to the facility on [DATE] and installed new punch pad locks to the kitchen doors. The doors were monitored by a staff 24/7 until the wander guard system was installed on the kitchen doors. The SA validated through interviews and record reviews that on 04/01/24 at 6:00 P.M. the ADM contacted the SA and the MS Attorney General's Office (AGO) to report the elopement of Resident #1. The SA validated through observations, record reviews, and interviews that all corrective actions were completed on 04/01/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 04/02/24.

Based on resident and staff interview, record review, and facility policy review, the facility failed to develop/implement care plans for (2) two residents related to shaving Resident #90 and Resident #173; failed to ensure a call light was in reach of (1) one resident, Resident #102; failed to consult a physician for medication changes for (1) resident, Resident #15; and failed to apply a splint for (1) one of (4) four residents reviewed with assistive devices, Resident #108; for a total of five (5) residents out of 26 sampled residents. Findings include: A review of the policy titled, Comprehensive Care Plans, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #90 An observation on 10/30/23 at 11:25 AM revealed Resident #90 in wheelchair with long facial hair. Resident #90 stated he wanted to be shaved. An observation and interview on 10/31/23 at 4:38 PM with Resident #90 and Licensed Practical Nurse (LPN) #4, LPN #4 confirmed the resident stated he wanted to be shaved. Resident #90 stated he tried his best about a week ago to do it himself but just couldn't. An interview, on 11/1/23 at 11:30 AM with CNA #4 revealed that she was assigned to Resident #90 this morning. She stated that residents should be shaved on their shower days or as needed unless they refuse. She stated that when she saw Resident #90 this morning the hair on his face was ridiculous and that she shaved him first thing this morning. Review of the Admission Record resident information form revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominate side, Anxiety disorder, Restlessness and Agitation, and Anemia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/23 revealed a Brief Review for Mental Status (BIMS) score of 12 which indicated Resident #90 had moderate cognitive impairment. Resident #173 An observation, on 10/30/23 at 1:20 PM revealed Resident #173 in bed, verbally unresponsive. Resident #173's spouse was at the bedside. She stated he has not been shaved since he was admitted . She stated the staff has not offered to shave him. Resident #173's spouse stated in the past Resident #173 always shaved his face except for a mustache. An interview, on 10/31/23 at 8:15 AM with the Director of Nursing (DON) revealed the staff should offer to shave residents, this was part of the resident's daily care. An interview, on 11/01/23 at 11:29 AM with Certified Nursing Assistant (CNA) #1 revealed when they give the residents a bath or shower, they should shave them if they have hair on their face. An interview, with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) nurse confirmed Resident #90 nor Resident #173 had an Activities of Daily Living (ADL) care plan for shaving. She stated that she thought everyone should know that shaving should be a part of bathing or showering. She confirmed it should be part of the care plan. The purpose of the care plan was to let staff know what care the resident should get. An interview on 11/02/23 at 8:57 AM with the DON revealed that care plans should be in place for resident's ADL care and stated the care plan should be in place to make sure appropriate care is provided to the residents and the care plan is the staffs' communication tool for resident care. Review of the Admission Record resident information form revealed the facility admitted Resident #173 on 10/17/23 with diagnoses that included Essential Hypertension, Acute Embolism and Thrombosis of Unspecified Deep Veins of left lower extremity, Cognitive Communication Deficit, and Diabetes Mellitus Type 2. 39807 Resident #102 An observation on 10/30/23 at 10:29 AM, revealed Resident #102's call light laying on the floor underneath the bed. A review of the care plan titled, I am at risk for falls related to New environment, CVA (cerebral vascular accident) needing assist with transfer and bed mobility, impaired cardiovascular, dementia and psychotropic medication use, revised 10/31/23 revealed Call light or personal items available and in east reach. An interview with the Minimum Data Set Nurse (MDS) on 10/31/23 at 3:19 PM confirmed after review of Resident #102's care plans, staff did not follow the care plan for keeping call light in reach and revealed the purpose of the care plan is direct resident specific care. The MDS nurse stated not following the care plan could lead to resident specific care needs not being met. Record review of the Admission Record revealed that the facility admitted Resident #102 to the facility on [DATE] with diagnoses Adult Failure to Thrive and Cerebral Infarction. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 9/28/23, revealed that Resident #102 had a Brief Interview of Mental Status (BIMS) score of 06 which indicated that she was severely cognitively intact. 47157 Resident #15 A record review of Resident #15's care plan, with an onset date of 6/20/23, revealed, Focus: Resident's proper name has Diabetes Mellitus with potential for complications .Interventions .If infection is present, consult doctor regarding any changes in diabetic medications . A record review of Resident #15's Blood Sugar Summary and Medication Administration Record (MAR) for October revealed that on 10/26/23 at 5:27 AM the resident's blood sugar was 466. A record review of October Physician orders revealed an order, with a start date of 10/25/23, for Macrobid Oral Capsule 100 milligrams (MG) give one (1) capsule by mouth two times a day for Urinary Tract Infection (UTI) for seven (7) days. During an interview on 11/1/23 at 3:00 PM, the Minimum Data Set Nurse (MDS) verified that Resident #15's care plan was not followed when the nurse failed to notify the Nurse Practitioner (NP) of Resident #15's blood sugar of 466. The MDS nurse stated failure to follow the care plan could lead to a delay in treatment. A record review of Resident #15's Admission Record revealed that the resident was readmitted to the facility on [DATE]. Resident #15's active diagnoses included Type 2 Diabetes Mellitus and Urinary Tract Infection. Resident #108 An observation/interview on 10/30/23 at 10:30 AM with Resident #108 confirmed that she was unable to open her left hand and that she could not move her left arm. The resident's left hand was contracted with her thumb pressed between the second and ring finger. There was no splint in Resident #108 left hand. Record review of Care Plans for Resident #108 revealed a care plan initiated on 10/22/23 for a Restorative Splint/Brace program - Place Carrot (hand roll) in hand as often as able to tolerate. An interview, with Director of Nursing (DON) on 11/01/23 at 4:11 PM confirmed that the purpose of the care plan was to provide a structured means of providing care and communicating with other staff. The DON confirmed that failure to follow a care plan could result in providing the wrong care to a patient or not providing the care that the resident needs. A review of the facility face sheet for Resident #108 revealed the facility admitted the resident on 3/08/23 with a diagnosis of Hemiplegia to left side, Contracture of left hand, Hyperlipidemia and Hypertension A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated Resident #108 was cognitively impaired. 47158

Based on observation, resident/staff interview, record review, and facility policy review the facility failed to apply a hand splint that was recommended by Occupational Therapy to prevent worsening of a contracture for one (1) of three (3) residents with splints resulting in loss of Range of Motion (ROM) for the resident. Resident #108 Findings Include: A review of the facility policy titled, Splinting and orthotics, revealed: It is the policy of (Proper Name) Rehabilitation that therapists recommend, within their scope of practice, appropriate splinting and orthotics for patients currently receiving therapy services, as the need arises. An observation and interview, on 10/30/23 at 10:30 AM with Resident #108 confirmed that she was unable to open her left hand and that she could not move her left arm. The resident's left hand was contracted with her thumb pressed between the second finger and the ring finger. There is nothing splinting the left hand. An observation, on 10/30/23 at 1:45 PM, confirmed that the resident's left hand is contracted and had a bath cloth rolled up and placed in her hand, however the resident's thumb was not on top or around the cloth and was pressed against the palm of her hand. The resident confirmed she was unable to open her hand or move her left arm. An observation/interview, on 10/31/23 at 9:48 AM revealed Occupational Therapist (OT) was sitting at a table in the day room with Resident #108 and was performing exercises to the residents left hand. There was a Carrot Splint (circular hand splint) inside of Resident #108 left hand. OT confirmed that he was evaluating Resident #108 to possibly be admitted back to therapy for contracture management. OT confirmed that they treated the resident previously and that when they discharged her from therapy to restorative care, therapy could open the resident's left hand halfway, and left thumb was extended out. OT stated that the facility's restorative staff were supposed to place the Carrot Splint inside her left hand daily. OT confirmed that the Carrot Splint had not been being placed into Resident #108 left hand due to being misplaced. OT confirmed that the hand now has an odor and that there is a reddening between the digits where the thumb is contracted and pressing. OT confirmed that Resident #108 has a decreased range of motion (ROM) to the left hand since being discharged from Occupational therapy. An interview, on 11/01/23 at 10:45 AM with Certified Nurse Aide (CNA) #2 confirmed she was the CNA assigned to Resident #108 for the day and that she did not put a splint on the resident. CNA #2 confirmed that she was unaware of needing to put a splint on Resident #108. An interview, on 10/31/23 at 02:00 PM with Director of Nursing (DON) confirmed that Resident #108 has a contracted left hand that OT recommended a splint for the left hand and that it had not been in her hand on 10/30/23. The DON confirmed that not having a splint in the contracted hand could result in a skin integrity issue and worsening of the contracture. A record review of the OT evaluation revealed Resident #108 was admitted by OT on 8/07/23. Review of the evaluation revealed: Clinical Impressions on 8/07/23 Patient has increased contractures at L hand/digits specifically. Since the last treatment period, seems from OT opinion that hands have become more contracture to the point where fingers are digging in palm which is causing deficits with skin breakdown and joint integrity and overall hygiene within the hand. Record review of OT discharge summary revealed Resident #108 was discharged from Occupational Therapy on 8/31/23 with Occupational Therapy documentation revealing that the patient is tolerating wearing splint for up to 8 hours without any complaints of pain and skin integrity intact with no redness or swelling. The discharge recommendations were for Restorative Program = Restorative Splint and Brace Program. A review of an OT evaluation dated 10/31/23 revealed OT readmitted the resident back to therapy with the following Clinical Impressions: Based on clinical assessment and analysis of the documented physical impairments and functional deficits: patient has severe contracture of left hand, due to non-compliance with past splinting schedule. A review of the facility face sheet for Resident #108 revealed that she admitted to the facility on [DATE] with a diagnosis of Hemiplegia to left side, Contracture of left hand, Hyperlipidemia and Hypertension A review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/23 revealed a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated Resident #108 was cognitively impaired.

Based on observations, interviews, and record review, the facility failed to follow the Center for Disease Control and Protection (CDC) guidelines for the use of face masks in a healthcare setting to prevent pathogen transmission in response to COVID-19 observed on two (2) of three (3) units, and also failed to communicate and report employee COVID-19 test results to positive employees in order to quarantine and prevent further COVID-19 exposure to other residents and staff throughout the building for 25 days, for two (2) of 27 employees positive for COVID-19, which potentially affected all residents and employees at the facility. On [DATE], the State Agency (SA) identified the facility had a total of two (2) positive COVID-19 employees who were not informed of their positive test results due to the delay from the Administrator to obtain the test results from the Mississippi State Department of Health laboratory. These two (2) employees worked with symptoms never quarantined, and potentially exposed 135 team members and 105 residents who were not previously COVID-19 positive. The facility's failure to follow appropriate COVID-19 infection control guidelines for wearing Personal Protective Equipment (PPE) and the failure to notify staff of positive COVID-19 lab results, had caused, or likely to cause serious injury, harm, impairment or death to residents and staff. The SA identified an Immediate Jeopardy (IJ) on [DATE], and determined the IJ existed on [DATE], when the first positive COVID-19 employee was identified at the facility by the MSDH lab. The facility had a total of two (2) employees positive for COVID-19, who had not been informed of their positive test results due to the delay by the Administrator to obtain the lab results from the MSDH lab. These two (2) employees worked with symptoms and was never quarantined. The facility was notified of the Immediate Jeopardy (IJ) on [DATE] at 11:13 AM, and an IJ template was provided to the interim Administrator. The IJ existed at: 42 CFR(s): 483.80(a)(1)(2)(4)(e)(f) - Infection Prevention and Control (F880) The SA validated the facility's Removal Plan and the IJ was determined to be removed on [DATE] prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.80(a)(1)(2)(4)(e)(f)-Infection Prevention and Control (F880) was lowered from a L to a scope and severity of a F, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's, COVID-19 Education, Prevention, and Response Guide policy, dated [DATE], revealed: Ensure all staff are using appropriate PPE (Personal Protective Equipment) when they are interacting with patients and residents. All long-term care facility personnel should wear a facemask and eye protection while they are in the facility. Cloth face coverings are not considered PPE because their capability to protect healthcare personnel is unknown. To ensure patient/resident safety and to comply with Center for Medicare and Medicaid Services (CMS) guidance, implement active screening of residents and staff for fever and respiratory symptoms. All individuals permitted entry to our centers are required to adhering to the preventions and precautions in place to ensure the safety and well-being of our patients, residents, and team members. Team members in our center should wear facemask at all times. Notify all team members working in the center any time a single new COVID-19 case is confirmed among resident or staff or any time three or more residents or staff have new onset respiratory symptoms within a 72-hour period. Record review revealed, the National Guard conducted a facility wide COVID testing on [DATE], for 100% of residents and 100% of the employees. During an observation and interview, at 10:10 AM on [DATE], Licensed Practical Nurse (LPN) #2 was observed on the West Wing of the facility, in the hall, administering medications without a mask on. LPN #2's mask was observed her lying on her medication cart. An interview with LPN #2, confirmed that she wasn't wearing her mask. LPN #2 stated, I have trouble wearing it because of my size but I'll get it on. LPN #2 confirmed she was aware that she should have her mask on at all times. She also confirmed that she had not received her COVID test results from the facility wide testing on [DATE]. An observation, on [DATE] at 10:15 AM, revealed, LPN #1 was in the hallway by the nurses' desk with a cloth mask pulled down under his chin, not covering his mouth and nose, and he was talking within a foot of two other employees. LPN #1 was also observed, on [DATE] at 1:30 PM, at the nurses' desk, on the East Hall, with his mask down around his neck. The State Agency (SA) asked him why he wasn't wearing his mask, and he stated, They told us that we didn't have to wear our mask when we were at the nurses desk charting. An observation made of the East Hall nurses' desk, revealed it was an open desk area that has no windows or doors, and was in the open common area where staff and residents are in close proximity to this nurses' desk, with some less than six (6) feet away. Another staff member was also sitting at the nurses' desk within less than six (6) feet from this LPN. LPN #1 also confirmed that he was not wearing his mask properly on [DATE] to cover his mouth and nose and that he wears it pulled down below his chin often while he is working. During an interview, at 10:00 AM on [DATE], the Administrator confirmed the facility was COVID free, and that the facility didn't have any positive tests when the facility wide testing was completed on [DATE]. The Administrator stated he had some test results still pending from the National Guard testing that occurred on [DATE], but he was not sure of the exact number of tests that the facility had pending. The Administrator stated, It doesn't matter anyway, we are past our 14 days, so I'm not worried about it. An interview, on [DATE] at 10:30 AM, with LPN #3, revealed, she stated that she had just found out her COVID results on [DATE]. She stated that she had to call the State lab office and obtain her COVID test results and she was negative. LPN #3 stated the staff had asked the Director of Nursing (DON) for their results, and she told them that the Administrator was handling all of the test results and she didn't have them. LPN #3 stated she asked the Administrator and he would always just say he had not got them yet. LPN #3 stated that Resident #1 had asked the Administrator several times for her results, but he has not told the residents their results yet either. An interview, at 10:40 AM on [DATE], with Resident #1, who had a Brief Interview for Mental Status (BIMS) score of 15, revealed, she stated she hadn't been told her results. She stated, It bothers me that I've not been told something. I've asked the Administrator and he told me don't worry about it because it has been over 14 days, but I do worry about it, I want to know something. During an interview, at 10:50 AM on [DATE], with Certified Nursing Assistant (CNA) #1, she stated, He (Administrator) said don't worry about it that the test results weren't any of our business and that it had been past 14 days anyway. CNA #1 stated that she had children at home, and she wanted to know if she had it or was working with people that may have it, but he said it was none of their business. An interview, on [DATE] at 11:15 AM, with CNA #2, revealed, she stated that she had not received her test results back from the [DATE] facility wide testing. On [DATE] at 11:25 AM, during an interview, with the Rehab Director, she confirmed that she had received her test results back on [DATE]. She stated, I know some people are still waiting on their results. An interview, on [DATE] at 11:45 AM, with the Infection Control Nurse/Assistant Director of Nursing (ADON), revealed, she stated that she was unable to confirm the numbers for the positive residents and positive employees in the building. She confirmed that she had not had access to the test results or the numbers of pending tests, because the Adm had been handling this outbreak. She stated this was the facility's second outbreak, and on the first outbreak, she, and the Director of Nursing (DON) completed all the facility wide testing and logged all the results. The ADON stated they knew how many residents and employees were positive, but on this second outbreak, they had not been given the information on the pending tests or the results. The DON confirmed this information and stated it had been very hard to keep up with because they were not given this information from the Administrator. The DON and ADON revealed they were told that they did not have any positive COVID residents or employees in the building. They stated that on [DATE], they had Resident #2 return from Geri-psych, and she tested negative at the hospital prior to admission, but began to have symptoms and tested positive on [DATE] at the facility. Resident #2 was discharged on [DATE] to the hospital because of elevated temperature and change in level of consciousness. They revealed this was the only positive resident that the facility had. They stated that they assumed all the test results were negative because they had not heard anything from the lab. Review of Resident #2's closed medical record, revealed, the resident was admitted to the facility on [DATE] from a Geri-psych facility, and had tested negative for COVID-19 prior to her discharge to the facility. Resident #2 was admitted by the facility, with [DIAGNOSES REDACTED]. Resident #2 began to have difficulty breathing, had a low oxygen level, and a change in level of consciousness. Resident #2 was sent to the Emergency Department on [DATE] at 7:44 AM and was retested for COVID-19 at the hospital on [DATE] at 8:37 AM. Resident #2 tested positive for COVID-19 via rapid test. The hospital admitted the resident and she died at the hospital on [DATE]. On [DATE] at 12:15 PM, during an interview, the Administrator stated they had not received all of the test results back from the facility wide testing on [DATE]. The Administrator confirmed that he had called multiple times to the lab, and they told him that the results were still pending. The Administrator stated, I've called every day, mine is one of the tests that we are still waiting on, but I'm not worried about it now, we are past our 14 days, so it don't matter. The Administrator confirmed, the facility was waiting on 58 staff test results and 42 residents' test results. The Administrator stated that for both outbreaks, so far, the facility has had 21 positive residents, 25 positive employees and three (3) deaths. The Administrator stated this outbreak started with a resident admission from Geri-psych facility on [DATE], and the resident went to the hospital and expired there, making the facility deaths at three (3). The State Agency (SA) informed the Administrator, DON and ADON that they had observed staff on the hallways not wearing mask. The Administrator stated, That's unacceptable, tell me the names of the employees, and I'll go write them up right now. The Administrator was asked by the SA why he didn't have a mask on, and he stated, I'm staying six (6) feet away. The Administrator was observed sitting less than six feet away from another employee and the SA surveyor, without a mask on. During an interview, with the DON and ADON, on [DATE] at 12:20 PM, the DON stated, We have in-serviced until we are blue in the face about the staff wearing their masks. The ADON and DON stated they could guess the two (2) employee names that were not wearing their masks. They stated it was LPN #1 and LPN #2 that the SA saw in the hallway not wearing a mask. They confirmed that they have had multiple discussions with these two employees regarding face coverings, and they still refuse to wear them. The SA asked if these employees had 1:1 in-services or disciplinary actions, and the DON stated that she wasn't sure, but she would have to check to see. Review of the facility's in-services, indicated that the last in-service LPN #1 attended was a group in-service on [DATE], titled COVID-19 Update, which covered wearing a mask. The last in-service LPN #2 attended was a group in-service on [DATE], titled COVID-19 which covered staff wearing mask during their shift. The ADON, who also serves as the Education Nurse, confirmed, these were the last in-services these two (2) employees attended and stated, I thought we had in-serviced them recently, but I couldn't find it. During an interview, at 12:40 PM on [DATE], the Administrator revealed to the SA, that he had just received a package of test results in the mail. The SA reviewed the envelope and observed it had a postmark date of [DATE] on the package and was mailed from Mississippi State Department of Health (MSDH). The package contained employees' COVID test results that were negative. The SA asked the Administrator to contact the MSDH lab and check to see if the 100 pending COVID lab test results from [DATE] were completed. An interview with the Receptionist, on [DATE] at 1:00 PM, she stated the facility had received two (2) big manila envelopes and one (1) small white envelope package from the MSDH lab. She confirmed that she knew they were the test results because she saw the address and knew that they were from the lab. The Receptionist stated she had handed the packages to the Administrator right away. She confirmed the first big, yellow manila package came on [DATE] and stated, I remembered the date because the first week of August we started getting phone calls from families saying that they had gotten an automated call that we had positives in our building. An interview with the ADON, on [DATE] at 1:40 PM, revealed, she stated, The facility has an automated alert system that notifies families if we have a positive COVID in the building, we email the alert system and it notifies them (families). The ADON stated that around [DATE] the Administrator began handling all the lab results from the COVID test and the notification of the residents and staff. The ADON stated the Administrator told her that he was handling it (lab results) because she was having to perform multiple roles right now because staff have been out sick or have quit. The ADON stated, I am doing the schedule for all the nurses and CNAs, I am the Director of Clinical Education, the Infection Control Nurse and the ADON, so I was overloaded. I would ask him about the test results, and he would say he didn't have any. During an interview, on [DATE] at 8:15 AM, the SA spoke with the Administrator to see if he had made contact with the MSDH lab and to find out if the pending COVID test results from [DATE] were received, and he stated, No, I called but they couldn't tell me anything. On [DATE] at 8:35 AM, the SA contacted the MSDH lab via speaker phone with the facility's Administrator and two (2) Corporate Nurse Consultants present for the conference call and spoke with a Lab Call Center for COVID-19 Employee #1. Employee #1 stated that the facility's Administrator had contacted the Lab Call Center for COVID-19 on [DATE] inquiring about the facility's COVID-19 lab results and she had informed him that he had failed to complete the HIPAA Right to Fax, form that was emailed to the facility in [DATE] in order to receive his test results from the lab immediately after each lab test was processed. She stated the Lab Call Center Supervisor had also called the facility in an attempt to get the form completed and was unsuccessful. Employee #1 stated due to the fact that the Administrator never responded to their attempts, the test results were mailed to the facility on [DATE]. She stated the facility had two (2) COVID positive employees, nine (9) employees whose test were unsatisfactory and needed to be recollected, and that they had four (4) residents COVID test results that were unsatisfactory and needed to be retested . She stated all this information was mailed to the facility on [DATE]. Employee #1 also stated that the facility's Administrator did not complete the Health Insurance Portability and Accountability Act (HIPAA) form to have COVID test results faxed to the facility through the Information Technology (IT) department in March (2020). She stated the IT department sent an email to the Administrator in March (2020) and also called the facility after the HIPAA form was not completed and due to the fact that this process was never completed the test results must be mailed. She revealed, if the facility would have completed the HIPPA Right to Fax Process, then they would have received their test results immediately like all the other facilities in the state. The MSDH Lab Call Center Employee #1 reviewed the recorded call log back to [DATE] and there were not any calls received from the facility inquiring about their COVID-,[DATE] test results. The Supervisor at the COVID Call Center confirmed the lab did not have any documentation on the call center log that this facility had notified them in an attempt to receive their COVID-19 lab results until [DATE] at 2:30 PM. The COVID Lab Call Center works seven (7) days a week to report COVID test results to the facilities. They stated the lab results are sent out three (3) times a day, and the notification date was on the lab results. They confirmed that the facility's Social Worker (SW) and Human Resource (HR) Officer were both positive for COVID-19, and their positive COVID test results were sent to the facility by mail on [DATE]. The MSDH Lab Call Center Employee #1 confirmed there was only one phone number to call to obtain results, and he (Administrator) would have talked to her or other call center employee (common name). She stated they had not heard anything from the Administrator until he called yesterday. The Lab Call Center for COVID-19 obtained a fax number from the facility's Administrator, while on the conference call, and faxed the test results to the facility of the positive COVID employees that had previously been mailed to the facility. Review of the MSDH Lab report, for the facility's Social Worker (SW), indicated the test was performed on [DATE] and positive test results were received by the lab on [DATE] at 9:38 AM. The results were mailed to the facility on [DATE]. The lab results for the Human Resource (HR) Officer, indicated the COVID test was performed on [DATE], and the positive test results were received by the lab on [DATE] at 9:35 AM. The results were mailed to the facility on [DATE]. On [DATE] at 9:20 AM, during an interview with the Human Resource (HR) Officer, she confirmed, the Administrator told her just a few minutes ago that she had tested positive on [DATE] from the COVID-19 test three (3) weeks ago. The HR Officer stated that she had a migraine and sinus allergies [REDACTED]. The HR Officer confirmed that she had her temperature checked every morning and used the sign and symptoms sheet to check in every morning. She revealed that she did not mark that she had a headache or runny nose. The HR Officer stated, I didn't think anything of it. In the last three (3) weeks, I have went to residents' rooms and delivered items that family members had dropped off and I have also completed three (3) new hire orientations, and I have conducted two (2) interviews. The Administrator said it had been over 14 days when I asked if I needed to leave. Review of the Diversicare Team Member daily sign-in sheet and Diversicare Time and Expense logs, revealed, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the facility's Social Worker and Human Resources Officer were clocked in and working, had signed in for these days and had marked No on the section of the symptoms sheet that indicated, At least two (2) of these symptoms: fever or chills, repeated shaking with chills, headache, new loss of taste or smell, diarrhea, congestion or runny nose, muscle or body aches, sore throat, nausea or vomiting and fatigue. On [DATE] at 10:00 AM, an observation of the Minimum Data Set (MDS) office, revealed, four (4) employees sitting in the MDS/SW office without masks on, with two (2) of the employees within two (2) feet of each other working daily. The employees were the facility's Social Worker and MDS Nurse #4. During an interview, with the Social Worker, on [DATE] at 10:05 AM, she confirmed that she had received her COVID-19 positive test results just a few minutes ago from the facility wide testing on [DATE]. She stated, I didn't know anything until today. I assumed I was negative because I hadn't heard anything. I always have headaches and I have sinus stuff, but I didn't think I had COVID. We were told that we (the facility) were COVID recovered on [DATE]. I went into Resident #2's room, but they said she was negative. I go into the residents' rooms daily for their social needs, to let them Face Time family members and to complete my psychosocial assessments. The Social Worker confirmed that her desk and MDS Nurse #4's desk are very close and are within less than six feet of each other, and that they were not wearing mask while working in their offices. On [DATE] at 10:15 AM, during an interview, with MDS Nurse #4, she stated that she does not wear her mask when she is sitting at her desk. She confirmed that she works daily at a desk that is less than six feet from her co-worker, who just received her test results that she was COVID positive. The MDS Nurse #4 stated, she assumed that she was negative. She stated, I have not received my test results from the facility wide testing on [DATE]. I have asked about them, but we were told that they haven't came in yet. During an interview, with the Corporate Nurse Consultant, on [DATE] at 10:25 AM, stated that they were going to conduct another facility wide testing of residents and employees today due to the Administrator's delay in obtaining the COVID test results and that they have completed the HIPPA Right to Fax with the MSDH so that they can obtain the test results immediately when they have another National Guard facility wide testing event or when their test results go to the MSDH COVID Lab. An interview with the Lab Call Center for COVID-19 Employee #1, on [DATE] at 11:00 AM, she confirmed, that since the facility did not complete the proper information to have the test results faxed to the facility, they were mailed from the lab department in manila folders to the facility. Employee #1 stated, He (Administrator) called yesterday for the first time and wanted the facility's lab results and I told him that they were mailed because he had not completed the proper information for the test results to be faxed to him. I asked him if he wanted to complete the process now and he said no. The SA informed Employee #1 that the Administrator stated that he had called daily since [DATE] for the COVID test results. Employee #1 stated, It's just me and another lady (Employee #2) here and we work this line every day, seven (7) days a week. I have reviewed the call logs and he has not called here until yesterday ([DATE]) at 2:30 PM to ask for the facility's COVID test results. The SA spoke with the Lab Call Center for COVID-19 Employee #2, on [DATE] at 11:25 AM, and she confirmed what Employee #1 stated regarding there had not been any calls from the facility until [DATE] to request COVID lab results. On [DATE] at 12:30 PM, during an interview, with the Corporate Nurse Consultant, she stated the Administrator had been suspended and was sent home pending an investigation into this incident. She stated the facility had requested 220 COVID test swabs and would begin testing 100% of the employees and residents today ([DATE]). An interview with the ADON, on [DATE] at 1:30 PM, she stated, During our May outbreak, I tested all the employees and residents. When the lab posted them on-line, we (ADON and DON) would check it daily and notify and isolate the residents and the staff. Then, when this outbreak occurred on [DATE], the Administrator said that he would handle all the testing and the Infection Control log because I was doing so many jobs. The National Guard came on [DATE] and tested everybody and I never saw any results. Me and the DON would ask him (Administrator) and he would say he didn't have any results. Everybody was asking about their results and the residents were wanting to know as well. During an interview, with the DON, on [DATE] at 10:15 AM, she stated LPN # 1 and LPN #2 had received a verbal correction for not wearing their mask, but that she could not find the documentation for it. The DON stated, We have had to stay on those two (LPN #1, LPN #2) constantly about wearing their mask. We allowed them to wear their own cloth mask, but they were responsible for cleaning their cloth masks and the employees who chose to wear the cloth mask took them home with them each night. The DON confirmed the facility did not mandate that the staff wore N95 or surgical masks. The DON confirmed that the facility's policy stated cloth face coverings were not considered Personal Protective Equipment (PPE) because their capability to protect the healthcare worker is unknown. An interview with the Corporate Nurse Consultant, on [DATE] at 10:30 AM, revealed, she stated, We would have weekly calls and he (Administrator) would tell us that they (COVID lab test) were still pending and he said that he had called and checked on them. We had told him to do weekly testing on the residents and staff and he had not told us that he had not tested again like we had asked him to do. The SA held a meeting with the facility's DON, the Corporate Nurse Consultant, and the Interim Administrator, on [DATE] at 11:13 AM, and notified the facility of an Immediate Jeopardy (IJ) due to the facility's delay of obtaining COVID test results in a timely manner, which allowed two COVID-19 positive employees to work during this time and exposed other employees and residents to COVID-19. The facility also failed to wear face masks appropriately and social distance at least six (6) feet apart. Review of the facility's Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy: On [DATE], Mississippi State Health Department Surveyor entered at Diversicare of Southaven for a COVID Infection Control Survey and a Complaint Investigation (CI). During observations by the surveyor on the hallways with residents present it was noted that team members working on the unit were not wearing masks and were not wearing masks appropriately. It was also noted that team members in offices were not six (6) feet apart and were not wearing masks. The center was delayed in obtaining COVID test results from facility wide testing on [DATE] and did not obtain the test results until [DATE]. Upon receipt of the COVID tests it was discovered that the center had two (2) additional positive team members that had worked with symptoms and had not isolated or taken time off because the facility had not made them aware that they had tested positive until [DATE], which was 25 days after the COVID test was administered. Measures taken to prevent further spread of COVID-19 in the center and to be in compliance with Infection control measures are: 1. Quality Assurance meeting completed on [DATE] at 1135 with plan of correction reviewed including: Identification of team members not wearing PPE appropriately. Team members were provided with 1:1 education regarding expectation of proper use of PPE at all times while in facility specific to mask and donning and doffing. Team members were educated on proper PPE that should be donned and doffed when working in areas of the COVID positive area, COVID observation/monitoring area and the non COVID area of the facility. It was also identified that COVID test results were not received timely. Results were received and notifications were completed. Actions taken because of the identified issues were: Rounds will be completed on all three nursing units in the facility (East, West, and Rehab Unit) to monitor for compliance with donning and doffing. Rounds will be completed by the Interim Administrator, Director or Nursing or the Assistant Director of Nursing and on weekdays and on the weekends. COVID testing will be completed weekly for all team members and residents/patients (not already COVID positive) for a minimum of 28 days or until cleared by the Mississippi Stated Department of Health. Monitoring for team members and residents/patients will continue daily. If any residents/patients develop symptoms of COVID they will be moved to the observation area. 2. This meeting was held via telephone conference and included: Medical Director, Regional Vice President- Diversicare, Director of Nursing Services, and Assistant Director of Nursing Services, Director of Nursing Management Services, and Director of Clinical Operations. 3. Administrator was placed on administrative leave on [DATE] at approximately 1500 related to delay in obtaining COVID test results. Administrator remains on suspension at this time pending investigation of failure to follow up on pending C tests and to complete additional required COVID testing. 4. COVID 19 testing immediately initiated on [DATE] at 1400 for current residents and team members and testing was ongoing until complete by the Nursing Management team. All residents COVID tests were completed on [DATE]. Team members who work sporadically will not work until testing is completed. 5. Communication regarding positive and negative COVID results will be communicated to Department Managers daily in the Daily Connect meeting by the Administrator or Director of Nursing Services. Responsible Representatives of residents/patients will be notified within 24 hours of the facility receiving positive COVID test results. This notification will be completed by Diversicare's automated calling system. And the facility Administration or Director of Nursing Services will notify all team members of their COVID tests results within 24 hours of receipt - including positive and negative results. 6. At present time the center has a total of 135 Diversicare team members, and an additional 25 Health Care Services team members. The center has received 66 COVID test results for team members that were all negative. And 105 residents/patients have been tested with 75 resulted negative. COVID testing will continue weekly until 28 days have passed with no positive results. 7. Team member #1 identified to not be wearing face mask PPE properly were immediately re-educated verbally by Assistant Director of Nursing on [DATE] at approximately 1230 regarding the expectation of compliance with use of proper PPE when working in any care area at all times. All team members were educated on wearing face mask and PPE properly and no employees will be allowed to start an assigned shift after [DATE] until education has been completed. 8. Team member #2 identified to not be wearing face mask PPE properly were immediately re-educated by Assistant Director of Nursing on [DATE] at approximately 1230 regarding the expectation of compliance with use of proper PPE when working in any care area at all times. 9. Team member #3 and #4, #5, #6 identified to be working in an office with another employee without wearing mask and not properly 6 feet apart was re-educated educated by Director of Clinical Operations on [DATE] at 1135 regarding the expectation of compliance with (TRUNCATED)

CI MS # Based on record review, interview and policy review, the facility failed to follow the care plan for Residents #1, #2, #3, #4, #6, #9, and #10, for seven (7) of 18 sampled residents reviewed for care plans, as evidenced by: a. Resident #1: Failed to follow the care plan for administration of medications and Diabetic Monitoring; Resident #2: Failed to follow the care plan to administer medications as ordered to help with Anxiety/Depression; Resident #3: Failed to follow the care plan for pain management; Resident #4: Failed to follow the care plan for medication administration and Diabetic monitoring; Resident #6: Failed to follow the care plan for pain assessments; Resident #9: Failed to follow the care plan to administer Antidepressant Medications; and Resident #10: Failed to follow the care plan for administering the [MEDICAL CONDITION] medication [MEDICATION NAME]. The failure to follow the care plan was a result of not having medications available from an out of state pharmacy, which was located in Atlanta Georgia, 373 miles from the facility, with over a five (5) hour drive time to the facility, lack of staff knowledge/training of a back up pharmacy plan, and failure of staff to administer/monitor medication per plan of care. The failure to follow the care plan for the administration of medications, monitoring of diabetic residents and residents with pain management, placed Residents #1, #2, #3, #4, #6, #9, and #10 and other residents in the facility, at risk for serious injury, harm, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ), which began on 10/30/17, when Resident #1 was admitted and did not receive medications for Diabetes as ordered and care planned. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.21 (b)(3)(ii) Comprehensive Care Plans, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the Resident Assessment Instrument (RAI) manual, dated (MONTH) (YEAR), and provided by the facility's Care Plan Coordinator as the policy for care planning, included the following statement: A care plan is based on a thorough assessment and provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being. Resident #1: The Facility admitted Resident #1 on 10/30/17, with [DIAGNOSES REDACTED]. A review of the Initial Nursing Assessment identified that Resident #1 was admitted to the facility on [DATE], via ambulance, from the hospital, with a history of Insulin Dependent Diabetes Mellitus. Resident #1 was noted to be alert and oriented. A Minimum Data Set (MDS) was not completed. A review of Resident #1's Care Plan documented as follows: 10/31/17 Focus: Alteration in Blood Glucose due to Insulin Dependent Diabetes Mellitus. Goal: Patient will experience minimal signs and symptoms associated with [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. Interventions included: Administer medications as ordered. Labs, (which include Blood Glucose) per physician order [REDACTED]. A review of physician's orders [REDACTED]. The sliding scale schedule directed staff to administer Insulin according to the Blood Glucose (BG) results, including BG results greater than 401. The physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) for (MONTH) (YEAR), for Resident #1, revealed the [MEDICATION NAME] Insulin was not administered on 10/30/17, for the 8:00 PM dose, or the 8:00 AM dose, which was scheduled on 10/31/17. A review of the MAR for (MONTH) (YEAR), revealed scheduled times for checking Blood Glucose (BG) levels, for Resident #1, as 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. The MAR documented that the resident had BG results of greater than 401 on four (4) of 10 days, with no notification to the physician documented, as care planned: 11/02/17: BG results 501 at 11:00 AM 11/04/17: BG results 450 at 11:00 AM 11/05/17: BG results 509 at 8:00 PM 11/08/17: BG results 449 at 11:00 AM The sliding scale insulin was administered as ordered, however, there was no documented evidence that staff monitored the elevated BG. A review of the progress notes and the (MONTH) (YEAR) MAR, revealed Resident #1 did not have results for BG checks documented on 10 scheduled administration times, to indicate the BG had been checked and PRN insulin administered, as ordered and care planned: 10/31/17 at 11:00 AM 11/01/17 at 6:00 AM 11/02/17 at 6:00 AM, 4:00 PM and 8:00 PM 11/03/17 at 4:00 PM and 8:00 PM 11/04/17 at 6:00 AM, 11/07/17 at 6:00 AM 11/09/17 at 6:00 AM Review of a Progress Note, with no time, dated 11/8/17, documented Resident #1 had no signs or symptoms of Hyper/[DIAGNOSES REDACTED]. This was the only documentation related to monitoring Resident #1's signs and symptoms. A review of Resident #1's progress notes did not document if the Physician had been notified about BG levels greater than 401, or why the BG results were not obtained, as care planned. Review of Resident #1's HGB A1C, a test used to monitor BG levels over a period of months, dated 10/31/17, revealed Resident #1 had a high level of 11.8, with normal ranges between 4.0-6.0. A telephone interview with Resident #1, on 02/08/18 at 11:20 AM, revealed the resident was admitted to the facility on [DATE], at approximately 6:00 PM. Resident #1 stated that medications were not given as ordered, especially the Insulin. Resident #1 stated that the Blood Sugars (BS) were not checked like they were ordered. She did not specify any adverse effects from not receiving the medication. A review of a Physician's Interim order, dated 11/06/17, documented an order for [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record (MAR), revealed no evidence that Resident #1 received the [MEDICATION NAME] as ordered on [DATE]. A progress note, dated 11/09/17, documented pending pharmacy delivery. The resident was discharged home on[DATE], without receiving the medication, per care plan. An interview on 03/01/18 at 2:30 PM, with the Nurse Practitioner (NP) revealed [MEDICATION NAME] was ordered on [DATE], for Resident #1, in an attempt to level out the resident's BG. The NP stated that the resident's BG ranged from 168-500, and if Insulin was increased, the BS could bottom out. The NP confirmed that not administering the [MEDICATION NAME], could have resulted in Ketoacidosis, which is a complication of high BG levels. During an interview on 2/14/18 at 9:35 AM, the Assistant Director of Nursing (ADON) acknowledged the care plans were not followed to monitor the effectiveness of sliding scale Insulin in assessing Resident #1 for Hypo/[MEDICAL CONDITION]. The ADON said nurses should follow the care plan to attend to the resident's daily nursing needs. Resident #2: The facility readmitted Resident #2 on 10/19/16, with [DIAGNOSES REDACTED]. The MDS, with an ARD of 12/05/17, revealed a BIMS score of 12, or moderately impaired cognition. Resident #2 required limited to extensive assistance with all Activities of Daily Living. A review of Resident #2's Care Plan, initiated 10/20/16, documented as follows: Focus: Gets sad, nervous and anxious at times. Goal: I will remain comfortable. Interventions included: Please give me my medications that help with my anxiety and depression. A review of the physician's orders [REDACTED]. During Med pass observation, on 02/08/18 at 10:10 AM, LPN #3 removed a plastic pouch with an individual dose of [MEDICATION NAME] 20 mg with Resident #2's name for the morning dose. It was the only dose of [MEDICATION NAME] in the medication drawer, for Resident #2. LPN #3 confirmed it was not the correct dosage for Resident #2 and attempted to get the correct dosage from the Automated Dispensing Unit (ADU) without success. A review of the MAR for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), documented [MEDICATION NAME] 60 mg had been administered daily for the 8:00 AM dose. The MARs were documented by staff of monitoring for anxiety, crying and agitation. There was no documented evidence of these behaviors. A review of medications dispensed from Pharmacy, per Pharmacy Manifest, revealed [MEDICATION NAME] 20 mg had been dispensed daily for the months of (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). This indicated that Resident #2 had not received the medication, as ordered, per care plan. An interview on 02/13/18 at 2:10 PM, with LPN # 3, revealed the LPN had been administering one (1) pill to Resident #2 daily. LPN #3 stated that if 20 mg was the only strength of [MEDICATION NAME] being sent, then 20 mg was being given, instead of 60 mg as ordered. LPN #3 stated she wasn't aware of when the strength had changed, she thought that the 60 mg was a purple pill and she thought she was administering 60 mg. Review of the MARs indicated that LPN #3 had electronically signed the MAR to indicate 60 mg had been administered for 16 days in (MONTH) (YEAR), 21 days in (MONTH) (YEAR), and six (6) days in (MONTH) (YEAR). An interview on 02/14/18 at 9:50 AM, with Registered Nurse (RN) # 3/Care Plan Coordinator, revealed a care plan is individualized for each resident. She said the care plan is basically a guide for nurses and other staff to take care of the patient and confirmed not getting the correct dosage of medication would not be following the care plan. Resident #3: The facility admitted Resident #3 on 12/04/17, with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 12/11/17, revealed fa BIMS score of 14, or cognitively intact. Resident #3 required limited to extensive assistance with all Activities of Daily Living. A Pain Assessment on the MDS identified almost constant pain limiting day-to-day activities. A review of the care plan for Resident #3, initiated 12/13/17, included the following: Focus: I will need pain management and monitoring. Goal: Will not experience a decline in function related to pain. Interventions included: Administer pain medication as ordered. A review of Resident #3's physician's orders [REDACTED]. A review of the MAR and progress notes, for (MONTH) (YEAR), documented that on 12/27/17, [MEDICATION NAME] 20 mg was not administered for 2:00 PM. The progress note documented Awaiting medication delivery from pharmacy. A review of the MAR, revealed on 12/27/17 at 10:00 PM and 12/31/17 at 2:00 PM, a check mark was documented to indicate [MEDICATION NAME] 20 mg was administered to Resident #3 by LPN # 1, however, the Controlled Substance Accountability Sheets, revealed two (2) [MEDICATION NAME] 5 mg tablets were administered on 12/27/17 at 10:00 PM, and three (3) [MEDICATION NAME] 5 mg tablets were administered on 12/31/17 at 2:00 PM, indicating the medication was not administered per orders, as care planned. A telephone interview on 02/13/18 at 3:10 PM, with LPN #1, revealed [MEDICATION NAME] 20 mg was not available for Resident #3 on 12/27/17, for the 10:00 PM dose; the only strength available in the Automated Dispensing Unit (ADU) in the facility, was a 5 mg [MEDICATION NAME]. LPN #1 stated that she administered 5 mg of [MEDICATION NAME] on 12/27/17 at 10:00 PM, and 15 mg [MEDICATION NAME] on 12/31/17, because the 20 mg [MEDICATION NAME] was not available at the administration times. LPN #1 acknowledged not following the plan of care to administer [MEDICATION NAME] 20 mg, as ordered by the physician. A review of physician's orders [REDACTED].#3: On 12/04/17: [MEDICATION NAME] 300 mg-twice daily related to Low Back Pain, and on 12/21/17, [MEDICATION NAME] 500 mg was ordered twice daily for pain. A review of the MAR and progress notes for (MONTH) (YEAR), documented the 4:00 PM [MEDICATION NAME] dose was not administered on 12/16/17 and 12/22/17. [MEDICATION NAME] was not administered for the 4:00 PM dose on 12/22/17. The Progress notes documented the medications were not available. A review of Resident #3's MAR for (MONTH) (YEAR), revealed: [MEDICATION NAME] was not administered on 01/04/18/, 01/08/18, 01/09/18. A review of the progress notes revealed the medications were not available. An interview on 03/02/18 at 2:55 PM, with the Director of Nursing (DON), revealed the facility did not follow the care plan for Resident #3's physician's orders [REDACTED]. Resident #4: The facility readmitted Resident #4 on 10/12/16, with [DIAGNOSES REDACTED]. The MDS, with an ARD of 12/12/17, identified the resident with a BIMS of 15, or cognitively intact. Resident #4 required set up help only for Activities of Daily Living. The MDS documented the resident received Insulin Injections daily. A review of Resident #4's care plan, initiated 5/26/17, documented: Focus: Alteration in Blood Glucose due to: Insulin Dependent Diabetes Mellitus. Goal: Patient will experience minimal signs and symptoms associated with [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. Interventions included: Labs (which include BG) per Physician order [REDACTED]. Further care plan review revealed to give medications as ordered. Review of the physician's orders [REDACTED].#4 had orders for Tresiba Flextouch Sol Pen 22 units, at bedtime. Review of the MAR, revealed Resident #4 did not receive the Tresiba on 11/2/17 or 11/3/17, due to awaiting receipt from the out of state pharmacy. A 7 was documented both days. Review of Progress Notes, dated 11/2/17 at 10:21 PM, revealed awaiting the Flextouch pen, and again on 11/3/17 at 9:43 PM the note documented the med was enroute from pharmacy. The Progress noted dated 11/3/17 at 11:54 PM, documented that Resident #4's BG had risen to 571 that evening. The Nurse Practitioner (NP) was notified and gave orders for 15 units of [MEDICATION NAME] Isulin and to recheck the BG in one (1) hour. When rechecked, the BG level was 543, the NP gave orders for an additional 15 units of [MEDICATION NAME] Insulin and recheck in one (1) hour. When rechecked, the BG had lowered to 525. The note documented continued monitoring. The care plan was not followed for giving medications as ordered. A review of Resident #4's physician's orders [REDACTED]. If greater than 400, give 12 units, recheck in two (2) hours, and call the physician. A review of the MAR, for (MONTH) and (MONTH) (YEAR), revealed Resident #4 had elevated Blood Glucose (BG) levels of 400 plus for 21 of 124 scheduled testing times for January, and four (4) of 32 scheduled testing times for (MONTH) (YEAR), before meals and at bedtime. There was no evidence of re-checking Resident #4's BG levels in two (2) hours after elevated levels of greater than 400, as ordered and care planned. During an interview, on 2/13/18 at 11:15 AM, LPN #6 revealed that a 7 on the MAR indicated the need to see the progress note. She stated that the 7 may mean the medication was not administered or not available. She stated that sometimes the medication did not arrive after being ordered, and the pharmacy had to be called again, meaning the medication would be late again. She stated that sometimes it took two (2) days before the medication is available. It's a missed dose if it's not available. In an interview, the ADON, on 02/14/18 at 9:35 AM, acknowledged the physician's orders [REDACTED].#4. Resident #6: Review of the facility's Face Sheet revealed Resident #6 was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's MDS, with an ARD of 12/29/17, revealed Resident #6 had a BIMS score of 15, which indicated no cognitive impairment. Review of Resident #6's care plan, Pain management and monitoring related to [MEDICAL CONDITION], with a revision date of 10/26/17, revealed an intervention to administer pain medication as ordered and evaluate what makes the patient's pain worse. Resident #6's goal for pain was to achieve acceptable pain level. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's (MONTH) (YEAR) MAR, revealed Resident #6 received five (5) [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablets during the month of (MONTH) (YEAR), however, review of the Controlled Substance Accountability Sheet revealed Resident #6 received the [MEDICATION NAME]-tablets 20 times during the month of January. There was no documented evidence that Resident #6's pain was evaluated for intensity and location, or the follow up for necessity of the medication, for the other doses signed out on the Accountability sheet, to determine effective pain control, per care plan. Interview with Resident #6 on 2/13/18 at 2:30 PM, confirmed that she had received pain medication approximately 20 times in the month of January, (YEAR). She stated she did not expected to have all of her pain relieved due to her condition. Interview with the ADON on 2/13/18 at 1:45 PM, revealed nurse's were not always documenting the administration of Resident #6's pain medication on the MAR and nurse's notes, therefore not assessing for the effectiveness of the pain medication or the resident's pain level. The ADON stated that it was important to ensure the effectiveness of pain relief, per care plan. Interview with LPN #15, on 3/6/18 at 7:25 AM, revealed pain was assessed by asking the verbal resident, using the pain scale of 0-10, or for non-verbal residents, use signs and symptoms. LPN #15 stated after administration of the pain medication, nurses should document the time, and follow up for the effectiveness, documenting on the MAR. She stated the importance of assessing the resident's pain, was so the physician and nursing staff know the resident's level of pain and what care was provided. Resident #9: Review of the facility's Face Sheet revealed Resident #9 was admitted on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #9's Quarterly MDS with an ARD of 11/15/17, revealed Resident #9 had a BIMS score of 14, which indicated no cognitive impairment. Review of Resident #9's care plan Antidepressant medication related to depression, with a revision date of 11/8/17, revealed interventions to administer antidepressant medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. Interview with Resident #9 on 2/13/18 at 8:10 AM, revealed she had asked the Psychiatric Nurse Practitioner (NP) for something for nerves, because she was so nervous all of the time, especially after an altercation with another resident. Resident #9 had no other complaints. Review of Resident #9's current Physician order [REDACTED]. Review of the MAR for (MONTH) and (MONTH) (YEAR), revealed Resident #9 never received the 150 mg Welbutrin as ordered. The care plan was not followed to give the increased antidepressant medication, as ordered. Review of a Behavior Health Note, dated 1/23/18, documented by the Psychiatric NP, revealed Resident #9 did admit to feeling anxious at times. The NP ordered the increase in the [MEDICATION NAME] to 150 mg twice daily. Interview with the Psychiatric NP on 02/13/18 at 9:45 AM, revealed she ordered Resident #9 an increase in [MEDICATION NAME] due to Depression, and to help control her compulsive behavior. Interview with the ADON, on 2/13/18 at 1:45 PM, revealed staff failed to identify the new order for Resident #9's increased [MEDICATION NAME] and did not place it on the MAR, and the medication was not administered as ordered/care planned. Resident #10: The facility admitted Resident #10 on 01/25/18, via ambulance, from the hospital, with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 02/01/18, revealed staff identified the Resident #10 with memory problems. The resident required supervision to extensive assistance with all ADLs. Review of Resident #10's Baseline Care plan, dated 1/25/18, revealed the use of [MEDICAL CONDITION] medications and other routine medications. Review of the physician's orders [REDACTED]. Interview with Resident #10, and the resident's significant other, on 2/12/18 at 11:45 AM, revealed part of the resident's medications were not available, on admission, for two and one half (2 1/2) days due to being ordered from the out of state pharmacy. The RP didn't know which medications, except for [MEDICATION NAME]. Resident #10 also had orders on 1/25/18, for [MEDICATION NAME] 40 mg once daily for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg three (3) times daily for Diabetic [MEDICAL CONDITION], and [MEDICATION NAME] 50 mg twice daily. Orders on 01/26/18 included: [MEDICATION NAME] 5 mg twice daily related to Diabetes, [MEDICATION NAME] 50 mg daily related to Diabetes, [MEDICATION NAME] 500 mg two (2) times a day for Diabetes, and [MEDICATION NAME] 5 mg once daily for Diabetes A review of Resident #10's MAR for (MONTH) (YEAR), revealed [MEDICATION NAME] was not administered for the 6:30 AM dose on 01/28/18. [MEDICATION NAME] was not administered on 01/26/18 for the 8:00 AM and 4:00 PM doses, and on 01/27/18 for the 8:00 AM or 4:00 PM scheduled doses. [MEDICATION NAME] was not administered on 01/25/18 or 01/26/18. [MEDICATION NAME]: not administered on 01/26/18 at 8:00 AM or 4:00 PM, on 01/27/18 at 8:00 AM or 4:00 PM, and 8:00 AM on 01/28/18. A review of progress notes documented that the above medications were not in stock, not available and/or orders had been refaxed to pharmacy. An interview on 03/05/18 at 8:45 AM with RN #5 (Regional Director of Clinical Systems and Quality Assurance), confirmed Resident #10 had missed five (5) doses of [MEDICATION NAME] after admission. The RN said missed doses could have affected the therapeutic level of [MEDICATION NAME] and behaviors could have escalated. RN #5 stated she did not look at the MAR for other medications which may have been missed. She stated the care plan directs the care for the resident and should be followed. Interview on 02/14/18 at 9:00 AM, with RN #2, revealed the care plan is developed to give guidance to staff regarding resident care and reflects the actual care that is provided to the resident. RN #2 stated that staff should follow the care plan to ensure proper care is provided to the resident. During an interview on 2/14/18 at 10:45 AM, the Administrator stated it was important to follow care plans as developed to ensure resident needs were met as identified. An interview on 02/14/18 at 9:50 AM, with the Care Plan Coordinator, revealed a care plan is individualized for each resident. She said the care plan is basically a guide for nurses and other staff to take care of the patient. The Care Plan Coordinator said the importance of following a care plan for diabetics is looking for signs/symptoms of Hypo/[MEDICAL CONDITION], to prevent possible hospitalization s, diabetic coma or complications. The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medication availability has continued on a daily basis and is being conducted by the medication and supervising nurses. Education was provided by the Director of Clinical Education (DCE) and Director of Nursing Services (DNS) to eight (8) Registered Nurses (RN) and 23 Licensed Practical Nurses (LPN) regarding medication administration on 2/8/18, through 2/22/18, and then started again 2/28/18, when surveyors identified further concerns. This education was provided by the DNS at times for all shifts. All nurses were also educated by DCE/DNS regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medications for all shifts. No staff member worked until this education was given. No agency staff is being utilized. All supervising and medication nurses, totaling eight (8) RNs and 23 LPNs, were educated regarding sliding scale accuchecks results and insulins and following MD orders with follow up regarding accucheck results on 2/8/18-2/22/18 by DCE/DNS. Education provided by the DNS and supervising nurses began again on 2/28/18 after surveyors returned. This education was provided at times for all shifts. No staff member worked until this education was given. No agency staff is being utilized. Systemic changes and monitoring have been developed, presented and approved by the Administrator, DNS, and Medical Director on 2/19/18, at 1:00 pm, during the Quality Assurance Performance Improvement (QAPI) meeting. The systemic changes and guidelines include algorithms for medication ordering, reordering and availability. These changes will be prepared for monthly reporting at QAPI. Education has been provided by the DNS/ADNS/DCE to all eight (8) RNs and 23 LPNs concerning the guidelines and changes on 2/22/18, and again after the immediate jeopardy identification on 2/28/18. This education provided for all shifts regarding the systematic changes includes: when new orders are received or orders for a new admission, the assigned medication nurse will review medication cart to assure medication is in center; should the medication not be available, the assigned medication nurse will notify the supervisor immediately as well as fax the order to the pharmacy; should the medication not arrive by administration time or within a two (2) hour timeframe, the physician will be notified by the nurse supervisor for follow-up orders. A pharmacy representative will be in the center at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability for at least 30 days and then two (2) times per week thereafter. A QAPI meeting was held on 2/19/18 at 1:00 pm. In attendance were the Administrator, DNS, ADNS, Medical Director, Social Workers, Unit Managers and other department leaders. Also, in attendance, were support resource members from the corporate office. Findings from the initial medication cart checks were discussed, along with the follow-up assignments, including medication cart match back, medication administration record monitoring for holes and missed accucheck follow up or medications and medication availability. Findings related to follow up for pain medication and sliding scale insulins were discussed with follow-up assignment to include monitoring of the medication administration record and nurses' progress note review. Another QAPI was completed on 2/28/18 at 7:00 pm with discussion surrounding the immediate jeopardy and continuing plans for correction. After the 2/28/18 QAPI monitoring of medication carts and medication availability continued, along with medication administration documentation and follow up of accucheck results. Education continued to the staff and medication nurses. Participants in this meeting were the Administrator, DNS, ADNS, Nurse Consultant, and Medical Director. NOTE/ADDENDUM : The facility sent documentation, dated 3/5/18, which advised the Out of State pharmacy of termination of the pharmacy contract. On 03/06/18 the State Agency (SA) va (TRUNCATED)

CI MS # Based on record review, interview, and policy review, the governing body failed to ensure Pharmacy Services, from an out of state Pharmacy, were provided in a manner to ensure the availability and/or accessibility of medications for residents in the facility. The Pharmacy site, providing medications to the facility, was located in Georgia. (According to MapQuest information the site is located 373 miles from the facility and five (5) hours and 38 minutes in travel time from the facility). The Governing Body initiated a contract with the out of State Pharmacy Provider, dated 10/03/16, to Provide Pharmacy Products to the facility and its residents in a prompt and timely manner. The out of state Pharmacy also was responsible for maintaining an Automated Dispensing Unit (ADU) in the facility which contained oral medications dispensed in individualized plastic pouches and a section for other medications, including Insulins and an Emergency Drug supply. The ADU was located in the West Hall Medication Room. According to staff interviews between 800-900 routine medications were dispensed from the ADU each day at 1:00 PM, in individually labeled plastic pouches for administration on the following day. The medications were then placed in the medication cart by the 3-11 Shift or the 11-7 Shift Nurses. If a medication was not available in the ADU, the nursing staff faxed an order to the Pharmacy Provider, prior to 6:00 PM, and the medication was supposed to be delivered the next morning by a courier from the Pharmacy Provider in Georgia. Interviews from Licensed Nursing staff, from 7-3 shifts, 3-11 shift and 11-7 shift, identified ongoing concerns with the availability/accessibility of medications from the ADU, and the delivery of medications from the Pharmacy located in Georgia. Concerns about the ADU included issues with frequent jamming of the paper or plastic pouches tearing or hanging up when dispensing from the ADU, machine would lock up and prevent dispensing, pouches dispensed empty from the machine, and unable to repeat the dispensing for the medication without contacting Pharmacy, and waiting for the Pharmacy to electronically allow the medication to be dispensed. The ADU showed medications were available and then would not dispense. Concerns from nursing staff about receiving medication from the dispensing site in Georgia, included issues related to incomplete shipments, medications not sent as requested, and lack of communication from Pharmacy regarding inability to fill prescriptions (if the Rx was not readable there was no communication follow up from the Pharmacy to let staff know to submit another Rx,). If the medication had to be reordered, and not available in the ADU, the residents missed doses of medication, including medications requiring therapeutic levels and pain relief. The Pharmacy Provider was responsible for making arrangements for medications to be delivered by a Back-up Pharmacy, upon notification by the facility, that a medication was not available. The facility failed to ensure staff was trained in what to do if a medication was not available and not provided by the Pharmacy Provider, to ensure residents received medications as ordered by the Physician. The governing body failed to provide oversight in assuring medications were available /accessible to be administered in the right dose at the right time in the right strength to the right resident and monitored according to current standards of nursing practice, physician's orders [REDACTED]. The governing body failed to assist the facility to implement corrective action through the facility's QAPI process, including the development of a monitoring tool to assess the significance related to medications not being available, and to monitor the effectiveness of interventions, and update as necessary, to resolve ongoing issues related to the accessibility/availability of medications from the out of state Pharmacy. The governing body had been made aware of concerns with Pharmacy Services through Resident Council Complaints, from the Ombudsman, Grievances, and by staff. Failure of the Governing Body to take appropriate action, when made aware of issues with the out of state Pharmacy Provider, resulted in delays in acquiring routine and/or new admit medications, inability to acquire medications and/or the right strength of medication from a dispensing center located in the facility, missed doses of medications, and significant medication errors. This also resulted in failure to follow physician's orders [REDACTED]. The facility's failure to ensure the Governing Body addressed ongoing issues of medication availability to residents from an out of state Pharmacy Provider and/or back up pharmacy, administration and monitoring of resident medication, and training of staff on medication availability and/or back up pharmacy plans, placed Residents #1, #2, #3, #4, #6, #9, #10, and other residents with medication orders, at risk for the likelihood of serious injury, harm, impairment or death. This affected Resident #1, #2, #3, #4, #6, #9 and #10, seven (7) of eighteen (18) sampled residents, but had the potential to affect residents receiving medications in the facility. Resident #1 Resident #1 had a history of [REDACTED]. The resident's physician had specific orders for Blood Glucose (BG) monitoring and to administer Insulin according to the BG levels before meals and at bedtime. The physician also ordered staff to report BG levels greater than 401. The MAR revealed the resident had BG results of greater than 401 on 4 (four) of 10 days, without the appropriate monitoring and notification to the physician, including the following: 11/02/17: BG results 501; 11/04/17: BG results 450; 11/05/17: BG results 509; 11/08/17: BG results 449. On 11/06/17, the Nurse Practitioner (NP) ordered [MEDICATION NAME] (an oral medication to lower BG levels. Scheduled Insulin was not administered on admission as ordered. The [MEDICATION NAME] was not available from the out of state Pharmacy or a back-up Pharmacy until 11/09/17. Resident #1 was discharged home on[DATE], without receiving the medication. Resident #1 had a range of BG levels of 128-509 (normal 70-110), and an elevated HGB A1C (test of blood sugar levels over a period of time) of 11.8 (normal range 4.0-6.0). Interview with the Resident revealed she was admitted on [DATE] around 6:00 PM, and did not get her Insulin as ordered and her BG levels were checked consistently. The facility failed to follow physician's orders [REDACTED]. Although the facility had no documented adverse effects of Hypo/[MEDICAL CONDITION] for Resident #1, an interview with the NP revealed that BG levels greater than 400 is a danger zone, leading to Ketoacidosis. Resident #2: Resident #2 had a physician's orders [REDACTED]. The facility failed to match the medication dispensed/delivered by an out of state Pharmacy Provider, with the physician's orders [REDACTED]. According to staff interviews, and a copy of the Pharmacy's dispensing manifest record, [MEDICATION NAME] 20 mg had been the only strength dispensed, and administered, for more than 60 days, resulting in a significant medication error, failure to follow the physician's orders [REDACTED].#2's depression. Resident #3 Resident #3 was admitted to the facility on [DATE], from the hospital, with a history of [MEDICAL CONDITION] lower extremity. Resident #3's Physician ordered a pain-relieving medication, [MEDICATION NAME] 20 mg, to be given every eight (8) hours. Although the Pharmacy Provider was notified of the unavailability of the [MEDICATION NAME] 20 mg, the out of state Provider failed to provide the correct strength from a Back-up Pharmacy and the medication was not available for the scheduled administration times on 12/27/17. As a result of the correct strength not being available from Pharmacy, or the ADU, the resident missed a scheduled dose of [MEDICATION NAME] on 12/27/17. Resident #3 also was administered a lesser strength of [MEDICATION NAME], that was available from the Automated Dispensing Unit (ADU) in the facility, at least two (2) additional administration times, (10 mg once and 15 mg once) as a result of the correct strength not being available. Tylenol was ordered and administered for Resident #3's break-through pain six (6) times from (MONTH) to (MONTH) (YEAR). Interview with the Resident revealed she had to wait a day and a half for her medications after admission, because they had to be ordered from an out of state pharmacy. The facility failed to follow the physician's orders [REDACTED]. Pain assessments by facility staff documented Resident #3 had a pain level ranging from 0-8 (with 0 being no pain and 10 the worst pain). Resident #3 was discharged home with medications, on 02/17/18. Resident #4: Resident #4 had physician's orders [REDACTED]. The pen was not available to be administered on 11/02/17, and 11/03/17, from the out of state Pharmacy or a Back-up Pharmacy, or the ADU in the facility. Resident #4's BG levels were elevated to 571 at 4:00 PM and 8:00 PM on 11/03/17, and had to be given two (2) extra doses of [MEDICATION NAME] (fast acting Insulin) to bring the BG level down. Resident #4 also had Physician orders [REDACTED]. The amount of Insulin was ordered to be administered according to Blood Glucose (BG) levels. If the level was greater than 400, the order directed staff to administer 12 units of fast acting Insulin, recheck the BG level in two (2) hours, and call the physician. Resident #4 had elevated BG levels greater than 400 for 21 of 124 testing times during (MONTH) (YEAR), and four (4) of eight (8) days reviewed in (MONTH) (YEAR). There was no evidence of rechecking the BG levels, as ordered, or notifying the physician. According to interviews with Resident #4's Physician/Nurse Practitioner, BG levels greater than 400 are in a danger zone, and administering Insulin, without monitoring the effectiveness, could lead to severe consequences including Hypo/[MEDICAL CONDITION] or Ketoacidosis. Resident #6 Resident #6 had a physician's orders [REDACTED]. According to the facility's policy and procedures for administering PRN (as needed) medications, the Licensed staff were directed to ensure documentation of the date and time administered, complaints for which the medication was administered, and results achieved from giving the dose and the time results were noted. Licensed staff administered pain medication to Resident #6 without consistently assessing the level, location and intensity of pain prior to administering the pain-relieving medication, and completing a follow up on the effectiveness of the pain medication. Failure to complete assessments could have resulted in ineffective pain relief and/or the need for additional medications. Resident #6's pain scale when assessments were completed ranged from 3-8 (on a scale of 0 with no pain and 10 the worst. Resident #9 Resident #9 was assessed by the Psychiatric Nurse Practitioner on 01/23/18. According to the Behavior Health Progress Notes, the NP ordered an increase in dosage of Welbutrin from 100 mg twice daily to 150 mg twice daily, on 01/23/18, after the resident admitted feeling anxious. The facility failed to transcribe the order and administer the medication, resulting in failure to follow the physician's orders [REDACTED]. The resident did not receive the increased strength as ordered for 21 days, resulting in risk of increased depression/anxiety for Resident #9. Resident # 10 Resident # 10 was admitted to the facility on [DATE], with a history of [MEDICAL CONDITION] Disorder. Upon admission to the facility on [DATE], the resident had physician's orders [REDACTED]. The resident missed the first five (5) scheduled doses of the [MEDICATION NAME], related to the medication not being available from the out of state Pharmacy or from a back-up Pharmacy. The resident also had other medications, including [MEDICATION NAME] and [MEDICATION NAME] that were not available for administration. The medical record documented that medications were not in stock, not available and/or orders had been refaxed to pharmacy. Resident #10's Responsible Party (RP) completed a grievance on 01/29/18, about the resident's medication not being available for administration. The RP stated during an interview that she had been told the medications had to be ordered from a Pharmacy in Georgia and the facility was waiting for the medications to be delivered. The grievance was signed by Registered Nurse #5 (Corporate Regional Director of Clinical Systems and Quality Assurance). The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services and as ordered. This also affected Resident #2, #3, #4, #6, #9 and #10. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.70 (d) (1) (2), Governing Body, F837, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of a Pharmacy Provider Agreement, commencing on 10/01/16, and signed by a Corporate Representative on behalf of the facility, identified the Pharmacy as an out of State Provider (Located in Atlanta Georgia). The Agreement included the following information: Scope of Services: Provide Pharmacy Products to Facility and its residents in a prompt and timely manner in accordance with Applicable Law. For purposes of this Agreement, the term Patient shall only include residents that receive pharmacy services from Pharmacy; provide House Stock to facility upon request, label all Pharmacy Products in accordance with Applicable Law; maintain a drug profile on each Patient served by Pharmacy; and collaborate with Facility to coordinate pharmacy documentation processes. Delivery: Pharmacy shall arrange for all new admissions orders and routine reorders to be delivered by Pharmacy or another pharmacy within a timely fashion to meet the needs of the Patient. Emergency Drug Services: Pharmacy will provide any prescriptions and supplies requested by Facility for its patients, on an emergency basis or stat (statim) basis, within no more than four (4) hours of Pharmacy's request or sooner if state law requires. This emergency service will be provided twenty-four (24) hours per day, seven (7) day per week. In the event Pharmacy cannot timely furnish an ordered medication due to circumstances beyond its control, Pharmacy will make arrangements with another pharmacy to provide such Pharmacy Product to Facility (a Back-Up Pharmacy) as soon as possible and will be responsible for ensuring that any medication quantities provided by a Back-Up Pharmacy are dispensed in limited quantities and billed to the appropriate third-party payor or directly to Pharmacy. A review of the facility's policy on Quality Assurance and Performance Improvement (QAPI) Center Plan reviewed 01/03/18, identified the Administrator and Director of Nursing as part of the Governance and Leadership of the Center and documented as follows: The Governing Body is responsible for the development and implementation of the QAPI program. The Governing body is responsible for: Identifying and prioritizing problems based on performance indicator data: Incorporating resident and team member input; ensuring that corrective actions address gaps in the system and are evaluated for effectiveness; setting clear expectations for safety, quality, rights, choices, and respect; ensuring adequate resources exist to conduct QAPI efforts; ensuring contingency plans for program sustainability during times of leadership transition. Review of the Position Description of the Administrator, dated 1/4/17, revealed that the Administrator reported to the Regional Vice President. The Administrator directs, oversees and manages the 24/7 day to day operations of the facility. A review of Resident Council Minutes documented on 09/11/17: Meds given late or not at all; 10/02/17: Meds given late or not at all; 11/06/17: Meds given late or not at all; and 02/05/18: Residents states they only get half their medications on the weekend. A telephone interview, with the Ombudsman, on 02/09/18 at 9:30 AM, revealed that residents had voiced concerns at the resident council meetings for the past five (5)months about medications being late, or not given at all. The Ombudsman said residents reported that they were told by staff that the machine, which is the Automated Dispensing Unit (ADU), was out of order all the time, out of paper, or Pharmacy didn't send their medicines. The Ombudsman said there were so many complaints the residents had invited the Administrator and Director of Nursing (DON) to attend the Resident Council meeting on 02/05/18. An interview with the Administrator on 02/14/18 at 10:30 AM, revealed she had been the Administrator at this facility since April, (YEAR) and had experience as an Administrator for five (5) years. The Administrator said she attended QAPI meetings monthly, but was not aware of any recent concerns about availability of medications. The Administrator said she did not think Resident Council Minutes were included on the QAPI meeting form, and was not aware of any recent concerns about availability of medications. The Administrator stated, however, that she had attended a meeting (unsure of date but thought late last year in (YEAR)) at the hospital because of a concern about medications not being available for new admissions. The Administrator said she thought that issue was resolved, due to the hospital was to send prescriptions on new admissions. The Administrator confirmed being aware of Resident #10's grievance (newly admitted resident), dated 01/29/18, about medications not being available after admission to the facility. The Administrator said she planned to bring that grievance to the next QAPI meeting in February. The Administrator said she had attended Resident Council on 02/05/18, and was made aware of resident council concerns about medication issues, such as the medication being late. Interviews with QAPI committee members confirming attendance in QAPI meetings, included the Maintenance Director and LPN (Licensed Practical Nurse) #11, who indicated medication concerns of availability had been discussed during QAPI meetings. Interviews were conducted during the survey, with Licensed Practical Nurses (LPNs), regarding availability and accessibility of medications, including the following: LPN #1 on 02/12/18 at 3:25 PM, LPN #2 on 02/12/18 at 3:30 PM, LPN #9 on 02/13/18 at 8:55 AM, LPN #5 on 02/13/18 at 3:45 PM, LPN #6 on 02/13/18 at 11:15 AM, LPN #7 on 02/14/18 at 9:55 AM and LPN #10 on 03/01/18 at 5:00 PM The interviews with staff revealed ongoing problems with obtaining medication from an out of state Pharmacy provider, problems with dispensing medications from a machine located in the facility, problems with communication with Pharmacy, incomplete shipments, lack of availability of medications, no deliveries on weekends, limited amount of medications dispensed from machine, and lack of knowledge of how to obtain medications from a back-up pharmacy plan. During a second interview on 03/01/18 at 3:30 PM, the Administrator acknowledged she was aware of concerns about medications not being available. The Administrator said she was responsible to see that quality care and services were provided the all residents in the facility. The Administrator said she had notified Corporate several times about problems with the Pharmacy, including the Senior Director of Clinical Operations, the Director of Clinical Operations and the Regional Director of Clinical Systems and Quality Assurance, regarding problems with acquiring medications/or dispensing medications from the ADU machine/or obtaining meds from an out of state Pharmacy. The Administrator revealed the facility should have put monitoring tools in place, to give the magnitude of ongoing concerns related to medications not being available, put tracking in place to identify concerns and follow up. The Administrator confirmed the issues of medication had not been resolved. The Administrator said the facility should have put monitoring tools in place, tracking to identify concerns and follow up on the tracking. An interview with the Director of Nursing (DNS) on 03/01/18 at 8:30 AM, revealed the facility and QA committee had not been effective in issues related to medication availability. The DON confirmed that the Administrator and Corporate were aware of the issues. An interview on 03/02/18 at 8:45 AM, with the Corporate Representative (Senior Director of Clinical Operations) revealed the Corporate Office had been aware of some concerns about obtaining medications from Pharmacy, but the Survey was the culmination of identifying the severity/magnitude of the issues. The CR said she did not have an answer about why another direction was taken for another Pharmacy Provider, the answer to that question would have to be answered by the Chief Operating Officer. The CR said there was a potential for negative outcome, including complications for diabetics with residents not receiving medications, not following physician's orders [REDACTED]. The CR said prior to the survey, concerns were addressed in the facility and communicated to the Corporate Office. The CR said there was no reason for a resident to go without medications, including Insulin or other medications that require therapeutic levels. Goes in GB An interview on 03/05/18 at 8:45 AM, with RN #5 (Corporate Regional Director of Clinical Systems and Quality Assurance), revealed she had met with Resident #10 and was aware of Resident #10's grievance about medications, including the medication [MEDICATION NAME], not being available upon admission. The RN said Resident #10 missed five (5) scheduled doses of the medication [MEDICATION NAME], which required therapeutic levels to be monitored. The RN said she thought the grievance was resolved because the medications were available on 01/29/18. The RN acknowledged not reviewing the Medical record or MAR to identify delays in obtaining medications other than the [MEDICATION NAME]. The RN said if she had reviewed the MAR and the nurse's notes, she would have called Pharmacy to find out why medications were not delivered or why the medications were not in the ADU (Automatic Dispense Unit) in the facility. An interview on 02/14/18 at 12:00 PM, with Registered Nurse #4 (Corporate Director of Clinical Operations), revealed a significant medication error occurred because Resident #3 received the lesser strength of [MEDICATION NAME]. The RN said according to the Controlled Substance Accountability Sheets Resident #3 was administered the wrong dose, five (5) mg [MEDICATION NAME] on 12/27/17, and 15 mg of [MEDICATION NAME], on 12/31/17, instead of the 20 mg as ordered. Progress notes in the medical record documented the medication was not available and Pharmacy Services had been notified of the unavailability. An interview with the General Manager (GM) of the Pharmacy Provider, on 03/26/18 at 2:25 PM, revealed he had been in the position of GM for three (3) months. The GM acknowledged the Pharmacy Provider's Corporate office is located in Texas (465 miles, according to MapQuest, from the facility.) The GM confirmed the Pharmacy site providing/dispensing medications to the facility, is located in Atlanta Georgia (according to MapQuest information, the site is 373 miles or five hours and 38 minutes in travel time.) The GM acknowledged Emergency Drug Services were available from an Electronic Medication Cabinet in the facility. The GM said he did not know the schedule for ensuring the ADU unit in the facility was serviced, or the location of the person responsible for servicing the unit. The GM said he was aware of Pharmacy staff providing training in the facility on using the ADU sometime in (MONTH) (2018), but was unsure of the dates. The GM said he would have to check on any other information regarding questions about Pharmacy services, because he did not know the answers. An interview with the facility's Chief Operating Officer (COO), on 03/27/18 at 11:15 AM, revealed when the Corporate Office leased the facility's property in (YEAR), the decision was made to maintain the current Pharmacy Vendor to decrease stress and minimize disruption of services. The COO said meetings from the Corporate level, with the Pharmacy Provider, were very clear about expectations and Pharmacy implemented changes in (YEAR). The COO said late in (YEAR), a transition occurred in the Management of the Pharmacy Provider, and the Corporate Office was not made aware of the transition by the Pharmacy Provider until concerns started occurring again in the facility, in (MONTH) (YEAR), about availability of medications. The COO said Corporate issued a notice to the out of state Pharmacy Provider on 02/15/18, concerning a plan of correction. The COO said the Contract with the out of state Pharmacy, located in Georgia, has been canceled related to no resolution to the concerns with availability of medications. The facility was asked to provide any in-service records, regarding procedures for acquiring medications, if they were not available for administration. A review of in-service records dated 11/02/17, 11/17/17, 01/03/18, 01/23/18, and 02/08/18, revealed no documented evidence that staff were educated on procedures to obtain medications from a back-up pharmacy, or what to do if medications were not available. Information, sent from the corporate office, on 4/5/18, revealed the nurse's only contact for unavailable medications, was the Pharmacy Provider, from Atlanta Georgia. The Pharmacy Provider was to provide the back up pharmacy delivery of medications to the facility if unable to deliver them timely. Review of a document, dated 2/15/18, from the Senior Vice President, Chief Risk Officer of the corporation, addressed to the Senior Vice President of the Pharmacy Provider revealed: Notice Regarding (Name of Pharmacy Service Provider) Service Issues. The notice included a formal request to address serious and ongoing service issues that the facility was experiencing with regard to pharmacy services provided by the (Pharmacy Provided). These issues included: 1) State Survey Agency issues which identified failure to deliver insulin, dispensing from the automated machine and checks/balances to ensure safe and accurate provisions of medications. 2) Board of Pharmacy Investigations regarding medication availability and pharmacy services. 3) Medication Availability, which identified documented and ongoing issues at a number of the facilities. 4) Timely Medication Delivery, which include ongoing reports by multiple centers around failures to ensure timely delivery of medications-including pain medications-due to communication breakdowns between the Pharmacy Provider and the back up pharmacy contracted by the Pharmacy Provider. 5) Automated Dispensing Unit (ADU) Breakdown/Issues, which impacts the delivery of appropriate care to patients with examples of no medication for scheduled medication passes, and no communication from the pharmacy to the facility. The notice documented there was an overall service delivery failure that is impacting the delivery of care to the residents. The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ, prior to exit: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medic (TRUNCATED)

CI MS # Based on observation, record review, interview, facility policy review, Resident Council minute review, and complaint review, the facility failed to ensure the availability and/or accessibility of medications from an out of state pharmacy, located in Atlanta Georgia, which was located approximately 373 miles from the facility, to provide continuity of medication administration and availability of the medication from an Automated Dispensing Unit (ADU). The facility also failed to train nursing staff on the availability and how to contact the back up pharmacy for medication or what to do if medication was not available. The facility failed to ensure staff matched medications to the Medication Administration Record (MAR) and physician's orders [REDACTED]. This resulted in a delay of acquiring medications for residents, including new admissions, missed doses of routine medications and/or significant medication errors from not having the medication and/or the correct strength of medication. This affected Resident #1, Resident #2, Resident #3, Resident #4, Resident #9, and Resident #10, for six (6) of 18 sampled residents: Resident #1: Resident #1 was admitted to the facility on [DATE], and had delays of Insulin administration, and lack of availability of [MEDICATION NAME], ordered for Diabetes, due to the medication was not available from the dispensing out of state pharmacy, located 373 miles from the facility, and/or the back up pharmacy, resulting in the potential for Ketoacidosis and Hypo/[MEDICAL CONDITION]. Resident #1 had a range in Blood Glucose (BG) levels from 128-501. Normal levels range from 70-110. Resident #2: Resident #2 was ordered [MEDICATION NAME] 60 mg daily for Depression and staff administered 20 mg daily for at least three (3) months, (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). Nursing staff failed to check the order against the Medication Administration Record (MAR) and the actual medication to ensure the right dose of [MEDICATION NAME] was administered. The out of state pharmacy Manifest revealed the pharmacy had sent 20 mg of [MEDICATION NAME] for the months of (MONTH) (YEAR), (MONTH) and (MONTH) (YEAR), and nurses continued to administer the wrong dose. The facility documented no increase in signs and symptoms of Depression for Resident #2. Resident #3: Resident #3 was admitted on [DATE]. The inability of staff to obtain medications as ordered, from the Automated Dispensing Unit (ADU) provided by the out of state pharmacy, resulted in missed doses of the pain relieving medication [MEDICATION NAME], as ordered by the physician, and a significant medication error of administering a lesser dose of medication at least twice. This error had the potential to result in decreased effectiveness of the medication for pain control. Resident #3 received Tylenol for break-through pain at least six (6) times from (MONTH) through (MONTH) (YEAR). Resident #4: Resident #4 had physician's orders [REDACTED]. Resident #4 had elevated Blood Glucose (BG) Levels greater than 400, for 21 of 124 scheduled testing times. There was no evidence of rechecking the levels in two (2) hours as ordered by the physician to monitor the residents Hypo/[MEDICAL CONDITION]. Resident #4 had orders for Tresiba insulin on 11/2/17, and it was not administered until 11/4/17. The resident received additional insulin twice to bring the Residents BG level down. Resident #4 did not receive [MEDICATION NAME] for two (2) doses, due to the medication not being available for administration in the facility from the out of state pharmacy, the Automated Dispensing Unit (ADU) or the back up pharmacy. Resident #9: Resident #9's physician orders [REDACTED]. There was no evidence to indicate the [MEDICATION NAME] was transcribed to the Medication Administration Record (MAR) or administered to Resident #9 as ordered, for 21 days. Nursing Staff failed to match the MAR and the physician's orders [REDACTED].#9, resulting in the incorrect dose of medication for Resident #9. A Behavioral Health note, documented by the Nurse Practitioner revealed that Resident #9 confirmed she was anxious at times. Resident #10: Resident #10 was admitted to the facility on [DATE], and had delays in receiving medication, including medications [MEDICATION NAME] for Diabetes and [MEDICATION NAME] for [MEDICAL CONDITION] Disorder, due to the unavailability from the out of state pharmacy, the ADU, and/or back up pharmacy. Although there were no documented adverse effects, there was a potential Hypo/[MEDICAL CONDITION] and potential decrease in therapeutic levels of the medication [MEDICATION NAME]. The facility's failure to provide pharmacy services, due to frequent problems with acquiring medications from an out of state pharmacy provider, which was located in Atlanta, Georgia, located more than five (5) hours from the facility, problems with getting medications from the ADU machine located in the facility, staff not matching the medication against the orders/MAR, and inadequate staff knowledge for obtaining medications through a back-up pharmacy plan, resulted in the likelihood of serious injury, harm, impairment or death for Resident #1, Resident #2, Resident #3, Resident #4, Resident #9, Resident #10, and other residents who receive pharmacy services in the facility. The situation was determined to be an Immediate Jeopardy (IJ), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services for Diabetes as ordered. This also affected the other identified Residents. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.45 (a)(b)(1)-(3) Pharmacy Services, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of a contract agreement between the facility and the Pharmacy Provider, dated 10/01/16, revealed the following information: Delivery: Pharmacy shall arrange for all new admissions orders and routine reorders to be delivered by Pharmacy, or another Pharmacy within a timely fashion to meet the needs of the patient. Facility shall use reasonable efforts to aggregate, organize and plan all new admissions orders and routine reorders with Pharmacy to minimize the need for stat orders by Pharmacy or another pharmacy. Emergency Drug Services. Pharmacy will provide any prescriptions and supplies requested by Facility for its Patients, on an emergency basis or stat (statim) basis, within no more than four (4) hours of Pharmacy's receipt of such request. This emergency service will be provided 24 hours per day, seven (7) days per week. In the event Pharmacy cannot timely furnish an ordered medication due to circumstances beyond its control, Pharmacy will make arrangements with another pharmacy to provide such Pharmacy Product to Facility (a Back-Up Pharmacy) as soon as possible. This pharmacy provider was located approximately 373 miles from the facility, per map quest, and over five (5) hours from the facility in drive time. A review of the facility's policy titled, Medication Ordering and Receiving From Pharmacy, dated 06/15, documented as follows: Policy. Medications (meds) and related products are received from the dispensing pharmacy on a timely basis. Quantities of medication sent from pharmacy may vary in accordance with payer status, insurance plan or law. Examples include Medicare A vs (versus) Medicaid, plan limitations on quantities under Medicare Part D and quantity ordered by the prescriber. Stat and emergency medications are ordered as follows: During regular pharmacy hours the pharmacy is notified of the emergency or stat order; the order is then phoned, sent electronically or faxed to the pharmacy. Such medications are delivered and administered as soon as reasonably possible. If available the initial dose is obtained from the emergency kit, when necessary. Review of a written statement, dated 3/28/18, provided by the Chief Operating Officer, identified that the only point of contact the facility nurse had was through the pharmacy provider located out of state. The decision and communication to a back up pharmacy came from the Pharmacist at the dispensing pharmacy provider, located in Atlanta Georgia. A review of the facility's policy titled Medication Administration General Guidelines, dated as reviewed (MONTH) 2014, included the following documentation: Medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). This would also indicate orientation to a back up system. The policy also included: FIVE RIGHTS-Right Resident, right drug, right dose, right route and right times are applied for each medication being administered. A triple check of these five (5) rights is recommended at three (3) steps in the process of preparation of a medication for administration: (1) when the medication is selected. (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. If a medication with a current, active order cannot be located in the medication cart/drawer, either areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. Medications are administered in accordance with written orders of the prescriber. A review of a complaint, received by the State Agency (SA), dated 02/05/18, identified a concern at the facility regarding Quality of Care, including medications not given timely or as ordered by the physician, especially Diabetic medication and not checking blood glucose as ordered. The complaint also revealed concerns of the dispensing machine in the facility, that it was broken at times. Resident #1: The Facility admitted Resident #1 on 10/30/17, with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) was not completed. A review of the Initial Nursing Assessment identified the resident was admitted to the facility on [DATE], via ambulance, from the hospital, with a history of Insulin Dependent Diabetes Mellitus. In an interview, per telephone, on 2/8/18 at 11:20 AM, Resident #1 stated she was admitted to the facility on [DATE], at approximately 6:00 PM. Resident #1 stated that medications were not given to her as ordered, especially the Insulin. Resident #1 said that her Blood Sugars (BS), which were to be done before meals and at bedtime, were not always checked the way they were supposed to be. Review of physician's orders [REDACTED]. The physician's orders [REDACTED]. The sliding scale order directed staff to administer Insulin according to the BG levels every time the BG was checked. If the BG was greater than 401, the resident was to receive 12 units of Insulin and notify the physician. A review of Resident #1's MAR for (MONTH) (YEAR), revealed the [MEDICATION NAME] Insulin was not administered on 10/30/17, for the 8:00 PM dose (Resident admitted at 6:00 PM) or the 8:00 AM dose on 10/31/17. A review of the MAR for (MONTH) (YEAR), documented scheduled times for checking Blood Glucose (BG) levels for Resident #1 as 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. The MAR documented the resident had BG results of greater than 401 on 4 (four) of 10 days, the correct amount of Insulin was provided for the BG results, but not follow-up was documented. There was no documented evidence that the physician had been notified of the results greater than 401 to determine if further action was needed: 11/02/17: BG results 501 11/04/17: BG results 450 11/05/17: BG results 509 11/08/17: BG results 449 Review of a HGB A1C, a test used to monitor BG levels over a period of months, dated 10/31/17, revealed the level was high, with a value of 11.8, with normal ranges of 4.0-6.0. This indicated that Resident #1's BG levels were not being controlled. Review of a Nurse's Note, with no time, dated 11/8/17, documented Resident #1 had no signs or symptoms of Hyper/[DIAGNOSES REDACTED]. This was the only documentation provided of monitoring for signs and symptoms of Hyper/[DIAGNOSES REDACTED] during Resident #1's admission. A review of physician's orders [REDACTED]. The order also included Trazadone 50 milligram (mg) at HS. A review of the (MONTH) (YEAR) MAR, revealed no evidence that Resident #1 received the [MEDICATION NAME] as ordered on [DATE] through home discharge on 11/10/17. The Pharmacy manifest documented that the medication was not delivered to the facility until 11/9/17. A progress note, electronically signed by LPN #11, dated 11/09/17, documented, Pending pharmacy delivery. The MAR documented the first dose of Trazadone on 11/9/17, but the Pharmacy Manifest documented that the medication was delivered the night of 11/7/17. During an interview, on 03/05/18 at 11:15 AM, LPN #11 stated that getting medications for the residents had been a war. She stated that the Pharmacy would say there was no active prescription. Medicines were not delivered or not available through the ADU machine, therefore the medications could not be administered. LPN #11 confirmed the [MEDICATION NAME] was not available on 11/9/17 and she had called the pharmacy provider to let them know. LPN #11 stated that Resident #1's blood sugars, also known as BG levels, was not stable and she needed the [MEDICATION NAME] in conjunction with the insulin. LPN #11 stated that she discussed BG levels with the NP, as she was in the building five (5) days weekly. An interview on 03/01/18 at 2:30 PM, with the NP, revealed the [MEDICATION NAME] was ordered on [DATE], for Resident #1, in an attempt to level out the resident's Blood Sugar (BS). The NP said the resident's BS results had ranges from 168-500, and if the Insulin was increased, the BS could bottom out. The NP said the significance of not administering the [MEDICATION NAME], and providing sliding scale insulin, could have resulted in Ketoacidosis, or complications from [MEDICAL CONDITION]. Interview with Resident #1's Physician on 3/2/18 at 2:00 PM, revealed that giving insulin and not following up on the BG levels, could lead to severe consequences, even life-threatening situations. The Physician stated that he or the NP was available by phone at all times. Resident #2: The facility readmitted Resident #2 on 10/19/16, with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 12/05/17, identified the resident with a Brief Interview for Mental Status (BIMS) Score of 12, which indicated moderately impaired cognition. The resident required limited to extensive assistance with all Activities of Daily Living. Interview with Resident #2 on 2/8/18 at 10:10 AM, revealed she had not always received medications/treatments at times. She did not say which medications she didn't receive. A review of Resident #2's Active physician's orders [REDACTED]. During the medication (Med)-pass observation, on 02/08/18 at 10:10 AM, Licensed Practical Nurse (LPN) #3 obtained an individual dose, in a plastic pouch, from the med cart, which was labeled with Resident #2's name. LPN #3 identified the medication as [MEDICATION NAME] 20 mg for the 02/08/18 morning dose. The LPN confirmed the strength documented on the MAR was for [MEDICATION NAME] 60 mg. LPN #3 attempted to get the [MEDICATION NAME] from the ADU machine, without success. LPN #3 stated that the machine was, locked up and she would have to try to get someone to unlock the machine. She did not administer the 20 mg dose. Review of Resident #2's MAR for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed [MEDICATION NAME] 60 mg had been documented daily for the 8:00 AM dose. Review of the Pharmacy Manifest, which documented medications that were sent from the out of town pharmacy in Atlanta Georgia, revealed [MEDICATION NAME] 20 mg had been dispensed from Pharmacy daily for at least the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), for Resident #2. The MAR documented that [MEDICATION NAME] 20 mg had been documented as administered by the following nurses: LPN #13-twice in (MONTH) (YEAR), and once in (MONTH) (YEAR). LPN #14-documented administration eight (8) times in (MONTH) (YEAR), and six (6) times in (MONTH) (YEAR). LPN #3 had documented administration 16 times in (MONTH) (YEAR), 21 times in (MONTH) (YEAR), and six (6) times in (MONTH) (YEAR). Five (5) other nurses had documented that they had administered [MEDICATION NAME] 60 mg one (1) to two (2) times from (MONTH) (YEAR)-February (YEAR). There was no evidence that the nurses were matching the medication to the MAR to ensure the proper dose of medication as ordered, and continued to give 20 mg of [MEDICATION NAME] to Resident #2, instead of the ordered 60 mg. Interview on 02/13/18 at 2:10 PM, revealed LPN #3 acknowledged signing the MAR as administering [MEDICATION NAME] 60 mg during the months of (MONTH) (YEAR) and January/February (YEAR). LPN #3 stated that she had been administering one (1) purple pill daily and if 20 mg was the only strength being sent, then 20 mg was being given instead of 60 mg. The LPN also confirmed that [MEDICATION NAME] 20 mg was the only strength available on the medication cart labeled for Resident #2 on 02/08/18. LPN #3 confirmed the dose was not accurate, that it should have been 60 mg. She stated she wasn't aware of when or if the order had been changed, she just knew it was a purple pill that she'd been giving. During an interview, on 2/8/18 at 3:15 PM, LPN #3 stated that during med pass, on 2/8/18 at 10:10 AM, she discovered that the [MEDICATION NAME] was not the proper dose because the label didn't match the MAR. LPN #3 confirmed the label on medication should have the right dose, time, name of resident, medication and right route. She stated that nurses should always compare the label to the MAR. She stated a medication error could have occurred if she had not looked at the MAR. She stated the medications are printed from the ADU machine, by a facility nurse at 1:00 PM daily, and once printed, the 3-11 or 11-7 nurse puts the medication in the carts, it depended on whoever had the time. LPN #3 stated that there were from 800-900 medications printed daily, to be put in the medication cart. LPN #3 stated that there were no match backs when the medications were put in the medication cart drawer, but nurses were supposed to do the match back of medications with the MAR when medications were administered. Review of Resident #2's (MONTH) (YEAR) and January/February (YEAR) MARs revealed staff documented monitoring of the resident's anxiety, agitation and crying. There was no documentation of any increased behaviors. During an interview, on 02/12/18 at 1:45 PM, the Physician confirmed she had been made aware of a medication error related to the incorrect administration of [MEDICATION NAME], for Resident #2. The Physician said that Resident #2 would need to be re-evaluated to due to the resident receiving 20 mg of [MEDICATION NAME] instead of the 60 mg, since the resident had not had any problems. Resident #3: The facility admitted Resident #3 to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 12/11/17, revealed Resident #3 had a BIMS score of 14, or cognitively intact. A Pain Assessment, documented on the MDS, identified almost constant pain limiting day-to-day activities. In an interview, on 02/08/18, Resident #3 revealed she was alert and oriented and stated that she had problems with getting her medication when first admitted . The resident said she had nausea and vomiting on admission and had to wait a day and a half before her medicines were available. Resident #3 said she was told by the nurse the medicines had to be ordered from an out of state pharmacy and they would have to wait for them to get there. Resident #3 stated after the initial problem with medications, there had not been any further concerns with her meds and had gotten her pain meds. She stated she was going home on Saturday. A review of physician's orders [REDACTED]. On 12/07/17, orders for [MEDICATION NAME] 20 mg every eight (8) hours for pain; and on 12/21/17, [MEDICATION NAME] 500 mg was ordered twice daily for pain. A review of the MAR and progress notes for (MONTH) (YEAR), documented: [MEDICATION NAME] for the 4:00 PM dose not administered on 12/16/17 and 12/22/17. [MEDICATION NAME] was not administered for the 4:00 PM dose on 12/22/17. [MEDICATION NAME] was not administered until 12/5/17. Progress notes documented the medications were not available, which corresponded to the resident's statement of having nausea and vomiting and not receiving medication for one and one half days. A review of Resident #3's MAR for (MONTH) (YEAR), revealed the following: [MEDICATION NAME]: not administered on 01/21/18 and 01/28/17. Carvedilol: not administered on 01/04/18, 01/07/18, 01/08/18, and 01/09/18. [MEDICATION NAME]: not administered on 01/04/18/, 01/08/18, 01/09/18. A review of the progress notes revealed the medications were not available. Review of the (MONTH) (YEAR) MAR, for Resident #3, revealed on 12/27/17, that [MEDICATION NAME] 20 mg was not administered for the 2:00 PM administration time. Review of the progress note, for Resident #3, regarding the [MEDICATION NAME], revealed, Awaiting medication delivery from pharmacy, machine has only 15 mg, order is for 20 mg. Pharmacy called twice concerning medication. States will be delivered tonight. A review of the MAR for the 10:00 PM administration time of the [MEDICATION NAME], on 12/27/17, and the 2:00 PM administration time on 12/31/17, documented a check mark to indicate [MEDICATION NAME] 20 mg was administered to Resident #3 by LPN #1. Although the MAR documented that [MEDICATION NAME] 20 mg was administered on 12/27/17, and 12/31/17, by LPN #1, review of the Controlled Substance Accountability Sheets identified that two (2) 5 mg [MEDICATION NAME] was signed out and administered on 12/27/17, for the 10:00 PM dose, and 15 mg was signed out and administered on 12/31/17, for the 2:00 PM dose. A review of a handwritten note on Resident #3's Controlled Substance Accountability Sheets, signed by LPN #1, documented: 12/27/17: 11:50 PM (Name of dispensing machine) only had two (2) 5 mg [MEDICATION NAME]. Pharmacy called. Two (2) 5 mg dispensed and administered to Resident #3 at 11:50 PM. On 12/31/17, the Controlled Substance Accountability Sheet documented that [MEDICATION NAME] three (3) 5 mg tablets of [MEDICATION NAME] were dispensed at 2:00 PM, for Resident #3. As a result of [MEDICATION NAME] 20 mg not being available, Resident #3 did not receive the medication for the 2:00 PM dose on 12/27/17, and received a lesser dose at 10:00 PM on 12/27/17, and again on 12/31/17 at 2:00 PM. This could have resulted in pain control issues and ineffective pain relief. There was no documented evidence that a back up pharmacy was notified of the unavailability of the correct dosage of medication, or that the Physician, DON, or Administrative staff was notified of the ADU/Pharmacy issue at that time. In a telephone interview, on 02/13/18 at 3:10 PM, LPN #1 stated that the [MEDICATION NAME] 20 mg was not available for the 10:00 PM dose on 12/27/17, for Resident #3, and the only strength available in the ADU in the facility was a 5 mg [MEDICATION NAME]. The LPN said that medications come from a Pharmacy located out of state and she was not aware of a back-up Pharmacy being available. The LPN acknowledged she administered 5 mg of [MEDICATION NAME] on 12/27/17, because she thought, something was better than nothing. The LPN also acknowledged administering 15 mg on 12/31/17 at 2:00 PM, because 20 mg of [MEDICATION NAME] was not available. LPN #1 confirmed she had only notified the Pharmacy Provider of the unavailability of the [MEDICATION NAME] at the correct strength. An interview on 02/14/18 at 12:00 PM, with Registered Nurse #4, who is the Director of Clinical Operations, confirmed a significant medication error had occurred because Resident #3 received the lesser strength of [MEDICATION NAME]. The RN stated that according to the Controlled Substance Accountability Sheets, Resident #3 was administered the wrong dose, lesser doses of [MEDICATION NAME], on 12/27/17, and on 12/31/17, instead of the 20 mg as ordered, which could have led to insufficient pain relief. A review of a pain assessment, dated 12/28/17 at 10:00 PM, revealed Resident #3's pain level was 5 (0=none and 10=worst). The pain assessment on 12/27/17 at 10:00 PM was a level of 2, and on 12/31/17 at 2:00 PM, the level was 0. Review of the progress notes revealed Resident #3 was administered Tylenol 325 mg for break-through pain six (6) different times, on 1/22/18, 1/24/18, 1/26/18, 2/3/18, and 2/12/18. Review of progress notes, dated 12/16/17, 12/22/17, 1/21/18, and 2/3/18 revealed entries that medications were not available, with no documentation of Administrative staff notified. The entries did not specify which medications. Interview with the Medical Director on 3/2/18 at 2:00 PM, revealed if medications were not available, the nurse should notify the physician or NP for any further instructions. The Medical Director stated that nurses could not alter the dosage or strength of medication without a physician's orders [REDACTED].>Resident #4: The facility readmitted Resident #4 on 10/12/16, with [DIAGNOSES REDACTED]. The MDS with an ARD of 12/12/17, identified the resident with a BIMS of 15, or cognitively intact. Resident #4 required set up help only for Activities of Daily Living. The MDS identified the resident received Insulin Injections daily. Review of a physician's orders [REDACTED].#4 had orders for Tresiba Flextouch Sol Pen (Insulin), 22 units at bedtime. Review of the (MONTH) (YEAR) MAR revealed the Tresiba was not administered until 11/4/17, due to unavailability. Review of Resident #4's Progress Notes, dated 11/2/17 at 10:21 PM, revealed, awaiting for the Tresiba. The note on 11/3/17 at 9:43 PM, revealed, med in route from pharmacy. There was no documented evidence that administrative staff or the physician was notified of the unavailability of the Flextouch Insulin pen from the out of state pharmacy provider. Review of the Progress Notes revealed Resident #4's BG was elevated on 11/2/17. At 11:00 AM-597, at 4:00 PM-439, and at 8:00 PM-318. On 11/3/17 at 6:00 AM-249, at 11:00 AM 403, at 4:00 PM 571 and at 8:00 PM:571. Sliding scale insulin was administered. On 11/3/17 at 11:54, the Progress Note revealed Resident #4's BG was elevated this shift to 571. The Nurse Practitioner was notified and gave orders for 15 units of [MEDICATION NAME] and recheck in one (1) hour, with results of 543. Another order was given for 15 more units of [MEDICATION NAME] and recheck in one (1) hour, with results of 525. The note documented: No signs of Hyperglycemic reactions noted, blood sugars decreasing, will continue to monitor. Review of Nurse's Notes, dated 1/17/17, no time, revealed there were no signs of Hyper/[DIAGNOSES REDACTED]. No other information was provided for monitoring Resident #4's status for the above mentioned dates. Review of a Hemaglobin (HGB) A1C, which tests the blood sugar over a period of months, dated 1/27/18, revealed results of 10.1, and on 2/13/18, revealed a result of 8.1, with normal ranges of 4.0-6.0, which indicated the level was high. Interview with the NP on 2/14/18 at 9:30 AM, revealed the Resident #4's BG ranged from 89-590 and it was important to keep her from going into a danger zone for BG greater than 400, and going to the hospital. Review of a physician's orders [REDACTED]. Review of the MAR, for (MONTH) (YEAR), revealed [MEDICATION NAME] was not administered on 2/3/18 at 6:00 PM, or on 2/4/18 at 6:00 AM, indicated by a 7. The progress notes revealed the [MEDICATION NAME] was not in stock and not in the med cart. Interview with LPN #6 on 2/13/18 at 11:15 AM, revealed that a 7 on the MAR indicated the need to see the progress note. The 7 may mean the medication was not administered or not available. She stated that sometimes the medication did not arrive after being ordered, and pharmacy had to be called again, meaning the medication would be late again. LPN #6 stated that it sometimes took two (2) days before the medication was available. She stated, It's a missed dose if it's not available. Resident #9: Review of the Face Sheet revealed Resident #9 was admitted on [DATE], and readmitted to the facility on ,[DATE] 7/17, with [DIAGNOSES REDACTED]. Review of Resident #9's Quarterly MDS, with an ARD of 11/15/17, revealed Resident #9 had a BIMS score of 14, which indicated Resident #9 had no cognitive impairment. Interview with Resident #9 on 2/13/18 at 8:10 AM, revealed she had an altercation with another resident and had asked the Psychiatric Nurse Practitioner (NP) to give her something for her nerves, because she just felt so nervous all of the time. She stated she did not have other concerns at present. Review of Resident #9's physician orders [REDACTED]. Review of Resident #9's MAR revealed no evidence that [MEDICATION NAME] 150 mg twice daily was transcribed to the MAR or administered to Resident #9. The staff kept administering the 100 mg of [MEDICATION NAME] twice daily. Nursing Staff failed to match the order to the MAR, resulting in the incorrect dose of medication. Interview with the Psychiatric NP on 02/13/18 at 9:45 AM, revealed she ordered an increase in Resident #9's [MEDICATION NAME] due to the resident's depression, and to help control her compulsive behavior. The Nurse Practitioner stated she wanted the resident to receive the medication as ordered, and would contact the facility to carry out the order. A review of the Behavior Health Note, documented by the NP on 1/23/18, revealed she was unable to engage the resident to discuss the altercation with another resident, however, Resident #9 admitted to feeling anxious at times. The NP ordered the increase of [MEDICATION NAME] to 150 mg twice daily at that time. During an interview, on 3/2/18 at 2:00 PM, Resident #9's Primary Physician, revealed when a medication is ordered, the expectation is that the resident will receive the medication as ordered. The Physician stated that if the medication is not available, the n

CI MS # Based on record review, interview, and facility policy review, the facility's administration failed to manage the facility in a manner to ensure Pharmacy Services were provided from an out of state Pharmacy provider, located in Atlanta Georgia, in a manner to meet the needs of the residents of the facility as evidenced by the facility: (a) failed to ensure medications acquired from an out of state Pharmacy Provider were available/or accessible for residents receiving medications. (b) failed to ensure medications received in the facility were matched and compared to physician's orders [REDACTED]. (c) failed to ensure the Pharmacy Provider maintained an Automated Dispensing Unit (ADU) in the facility to ensure routine medications and Emergency medications could be dispensed without frequent problems of the machine jamming, and/or medications not available in the right strength, or not dispensing at all. (d) failed to ensure Licensed staff administered medications at the right time in the right strength and monitor the administration of medications as ordered by the physician and care planned. (e) failed to act upon complaints voiced by Resident Council for the past four (4) of six (6) months regarding medications being given late, or not at all, and provide resolutions in a timely manner, (f) failed to identify the magnitude/ or significance of ensuring accessibility and/or availability of medications to meet the needs of residents in the facility. Although the facility's Administration was aware of complaints from Resident Council about medications being late or not given at all, grievances from residents about medications not being available, and complaints from staff about accessibility/or availability of medications, the Administration failed to implement corrective action and monitor/assess the effectiveness of those actions, through the facility's Quality Assurance (QA) committee, to address complaints, grievances/concerns regarding Pharmacy Services in the facility. The out of state Pharmacy was located in Georgia, 373 miles away from the facility, and more than five (5) hours in travel time (according to MapQuest information). The facility had an agreement with an out of state Pharmacy Provider to provide Pharmacy Products in a prompt and timely manner for the residents of the facility. The Pharmacy Provider also maintained an Automated Dispensing Unit (ADU) within the facility for dispensing of routine medications and Emergency medication supply. If the medications were not available through the ADU, the medications were to be ordered from the Dispensing Pharmacy located in Georgia. The Pharmacy was responsible for arranging for all new admission orders [REDACTED]. The agreement also stated that the Pharmacy Provider would provide prescriptions and supplies requested by the facility on an emergency basis within no more than (4) four hours' time frame for 24 hours/day, seven (7) days per week. According to the agreement, if Pharmacy could not timely furnish an ordered medication the Pharmacy Provider would make arrangements with a Back-up Pharmacy to provide the Pharmacy Product. The facility's Administration had been made aware of complaints from Resident Council and Ombudsman about medications being late or not given at all, grievances from resident about medications not being available, and complaints from staff about accessibility/or availability of medications. Interviews with staff during the survey revealed problems with the availability/or accessibility of medications including frequent jamming of the ADU, medications not being available, unable to dispense medications from the ADU, incomplete shipments from the Pharmacy, lack of communication/feedback from pharmacy, and lack of knowledge of a back-up pharmacy and/or what to do if medications were not available. The facility's failure of Administration to ensure residents received and monitored medications as ordered by the Physician, resulted resulted in delays in shipments, incomplete shipments, and medications not being available at administration time, which also resulted in significant medication errors, missed doses, failure to follow physician's orders [REDACTED]. This placed Residents #1, #2, #3, #4, #6, #9, #10, and other residents with medication orders, at risk for the likelihood of serious injury, harm, impairment or death. The facility's census identified 134 residents, seven (7) of 18 residents) Resident #1: Resident #1 was admitted to the facility on [DATE], from the hospital with a history of Diabetes Mellitus. Resident #1's Medical Doctor (MD) had specific orders to administer Insulin, monitor the Blood Glucose (BG) levels and report to the MD is the BG was greater than 401. The Nurse Practitioner (NP) ordered [MEDICATION NAME] on 11/06/17, for Resident #1's BG level. Insulin and the [MEDICATION NAME] was not administered as ordered by the Physician, related to the unavailability of the medications from the out of state Pharmacy and/or Back up Pharmacy. Resident #1 had a range of BG levels of 128-501, (normal 70-110) and an elevated A1C (test of blood sugar levels over a period of time) of 11.8 (normal range 4.0-6.0). The facility failed to follow physician's orders [REDACTED]. Although the facility had no documented adverse effects of Hypo/[MEDICAL CONDITION] for Resident #1, an interview with the Nurse Practitioner (NP) revealed that BG levels greater than 400 was a danger zone, leading to Ketoacidosis. Resident #2: Resident #2 had a physician's orders [REDACTED]. The facility failed to match the medication dispensed/delivered by an out of state Pharmacy Provider with the physician's orders [REDACTED].#2's depression. Resident #3: Resident #3 was admitted to the facility from the hospital on [DATE], with a [MEDICAL CONDITION] lower extremity. The Resident's Physician ordered [MEDICATION NAME] 20 mg to be given every eight (8) hours for relief of pain. Although the Pharmacy Provider was notified of the unavailability of the [MEDICATION NAME] 20 mg, the out of state Provider failed to provide the correct strength from a Back up Pharmacy. As a result of the correct strength not being available, a lesser strength of [MEDICATION NAME] that was available from the Automated Dispensing Unit (ADU) in the facility, was administered to Resident #3. Tylenol was ordered and administered for Resident #3's break-through pain six (6) times from (MONTH) to (MONTH) (YEAR). The facility failed to follow the physician's orders [REDACTED]. Pain assessments by facility staff documented Resident #3 had a pain level ranging from 0-8 (with 0 being no pain and 10 the worst pain). Resident #3 was discharged home with medications on 02/17/18. Resident #4: Resident #4 had physician's orders [REDACTED]. The pen was not available to be administered on 11/02/17 and 11/03/17, from the out of state Pharmacy or a Back-up Pharmacy. Resident #4's BG levels were elevated to 571 at 4:00 PM and 8:00 PM on 11/03/17, and had to be given two (2) extra doses of [MEDICATION NAME] (fast acting Insulin) to bring the BG level down. Resident #4 also had Physician orders [REDACTED]. The amount of Insulin was to be administered according to Blood Glucose (BG) levels. If the level was greater than 400, the order was to administer 12 units, recheck the BG level in two (2) hours, and call the physician. Resident #4 had elevated BG levels greater than 400 for 21 of 124 testing times during (MONTH) (YEAR) and four (4) of eight (8) days reviewed in (MONTH) (YEAR). There was no evidence of rechecking the BG levels as ordered, or notifying the physician. According to interviews with Resident #4's Physician/Nurse Practitioner, BG levels greater than 400 are in a danger zone, and administering Insulin without monitoring the effectiveness, could lead to severe consequences including Hypo/[MEDICAL CONDITION] or Ketoacidosis. Resident #6: Resident #6 had a physician's orders [REDACTED]. Licensed staff administered pain medication without consistently assessing the level, location and intensity of pain prior to administering the pain-relieving medication and completing a follow up on the effectiveness, after administration. Failure to complete assessments could have resulted in ineffective pain relief and/or the need for additional medications. Resident #6's pain scale, when assessments were completed, ranged from 3-8 (on a scale of 0 with no pain and 10 the worst). Resident #9: Resident #9 was ordered an increase in dosage of Welbutrin from 100 mg two (2) times a day to 150 mg two (2) times a day, following an assessment by the Psychiatric Nurse Practitioner, on 01/23/18. According to the Behavior Health Progress Notes, Resident #9 admitted feeling anxious during the assessment on 01/23/18. The facility failed to transcribe the order, match the order to the MAR, and the resident did not receive the increased strength for 21 days, resulting in risk of increased Depression/Anxiety for Resident #9. Resident #10: Resident #10 was admitted to the facility from the hospital on [DATE], with a history of [MEDICAL CONDITION] Disorder. The resident had physician's orders [REDACTED]. [MEDICATION NAME] is a medication that requires therapeutic levels, and Resident #10 missed the first five (5) doses because the medication was not available from the out of state Pharmacy Provider and not provided from a Back-up Pharmacy. The Resident's Responsible Party filed a grievance on 01/29/18. The grievance was signed by the Administrator on 02/03/18. The RP said they were told after admission, by staff, that the medications were not available because they had to be ordered from a Pharmacy in Georgia. Resident #10 was admitted to the hospital on [DATE], with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE], and the facility documented that a [MEDICATION NAME] Level was obtained on 03/05/18, and the resident showed no signs of depression or bazaar behaviors. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services and as ordered. This also affected Resident #2, #3, #4, #6, #9 and #10. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.70, Administration, F835, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the job description for Administrator, dated 01/04/2017, identified the key responsibilities of the administrator including: Ensures the patient and resident is at the center of every decision made; ensures that quality care and services is provided to all patients, residents and that it meets the satisfaction of the patient, resident, family, physicians and other partners; and leads an effective Quality Assurance and Process Improvement (QAPI) Program. A review of the facility's policy for the QAPI Center Plan, dated 01/13/18, identified QAPI Committee members to include the Administrator, Medical Director, Director of Nursing, and Social Services. The QAPI Center Plan documented as follows: The QAPI Committee reports to the Governing Body and is responsible for the following: Developing and implementing appropriate plans of action to correct identified quality deficiencies, determining areas for PIPs (Performance Improvement Plans), analyzing the AQPI performance to identify and follow up on areas of concern and/or opportunities for improvement. Regular reports and updates will be provided to the company, management, team members, resident/family council, external partners. This will be accomplished through multiple communications channels such as team member meeting, new hire orientation, memos, resident and family councils, administrative reports and posting minutes on the shared drive making them available to the supporting infrastructure. QAPI Guideline: PIPs is a concentrated effort on a particular problem in one area of the center or center wide: it involves gathering information systematically to clarify issues or problems an intervening for improvement. The center conducts PIPs to examine and improve care or services in areas identified as needing attention. Stage I. Identify Causes and Alternatives: Work to identify causes of the problem using tools. 2. Start to implement your action plan. Be sure to collect data as you go, to help you evaluate your plan in action. 3. Study, did your plan result in improvement. 4. Reflect on plan and outcomes, if a different approach would be more successful, return to Stage 1. The QAPI Center Plan also identified the Administrator and Director of Nursing as part of the Governance and Leadership of the Center and documented as follows: The Governing body is responsible for: Identifying and prioritizing problems based on performance indicator data: Incorporating resident and team member input; ensuring that corrective actions address gaps in the system and are evaluated for effectiveness; setting clear expectations for safety, quality, rights, choices, and respect; ensuring adequate resources exist to conduct QAPI efforts; ensuring contingency plans for program sustainability during times of leadership transition. A review of Resident Council Minutes documented as follows: 09/11/17: Meds given late or not at all. 10/02/17: Meds given late or not at all. Given to Social Services and ADON (Assistant Director of Nursing during Stand-up meeting at 9:00 AM on 10/04/17. 11/06/17: Meds given late or not at all. 02/05/18: Residents states they only get half their medications on the weekend. A telephone interview with the Ombudsman on 02/09/18 at 9:30 AM, revealed residents had been complaining at resident council meeting for the past four (4)-five (5) months about medications being late or not given at all. The Ombudsman said residents reported that they were told that the machine was out of order all the time, out of paper, or Pharmacy didn't send their medicines. The Ombudsman said there were so many complaints the residents had invited the Administrator and Director of Nursing (DON) to attend the Resident Council meeting on 02/05/18. Interviews were conducted during the survey, with the Licensed Practical Nurses (LPNs), and revealed repeated concerns regarding availability and accessibility of medications from the out of state Pharmacy Provider and the ADU in the facility. Interviews revealed problems with dispensing medications from a machine located in the facility including paper jamming, plastic pouches empty, machine showed medication in stock but failed to dispense, lack of communication by Pharmacy if scripts were not readable , incomplete shipments, lack of availability of medications, no deliveries on weekends, limited amount of medications dispensed from machine, and lack of knowledge of how to obtain medications from a back-up pharmacy if the medication was not available. The interviews revealed administrative staff were aware of the concerns. These interviews included the following staff, time and dates: LPN #1 on 02/12/18 at 3:25 PM, LPN #2 on 02/12/18 at 3:30 PM, LPN #9 on 02/13/18 at 8:55 AM, LPN #5 on 02/13/18 at 3:45 PM, LPN #6 on 02/13/18 at 11:15 AM, LPN #7 on 02/14/18 at 9:55 AM LPN #10 on 03/01/18 at 5:00 PM An interview on 03/05/18 at 11:15 AM, with Licensed Practical Nurse (LPN) #11, revealed concerns from nurses about availability of medications had been discussed in QAPI meetings. The LPN said she first attended QAPI meetings in (MONTH) (YEAR), and the Administrator was aware of the issues. An interview with the Director of Nursing (DNS) on 03/01/18 at 8:30 AM, revealed the QAPI committee had not been effective, because the facility was still having problems with medications not being available. An interview with the Administrator on 02/14/18 at 10:30 AM revealed she had been at the facility since April, (YEAR), and had QAPI meetings once a month. The Administrator said she was not aware of any recent concerns about availability of medications, however she had attended a meeting (unsure of date but thought late last year in (YEAR)) at the hospital because of a concern about medications not being available for new admissions. The Administrator said she thought that issue was resolved with the hospital. The Administrator confirmed being aware of Resident #10's grievance (newly admitted resident), dated 01/29/18, about medications not being available after admission to the facility. The Administrator said she planned to bring the grievance to the next QAPI meeting in February. The Administrator said she didn't think concerns from Resident Council were included on the QAPI form, however she had attended Resident Council on 02/05/18, and was made aware of resident council concerns about medications being late and/or issues with medication. During a second interview on 03/01/18 at 3:30 PM, the Administrator acknowledged being responsible for the facility. The Administrator acknowledged being aware of concerns of the functioning of the ADU for medications in the facility, and concerns about availability of medications. The Administrator said she had notified Corporate staff several times of concerns, including the Senior Director of Clinical Operations, the Director of Clinical Operations and the Regional Director of Clinical Systems and Quality Assurance, regarding problems with acquiring medications/or dispensing medications from the ADU machine and/or obtaining meds from the out of state Pharmacy. The Administrator acknowledged she was not sure of the Pharmacy Provider's location other than the Pharmacy was located out of state. The Administrator said the facility should have addressed ongoing concerns related to medications not being available. The Administrator said the facility should have put monitoring tools in place, given the magnitude of the problems, put tracking in place to identify concerns, kept logs to identify problems, and followed up on those concerns to ensure medications were available and grievances resolved for residents in the facility. The facility was asked to provide any in-service records regarding procedures for acquiring medications, if not available. A review of in-service records dated 11/02/17, 11/17/17, 01/03/18, 01/23/18, and 02/08/18, revealed no documented evidence of any education on procedures to obtain medications from a back-up pharmacy or what to do if medications were not available. Information sent from the corporate office on 4/5/18, revealed the nurse's only contact for medications was the Pharmacy Provider, from Georgia. The Pharmacy Provider was to provide the back up pharmacy delivery of medications. The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ, prior to exit: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medication availability has continued on a daily basis and is being conducted by the medication and supervising nurses. Education was provided by the Director of Clinical Education (DCE) and Director of Nursing Services (DNS) to eight (8) Registered Nurses (RN) and 23 Licensed Practical Nurses (LPN) regarding medication administration on 2/8/18, through 2/22/18, and then started again 2/28/18, when surveyors identified further concerns. This education was provided by the DNS at times for all shifts. All nurses were also educated by DCE/DNS regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medications for all shifts. No staff member worked until this education was given. No agency staff is being utilized. All supervising and medication nurses, totaling eight (8) RNs and 23 LPNs, were educated regarding sliding scale accuchecks results and insulins and following MD orders with follow up regarding accucheck results on 2/8/18-2/22/18 by DCE/DNS. Education provided by the DNS and supervising nurses began again on 2/28/18 after surveyors returned. This education was provided at times for all shifts. No staff member worked until this education was given. No agency staff is being utilized. Systemic changes and monitoring have been developed, presented and approved by the Administrator, DNS, and Medical Director on 2/19/18, at 1:00 pm, during the Quality Assurance Performance Improvement (QAPI) meeting. The systemic changes and guidelines include algorithms for medication ordering, reordering and availability. These changes will be prepared for monthly reporting at QAPI. Education has been provided by the DNS/ADNS/DCE to all eight (8) RNs and 23 LPNs concerning the guidelines and changes on 2/22/18, and again after the immediate jeopardy identification on 2/28/18. This education provided for all shifts regarding the systematic changes includes: when new orders are received or orders for a new admission, the assigned medication nurse will review medication cart to assure medication is in center; should the medication not be available, the assigned medication nurse will notify the supervisor immediately as well as fax the order to the pharmacy; should the medication not arrive by administration time or within a two (2) hour timeframe, the physician will be notified by the nurse supervisor for follow-up orders. A pharmacy representative will be in the center at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability for at least 30 days and then two (2) times per week thereafter. A QAPI meeting was held on 2/19/18 at 1:00 pm. In attendance were the Administrator, DNS, ADNS, Medical Director, Social Workers, Unit Managers and other department leaders. Also, in attendance, were support resource members from the corporate office. Findings from the initial medication cart checks were discussed, along with the follow-up assignments, including medication cart match back, Medication Administration Record [REDACTED]. Findings related to follow up for pain medication and sliding scale insulins were discussed with follow-up assignment to include monitoring of the Medication Administration Record [REDACTED]. After the 2/28/18 QAPI monitoring of medication carts and medication availability continued, along with medication administration documentation and follow up of accucheck results. Education continued to the staff and medication nurses. Participants in this meeting were the Administrator, DNS, ADNS, Nurse Consultant, and Medical Director. NOTE/ADDENDUM : The facility sent documentation, dated 3/5/18, which advised the Out of State pharmacy of termination of the pharmacy contract. On 03/06/18 the State Agency (SA) validated through record review and interview with staff, the Director of Nursing Service (DNS) and the Director of Clinical Operations (DCO) that the facility had implemented the following measures to remove the Immediate jeopardy, prior to exit: A: Resident #1: Validated a HgbAIC was obtained on 10/31/17 on Resident #1 and reviewed by the Medical Director. The resident was discharged on [DATE]. b. Resident #2: Validated Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order clarified on 02/12/18. c. Resident #3. Validated Resident #3 had pain monitoring assessments by the medication nurse on 02/08/18. Resident #3 was assessed with [REDACTED]. d. Resident #4: Validated Resident #4 had a HgbAIC level completed on 02/13/18 with the results being 8.1 (H) and reviewed by the Nurse Practitioner. e. Resident #6: Validated pain monitoring assessments by the medication nurse for pain on 02/08/18, 02/10/18, 2/11/18. Validated pain assessment was evaluated by the medication nurse as effective. f. Resident #9: Validated by review of physician's orders [REDACTED]. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] was clarified on 02/13/18. f. Resident #10: Validated Resident #10 had a [MEDICATION NAME] Level drawn on 03/01/18. The results were 1.5 and reviewed by the Medical Director. The SA validated through record review and interview on 03/06/18, with the DCO, that a 100% match back was completed on all medication carts beginning on 02/10/18, 02/11/18, 02/15/18 and 02/16/18. Interviews with two (2) Registered Nurses (RN) and six (6) Licensed Practical Nurses (LPN) validated the match backs were completed. The SA validated through record review and interview on 03/06/18, with the DCO that med carts were checked daily by medication nurse and verified by the DNS and ADNS that performance was completed daily. Interviews with 2 RNs and 6 LPNs validated daily checks of the med carts. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the Director of Clinical Education (DCE)/DNS beginning 02/08/18 through 02/22/18, and again on 02/28/18, for eight (8) RNs and 23 LPNs regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medication for all shifts. Interviews from three (3) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the DCE and DNS for eight (8) RNs and 23 LPNs on 02/08/18 through 02/22/18, and 02/28/18, regarding sliding scale accucheck results and insulins and following MD orders with follow up regarding accucheck results. Interviews with two (2) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO of systemic changes and monitoring guidelines, including medication ordering, reordering and availability, being developed, presented and approved by the Administrator, DNS, and Medical Director on 02/19/18. Interviews with the DNS, Administrator, Senior Director of Clinical Operations and Medical Director validated the systemic changes of monitoring of sliding scale insulin and pain assessments. The SA validated through record review and interview on 03/06/18, with the DCO of sign in sheets of education provided to eight (8) RNs and 23 LPNs on 02/22/18, and 02/28/18, by the DNS/ADNS/DCE of education regarding the systematic changes regarding ordering, reordering and availability of medications. Interviews with three (3) RNs and six (6) LPNs validated attendance and knowledge of in-service. The SA validated through record review and interview with the DCO on 03/06/18, of sign-in sheets of education beginning 02/28/18, provided to all staff by the DNS/ADNS for eight (8) RNs and 23 LPNs regarding Med cart match back, ordering medication, availability, administering medications, monitoring and documentation of Sliding Scale Insulin and pain medication. Interviews with three (3) RNs and six (6) LPNs validated attendance and knowledge of in-service. The SA validated through interview on 03/06/18, including the DCO and Pharmacy Representative on 03/06/18, of the pharmacy representative being in the facility at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability. Interviews with one (1) RNs and three (3) LPNs validated training by the (TRUNCATED)

CI MS # Based on record review, complaint investigation, interview, grievance review, Quality Assurance sign-in sheet review, and facility policy review, the facility's Quality Assurance and Performance (QAPI) Committee failed to develop, implement corrective action, and monitor the corrective interventions, to address grievances/concerns regarding the availability, accessibility, administration, and monitoring of medications, as ordered by the physician, for residents in the facility. Facility Administration was aware of issues with availability of medication from the out of state contracted pharmacy, which was located in Atlanta Georgia, 373 miles from the facility, and over five (5) hours drive time. The facility also failed to ensure staff were trained on the pharmacy procedures, including knowledge of a back up pharmacy plan. The staff failed to do matchbacks of medication to the order/Medication Administration Record). Failure to implement corrective action resulted in missed dosages, medications not available at administration times, a delay in obtaining medications for new admissions, significant medication errors, failure to administer medications as ordered by the physician and to monitor the effectiveness of those medications. These concerns were identified for five (5) of 18 sampled residents, Residents #1, #3, #4, #6, and #10, as evidenced by: 1. Resident #1 was admitted to the facility on [DATE], from the hospital, with specific physician's orders [REDACTED]. Resident #1 also had an order on 11/06/17, for [MEDICATION NAME] 500 milligram (mg) daily for diabetic control, which was never administered prior to the resident's discharge home. The facility failed ensure the availability and administration of the Insulin and [MEDICATION NAME] as ordered by the Physician. The facility also failed to monitor Blood Glucose (BG) levels as ordered, resulting in potential for severe consequences including Hyper/[DIAGNOSES REDACTED] and/or Ketoacidosis. 2. Resident #3 was admitted to the facility on [DATE], with physician's orders [REDACTED]. The facility failed to administer the correct strength on at least two (2)occasions due to unavailability of the correct strength from the Automated Dispensing Unit (ADU), or a back up pharmacy, resulting in a risk for ineffective pain management. 3. Resident #4 was admitted with orders for Insulin and BG monitoring. Resident #4 did not receive insulin as ordered due to unavailability from the out of state pharmacy, and received PRN (as needed) Insulin for elevated BG levels without re-checking and/or monitoring the effectiveness of the Sliding Scale Insulin. This resulted in the resident's continued high BG levels and a risk for severe consequences including Hypo/[MEDICAL CONDITION] and/or Ketoacidosis. 4. Resident #6 was ordered [MEDICATION NAME] 5-325 mg PRN for pain. Resident #6 received 20 doses of the medication in (MONTH) (YEAR), of which 15 doses had no monitoring for the level of pain, or follow up for the effectiveness, resulting in a risk of ineffective pain relief. 5. Resident #10 was admitted on [DATE], from the hospital, with orders for [MEDICATION NAME] 300 mg to be administered two (2) times a day. [MEDICATION NAME] is a medication that requires therapeutic level monitoring. The [MEDICATION NAME] was not available for administration for the first five (5) doses, due to non delivery from the pharmacy provider or the back up pharmacy. Administration was made aware of this medication issue, which potentially affected the therapeutic level of the medication and risk of ineffective psychiatric behavior control. The facility's failure to implement the QAPI program, and put corrective actions in place, after becoming aware of issues with medication availability from the out of state pharmacy provider in Atlanta Georgia, resulted in the likelihood of serious injury, harm, impairment or death for Residents #1, Resident #3, Resident #4, Resident #6, Resident #10, and other residents who received medication in the facility. There was a risk of severe life-threatening complications including Hypo/[MEDICAL CONDITION], and Ketoacidosis for Resident #1 and Resident #4, and other residents at risk who had orders for diabetic medications; at risk for ineffective pain management for Resident #3 and Resident #6, and other residents with pain medication; and risk for altered therapeutic levels of medications for Resident #10 and other residents who received medications requiring therapeutic levels. The situation was determined to be an Immediate Jeopardy (IJ), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services for Diabetes as ordered due to unavailability. This also affected Resident #3, who did not receive the correct doses of pain medication due to unavailability; Resident #4, who did not receive monitoring of blood sugars as ordered; Resident #6, who did not receive monitoring of pain medications/effectiveness and Resident #10, who did not receive [MEDICATION NAME] as ordered upon admission due to unavailability. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.75 (g)(2)(ii), Quality Assurance, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy on Quality Assurance and Performance Improvement (QAPI) with a review date of 01/03/18, included the following documentation: Mission statement: Improve every life we touch by providing exceptional healthcare and exceeding expectations. QAPI is a data-driven, responsive and proactive process for the purposes of evaluating indicators of the outcomes of care, quality of life and service with a focus on improvement within our center. QAPI involves team members at all levels of the organization and the activities include the following: Identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan; and continually monitor the effectiveness of our intervention. The center uses a systemic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, an implications of a change. Systemic actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. Review of the POS [REDACTED]. A complaint investigation was conducted beginning 02/08/18 through 02/14/18, and 02/28/18 through 03/06/18. Complaint MS # was substantiated regarding quality of care, specifically about medication availability, administration and monitoring of medications. A review of Resident Council Minutes revealed complaints of availability and timely administration of medication for four (4) of 6 months. Documentation included: 09/11/17: Meds given late or not at all, 10/02/17: Meds given late or not at all. Given to Social Services and Assistant Director of Nursing (ADON) during Stand-up meeting at 9:00 AM on 10/04/17. On 11/06/17: Meds given late or not at all, 02/05/18: Residents state they only get half their medications on the weekend. The facility failed to ensure the Resident Council concerns were taken to QA for further actions. Resident #1: A telephone interview with Resident #1 on 02/08/18 at 11:20 AM, revealed she was admitted to the facility on [DATE], at approximately 6:00 PM. Resident #1 said medications were not given as they were ordered, especially her Insulin. Resident #1 also stated that BG levels were not checked as ordered. Review of the medical record revealed Resident #1 was admitted on [DATE], from the hospital, with physician's orders [REDACTED]. Although ordered on [DATE], the [MEDICATION NAME] was not available from the out of state or backup Pharmacy until 11/09/17. Resident #1 was discharged home on[DATE], without receiving the [MEDICATION NAME] as ordered. Progress notes documented the medication was not available. Resident #3: An interview with Resident #3, on 02/08/18, revealed she had problems about receiving medication on admission. The resident said she had to wait a day and a half before her medicines were available. Resident #3 said she was told by the nurse the medicines had to be ordered from the out of state pharmacy and was not available. Resident #3 was admitted to the facility on [DATE], and had a physician's orders [REDACTED]. The facility failed to administer the correct strength due to unavailability of the correct strength from the out of state pharmacy provider. The resident did not receive the medication on 12/27/17 at 2:00 PM, and lesser doses of 10 mg on 12/27/17 at 10:00 PM, and 15 mg 12/31/17 at 2:00 PM. The Nurse documented that the lesser doses were all that was available and that the pharmacy had been notified. Resident #4: Review of Resident #4's physician's orders [REDACTED]. If BG level 400 or greater, give 12 units, recheck in two (2) hours and if still 400 plus, call the physician. Resident #4 had orders for Tresebia Insulin injections 22 units at bedtime on 11/2/17, and was not available, per documentation in progress notes, for 11/2/17 and 11/3/17. Resident #4's BG was elevated on 11/3/17, and required two (2) additional doses of insulin. Resident #4 received the sliding scale Insulin for elevated BG levels without consistent monitoring for the effectiveness of Sliding Scale Insulin administration, not checking results over 400 in two (2) hours to determine if the BG levels were coming down, not checking the BG as ordered, and not administering the insulin as ordered, resulted in the risk for severe consequences including Hypo/[MEDICAL CONDITION] or Ketoacidosis. Resident #6: An interview with Resident #6 on 02/13/18 at 2:00 PM, revealed the resident received the pain medication [MEDICATION NAME] ([MEDICATION NAME]), about 20 times during (MONTH) (YEAR). Resident #6 had a physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. However, a review of the Controlled Substance Accountability Sheet, revealed Resident #6 received [MEDICATION NAME]/Apap 20 times for the month of (MONTH) (YEAR). The facility failed to consistently assess the level of pain, and monitor for the effectiveness of pain relief, with the additional doses of [MEDICATION NAME] that was administered to Resident #6. Resident #10: During an interview, on 02/12/18 at 11:45 AM, Resident #10's Responsible Party (RP) stated that the resident did not receive all of his medications upon admission for three (3) days, including the medication [MEDICATION NAME]. The RP said they were told the facility did not have all the medications (meds), the meds had been ordered from an out of state pharmacy and they would have to wait for the meds to be delivered. The RP stated the [MEDICATION NAME] was the only medication she knew for sure that wasn't available. Resident #10 was admitted to the facility on [DATE], with physician's orders [REDACTED]. The [MEDICATION NAME] was not available for the first five (5) doses, beginning on admission, potentially affecting the therapeutic level of the medication and affecting the resident's behavior. Resident #10 filed a grievance on 01/29/18, for not receiving medications, including the five (5) doses of [MEDICATION NAME]. Review of the grievance, dated 01/29/18, initiated by the Social Services Designee and signed by the Regional Director of Clinical Systems and Quality Assurance/RN #5, on 1/29/18, and the Administrator on 02/03/18, revealed that Resident #10 had missed five (5) doses of [MEDICATION NAME]. This indicated that the facility had been made aware of the issues with residents not receiving their medication timely, upon admission, and did not take the issue to QA at that time. An interview with the SSD on 02/12/18 at 1:00 PM, revealed most complaints come from the Rehab Unit, a breakdown between hospital and admission; and/or medications not given or not available. This indicated that the facility social services department was aware of complaints of medication not being available/administered timely. A telephone interview with the Ombudsman on 02/09/18 at 9:30 AM, revealed ongoing complaints from residents every month about medications being late or not given at all. Complaints included the dispensing machine was out of order all the time or out of paper, Pharmacy didn't send medicine and meds were not given. The Ombudsman stated that there were so many complaints the Administrator and Director of Nursing (DON) had been invited, and came, to the Resident Council meeting on 02/05/18. This indicated the facility was aware of the issues with medication and had not presented the information to QA at that time. Interviews were conducted during the survey with Licensed Practical Nurses (LPNs) regarding availability and accessibility of medications, including the following: LPN #1 on 02/12/18 at 3:25 PM, LPN #2 on 02/12/18 at 3:30 PM, LPN #9 on 02/13/18 at 8:55 AM, LPN #5 on 02/13/18 at 3:45 PM, LPN #6 on 02/13/18 at 11:15 AM, LPN #7 on 02/14/18 at 9:55 AM LPN #10 on 03/01/18 at 5:00 PM The interviews with the LPNs revealed ongoing problems with obtaining medication from an out of state Pharmacy provider, problems with dispensing medications from a machine located in the facility, machine jamming and couldn't pull out meds, the paper or plastic gets jammed, problems with communication with Pharmacy, incomplete shipments, lack of availability of medications, no deliveries on weekends, limited amount of medications dispensed from machine, and no knowledge of obtaining medications through a back-up pharmacy plan. The LPNs had documented unavailability of medications in the progress notes. An interview with the Nurse Practitioner (NP) on 02/14/18 at 9:30 AM, revealed she had brought issues to the Nurses' attention about frequent complaints from residents about medications not being available. The NP said complaints were more prevalent among new admissions. The NP said these residents come from the hospital with a history of Diabetes,[MEDICAL CONDITION], and blood pressure concerns and the residents needed their medications upon admission and/or when ordered. This indicated awareness of issues with medication availability from the MD/NP, but had not been presented and/or acted upon in QA. An interview with the Administrator on 02/14/18 at 10:30 AM, revealed the QAPI committee meets one (1) time a month with every department head. The Administrator said if medications were not available the staff should have called Pharmacy or the DON. The facility was asked to provide any recent in-service records regarding procedures for acquiring medications if not available. A review of in-service records dated 11/02/17, 11/17/17, 01/03/18, 01/23/18, and 02/08/18 was provided. There was no evidence of education on procedures to obtain medications from a back-up pharmacy, or what to do if the medication was not available. The DON/Administrator was unable to provide documented education on the procedure of what to do if medications weren't available. An interview on 03/01/18 at 8:00 AM, with the Maintenance Director, revealed he attended QAPI meetings monthly and daily stand up meetings. He said all managers, Department Heads, DON, and Assistant Director of Nursing (ADON) attends the meeting which is led by the Administrator. The Maintenance Director said topics the last few weeks included talks about residents complaining about not getting their medications on time. This indicated that the facility was aware of medication concerns. There was no documented evidence that a plan was put into place as a result of discussing issues with medication. An interview on 03/05/18 at 11:15 AM, with LPN #11 revealed the LPN first attended QAPI meetings in (MONTH) (YEAR). The LPN said an issue was discussed about availability of medications. The LPN said the only discussion/intervention was for the DON to keep faxes and receipts to pharmacy. LPN #11 stated nurses had concerns about medication being available. There was no evidence that a monitoring tool or corrective actions were implemented to address medication issues or a back-up pharmacy plan to ensure availability of medication to residents, especially new admits. An interview with the DON on 03/01/18 at 8:30 AM, revealed the QA committee had not been effective in issues related to medication availability. She revealed she was aware of medication complaints, but they had not been addressed through the Quality Assurance Committee and corrective actions had not been put in place to fix the issues. She stated they did discuss concerns in daily stand up meetings. An interview on 02/14/18 at 12:30 PM, with the Registered Pharmacy (Rph) Consultant, revealed she was not aware of any concerns of availability of medications for new admissions. Review of the Job Description for the Clinical Pharmacist, dated 5/30/13, revealed the general purpose was to participate in continuous quality improvement and risk management activities that focus on medications or medication related systems that place patients at the highest risk for negative outcomes. The Pharmacy Consultant confirmed that she did on occasion observe medication passes with the Nurses and reviewed the medical record. An interview with the Administrator on 03/01/18 at 3:30 PM, revealed she was responsible for the facility and her job was to ensure quality care and services is provided to all residents. The Administrator stated that the facility should have put monitoring tools in place, given the magnitude of ongoing concerns related to medications not being available, put tracking in place to identify concerns and follow up. The Administrator said she had notified Corporate multiple times of problems with acquiring medications and/or dispensing medications from the machine in the facility or obtaining meds from the out of state pharmacy. The Administrator acknowledged the QA program had not been fully implemented for the concerns with medication availability and the pharmacy provider. An interview on 03/02/18 at 8:45 AM, with the Corporate Representative (Senior Director of Clinical Operations) (CR) revealed the Corporate Office had been aware of some concerns about obtaining medications from Pharmacy but the Survey was the culmination of the severity of the issues. The Corporate Representative (CR) said prior to the survey, concerns were addressed in the facility and communicated to the Corporate Office. She said Corporate did not realize the magnitude of the issues until surveyors were in the building. The Corporate Representative said there was a potential for negative outcome, including complications for diabetics with residents not receiving medications, not following physician's orders [REDACTED]. The CR said there was no reason for a resident to go without medications, including Insulin or other medications that require therapeutic levels. The Corporate representative acknowledged the QA process had not been implemented. During an interview, on 3/27/18 at 11:15 AM, the facility's Chief Operating Officer (COO), revealed when the Corporate Office leased the facility's property in (YEAR), the decision was made to maintain the current Pharmacy Vendor to decrease stress and minimize disruption of services. The COO said meetings from the Corporate level with the Pharmacy Provider were very clear about expectations and Pharmacy implemented changes in (YEAR). The COO said late in (YEAR), a transition occurred in the Management of the Pharmacy Provider, and the Corporate Office was not made aware of the transition until concerns started occurring again in the facility about medications. The COO said Corporate issued a notice to the Pharmacy Provider on 02/15/18, concerning a plan of correction. The COO said the Contract with the out of state Pharmacy had been canceled related to no resolution to the concerns with availability of medications. Review of QA sign in sheets revealed the QA committee met monthly with the Medical Director attending. There was no documented evidence provided that the facility's QAPI Committee initiated corrective action and monitoring to assess the effectiveness of any interventions to ensure medications were available, dispensed and monitored, as ordered by the Physician, after the facility was made aware of medicines not being available to meet residents' needs, especially for newly admitted residents. The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ, prior to exit: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medication availability has continued on a daily basis and is being conducted by the medication and supervising nurses. Education was provided by the Director of Clinical Education (DCE) and Director of Nursing Services (DNS) to eight (8) Registered Nurses (RN) and 23 Licensed Practical Nurses (LPN) regarding medication administration on 2/8/18, through 2/22/18, and then started again 2/28/18, when surveyors identified further concerns. This education was provided by the DNS at times for all shifts. All nurses were also educated by DCE/DNS regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medications for all shifts. No staff member worked until this education was given. No agency staff is being utilized. All supervising and medication nurses, totaling eight (8) RNs and 23 LPNs, were educated regarding sliding scale accuchecks results and insulins and following MD orders with follow up regarding accucheck results on 2/8/18-2/22/18 by DCE/DNS. Education provided by the DNS and supervising nurses began again on 2/28/18 after surveyors returned. This education was provided at times for all shifts. No staff member worked until this education was given. No agency staff is being utilized. Systemic changes and monitoring have been developed, presented and approved by the Administrator, DNS, and Medical Director on 2/19/18, at 1:00 pm, during the Quality Assurance Performance Improvement (QAPI) meeting. The systemic changes and guidelines include algorithms for medication ordering, reordering and availability. These changes will be prepared for monthly reporting at QAPI. Education has been provided by the DNS/ADNS/DCE to all eight (8) RNs and 23 LPNs concerning the guidelines and changes on 2/22/18, and again after the immediate jeopardy identification on 2/28/18. This education provided for all shifts regarding the systematic changes includes: when new orders are received or orders for a new admission, the assigned medication nurse will review medication cart to assure medication is in center; should the medication not be available, the assigned medication nurse will notify the supervisor immediately as well as fax the order to the pharmacy; should the medication not arrive by administration time or within a two (2) hour timeframe, the physician will be notified by the nurse supervisor for follow-up orders. A pharmacy representative will be in the center at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability for at least 30 days and then two (2) times per week thereafter. A QAPI meeting was held on 2/19/18 at 1:00 pm. In attendance were the Administrator, DNS, ADNS, Medical Director, Social Workers, Unit Managers and other department leaders. Also, in attendance, were support resource members from the corporate office. Findings from the initial medication cart checks were discussed, along with the follow-up assignments, including medication cart match back, Medication Administration Record [REDACTED]. Findings related to follow up for pain medication and sliding scale insulins were discussed with follow-up assignment to include monitoring of the Medication Administration Record [REDACTED]. After the 2/28/18 QAPI monitoring of medication carts and medication availability continued, along with medication administration documentation and follow up of accucheck results. Education continued to the staff and medication nurses. Participants in this meeting were the Administrator, DNS, ADNS, Nurse Consultant, and Medical Director. NOTE/ADDENDUM : The facility sent documentation, dated 3/5/18, which advised the Out of State pharmacy of termination of the pharmacy contract. On 03/06/18 the State Agency (SA) validated through record review and interview with staff, the Director of Nursing Service (DNS) and the Director of Clinical Operations (DCO) that the facility had implemented the following measures to remove the Immediate jeopardy, prior to exit: A: Resident #1: Validated a HgbAIC was obtained on 10/31/17 on Resident #1 and reviewed by the Medical Director. The resident was discharged on [DATE]. b. Resident #2: Validated Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order clarified on 02/12/18. c. Resident #3. Validated Resident #3 had pain monitoring assessments by the medication nurse on 02/08/18. Resident #3 was assessed with [REDACTED]. d. Resident #4: Validated Resident #4 had a HgbAIC level completed on 02/13/18 with the results being 8.1 (H) and reviewed by the Nurse Practitioner. e. Resident #6: Validated pain monitoring assessments by the medication nurse for pain on 02/08/18, 02/10/18, 2/11/18. Validated pain assessment was evaluated by the medication nurse as effective. f. Resident #9: Validated by review of physician's orders [REDACTED]. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] was clarified on 02/13/18. f. Resident #10: Validated Resident #10 had a [MEDICATION NAME] Level drawn on 03/01/18. The results were 1.5 and reviewed by the Medical Director. The SA validated through record review and interview on 03/06/18, with the DCO, that a 100% match back was completed on all medication carts beginning on 02/10/18, 02/11/18, 02/15/18 and 02/16/18. Interviews with two (2) Registered Nurses (RN) and six (6) Licensed Practical Nurses (LPN) validated the match backs were completed. The SA validated through record review and interview on 03/06/18, with the DCO that med carts were checked daily by medication nurse and verified by the DNS and ADNS that performance was completed daily. Interviews with 2 RNs and 6 LPNs validated daily checks of the med carts. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the Director of Clinical Education (DCE)/DNS beginning 02/08/18 through 02/22/18, and again on 02/28/18, for eight (8) RNs and 23 LPNs regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medication for all shifts. Interviews from three (3) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the DCE and DNS for eight (8) RNs and 23 LPNs on 02/08/18 through 02/22/18, and 02/28/18, regarding sliding scale accucheck results and insulins and following MD orders with follow up regarding accucheck results. Interviews with two (2) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO of systemic changes and monitoring guidelines, including medication ordering, reordering and availability, being developed, presented and approved by the Admin (TRUNCATED)

CI MS # Based on observation, record review, staff interview, and facility policy review, the facility failed to administer medications in a manner to prevent significant medication errors. This came about as a result of unavailability of medications from an out of state pharmacy, which was located in Atlanta, Georgia, which was approximately 373 miles from the facility, and/or back up pharmacy. Unavailability of the right dose of medication from the Automated Dispensing Unit (ADU), provided by the out of town pharmacy provider, lack of facility matchbacks for accurate order/medication, and the lack of staff knowledge/training on what to do if the medication was not available, affected Resident #1, #2, #3, #9 and #10, five (5) of 18 sampled residents reviewed for medication administration in a manner to prevent significant medication errors, as evidenced by: (1). Resident #1 was not administered the scheduled doses of ordered medications for Diabetes Mellitus including [MEDICATION NAME] Insulin, sliding scale Insulin, and [MEDICATION NAME], due to the out of state pharmacy did not have the medication available through the ADU and/or back up pharmacy, resulting in medication error of omission and potential for Ketoacidosis and complications of Hyper/[DIAGNOSES REDACTED], for Resident #1. (2). Resident #2 was administered the incorrect dosage of [MEDICATION NAME] for more than 60 days, due to the out of state pharmacy sent the wrong dosage to the Automated Dispensing Unit (ADU), and the staff administered the medication without matching it with the correct order. This resulted in a medication error for correct dosage for more than 60 days, potentially affecting the resident's level of Anxiety/Depression. (3). Resident #3 was administered the incorrect strength of [MEDICATION NAME] because the correct dosage was not provided by the out of state pharmacy, not available in the ADU, and staff did not follow up on getting the right dosage of the [MEDICATION NAME]. This resulted in medication error of correct dosage, potentially affecting the resident's relief of pain. (4). Resident #9 was administered the incorrect dosage of [MEDICATION NAME] for 21 days, due to the medication order not being transcribed to the Medication Administration Record (MAR) by nursing staff, and orders not matched against the MAR by nursing staff, resulting in medication error of dosage. This potentially affected mood and behavior of Resident #9. (5). Resident #10 missed five (5) doses of the medication [MEDICATION NAME], which was ordered for [MEDICAL CONDITION] Disorder, due to the unavailability of the medication from the out of state pharmacy/ADU, matchback of medication not performed and/or the lack of knowledge by staff of what to do if the medication was not available. This resulted a in medication error of omission, for five (5) doses, potentially affecting the therapeutic levels of the medication. The facility's failure to administer medication, due to the unavailability of the medication from the Atlanta Georgia pharmacy (either in strength or dosage), problems with the ADU containing the correct dosage of medication, the lack of staff performing matchbacks of medication, and/or the lack of knowledge of staff of what to do to obtain the medication, resulted in the likelihood of serious injury, harm, impairment or death for the identified Residents #1, #2, #3, #9 and #10, and other residents who received medication at the facility. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services and as ordered. This also affected Resident #2, #3, #9 and #10. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.45 (f)(2) Significant Medication Error, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy titled, Preparation and General Guidelines: Medication Administration General Guidelines, revised 2014, included the following documentation: FIVE RIGHTS-Right Resident, right drug, right dose, right route and right times are applied for each medication being administered. A triple check of these five (5) rights is recommended at three (3) steps in the process of preparation of a medication for administration: (1) when the medication is selected. (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. If a medication with a current, active order cannot be located in the medication cart/drawer, either areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. Medications are administered in accordance with written orders of the prescriber. Review of the Safe Medication Preparation, provided by the Nurse Consultant as the procedure for medication error, not dated, revealed Reporting medication errors: Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing, administering the wrong medication, by wrong route, in wrong time interval, and extra doses or failing to administer medications. A review of a complaint, received by the State Agency (SA), dated 02/05/18, identified a concern regarding Quality of Care, including medications not given timely or as ordered by the physician, especially Diabetic medication. Resident #1: The Facility admitted Resident #1 on 10/30/17, with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) was not completed. A review of the Initial Nursing Assessment identified the resident was admitted via ambulance from the hospital, with a history of Insulin Dependent Diabetes Mellitus. Resident #1 was noted to be alert and oriented. In an interview, per telephone, on 2/8/18 at 11:20 AM, Resident #1 stated she was admitted on [DATE], at approximately 6:00 PM. Resident #1 said medications were not available and given as ordered, especially Insulin. A review of physician's orders [REDACTED]. A review of a physician's orders [REDACTED].#1's Diabetes, due to elevated BG levels. A review of the Medication Administration Record (MAR) for (MONTH) (YEAR), for Resident #1, revealed the [MEDICATION NAME] Insulin was not administered on 10/30/17 at 8:00 PM, or 10/31/18 at 8:00 AM, resulting in a medication error for omission. A review of the (MONTH) (YEAR) MAR, revealed no evidence that Resident #1 received the [MEDICATION NAME], as ordered on [DATE]. The resident was discharged home on[DATE], without receiving any doses of [MEDICATION NAME] from 11/06/17 thru 11/10/17, resulting in an omission error and Resident #1's continued elevated BG. A review of the MAR for (MONTH) (YEAR), documented the scheduled times for checking the Blood Glucose (BG) levels for Resident #1 as 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. The MAR revealed the resident had BG results of greater than 401 on four (4) of 10 days including the following: 11/02/17 at 11:00 AM-BG results 501; 11/04/17 at 11:00 AM-BG results 450; 11/05/17 at 8:00 PM-BG results 509; and 11/08/17 at 11:00 AM-BG results 449. There was no documented evidence that the MD was notified for BG levels above 401, in order to have further instructions for Resident #1's [MEDICAL CONDITION] and staff failed to give the [MEDICATION NAME] as ordered to help reduce the BG levels. An interview on 03/01/18 at 2:30 PM, with the Nurse Practitioner (NP), revealed [MEDICATION NAME] was ordered on [DATE], for Resident #1, in an attempt to level out the resident's Blood Sugar (BS). The NP said the resident's BS ranged from 168-500, and if Insulin was increased, then the BS could bottom out. The NP said not administering the [MEDICATION NAME] was significant because it could have resulted in the resident going into Ketoacidosis or complications from [MEDICAL CONDITION]. The NP confirmed Resident #1's BS was not stable. An interview with the Medical Director, on 03/02/18 at 2:00 PM, revealed that Insulin should be available at administration times for Diabetics upon admission or shortly after, and those medications that required therapeutic levels should be available within at least 24 hours. During an interview on 03/02/18 at 2:55 PM, the Director of Nursing (DON) stated that not giving medications, especially Insulin, could place resident's at risk for life-threatening complications. She acknowledged the medication errors of omission in the Insulin and [MEDICATION NAME] for Resident #1. Review of a HGB A1C, a test used to monitor BG levels over a period of months, dated 10/31/17, revealed Resident #1 had a high level of 11.8, with the normal ranges of HGB A1C at 4.0-6.0. Resident #2: The facility readmitted Resident #2 on 10/19/16, with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 12/05/17, identified Resident #2 with a BIMS Score of 12, or moderately impaired cognition. A review of the physician's orders [REDACTED]. During a Medication (Med) pass observation, on 02/08/18 at 10:10 AM, Licensed Practical Nurse (LPN) #3 obtained an individual dose in a plastic pouch, from the medication cart, labeled with Resident #2's name and dosage of the medication which read: [MEDICATION NAME] 20 mg, 02/08/18, morning. The LPN compared the dose to the MAR and said the strength documented on the MAR was 60 mg, which would be an incorrect dose. LPN #3 did not give the 20 mg of [MEDICATION NAME] and attempted to get the correct dosage from the ADU, without success. She stated the machine was locked up and she would have to get someone to fix it. A review of the MAR for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), documented that [MEDICATION NAME] 60 mg had been administered daily for the 8:00 AM dose, for Resident #2, however, a review of the Pharmacy Manifest revealed the [MEDICATION NAME] 20 mg was sent daily from the out of state Pharmacy, for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), for Resident #2. There was no indication that Resident #2 had received 60 mg of [MEDICATION NAME] daily. Nurses had continued to give what the pharmacy had sent, which was [MEDICATION NAME] 20 mg for over three (3) months. This resulted in the failure of nursing staff to do matchbacks with the order/MAR/medication. A significant medication error was made in the dosage that was much less than ordered. During an interview on 02/13/18 at 2:10 PM, LPN #3 reviewed the MAR for (MONTH) and (MONTH) (YEAR), and acknowledged signing the MAR as administering [MEDICATION NAME] 60 mg for Resident #2 on multiple occasions. The LPN said she had been administering one (1) pill daily, a purple pill, and if 20 mg was the only strength being sent, then 20 mg of [MEDICATION NAME] was being given instead of 60 mg. The LPN also confirmed that only one (1) pill of [MEDICATION NAME] 20 mg was available on the medication cart labeled for Resident #2, on 02/08/18. LPN #3 stated the other nurses had to be giving the wrong dose as well. LPN #3 acknowledged the medication error in giving the wrong dose of medication to Resident #2. Interview with LPN #3, on 2/8/18 at 3:15 PM, revealed that the label on the medication should have the right dose, time, name of resident, medication and right route. She stated that nurses should compare the label to the MAR. LPN #3 stated that a medication error could have occurred if she had not looked at the MAR during the med pass on 2/8/18 at 10:10 AM. She stated the medications are printed from the ADU machine by a nurse/staff at 1:00 PM each day, and once printed, the 3-11 or 11-7 nurse put the medication in the carts, depending on whoever had the time. LPN #3 stated that there were from 800-900 medications printed out daily from the ADU. LPN #3 stated that there were no match backs when medications are put in the drawer, but when medications are administered, the nurses are supposed to match the medication with MAR at that time, to ensure the right medication. A review of the MAR for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), revealed [MEDICATION NAME] 60 mg had been administered to Resident #2 daily for the 8:00 AM dose, however, review of the Pharmacy Manifest, (medications that were sent from the out of town pharmacy in Atlanta Georgia), revealed [MEDICATION NAME] 20 mg had been dispensed from the Pharmacy daily, for at least the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), for Resident #2. The MAR documented that [MEDICATION NAME] 20 mg had been administered by LPN #13 twice in (MONTH) (YEAR), and once in (MONTH) (YEAR). LPN #14 documented administration of [MEDICATION NAME] 60 mg eight (8) times in (MONTH) (YEAR), and six (6) times in (MONTH) (YEAR). LPN #3 had documented administration of [MEDICATION NAME] 60 mg 16 times in (MONTH) (YEAR), 21 times in (MONTH) (YEAR), and six (6) times of the eight (8) days reviewed in (MONTH) (YEAR). Five (5) other nurses had documented administering the [MEDICATION NAME] 60 mg, one (1) to two (2) times from (MONTH) (YEAR)-February (YEAR), for the 8:00 AM dose daily, for Resident #2. There was no evidence that the nurses were matching the medication to the orders/MAR to ensure the right dosage of [MEDICATION NAME] was administered to prevent medication errors, for over 60 days. Review of the MAR for the three (3) months revealed documentation that staff monitored Resident #2 for adverse effects of anxiety, agitation, and crying, without any evidence of increase of anxiety. An interview with the Physician, on 02/12/18 at 1:45 PM, revealed she had been made aware of a significant medication error related to the incorrect administration of [MEDICATION NAME] for Resident #2. The Physician said the resident's order was for 60 mg, however the resident would need to be re-evaluated before initiating the 60 mg, since the resident had actually been receiving 20 mg since at least December. Resident #3: The facility admitted Resident #3 on 12/04/17, with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 12/11/17, documented that Resident #3 had a BIMS score of 14, or cognitively intact. The MDS documented a Pain Assessment, which identified pain limiting day-to-day activities. A review of Resident #3's physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR), revealed that on 12/27/17, the 2:00 PM dose of [MEDICATION NAME] 20 mg was not documented as administered to Resident #3. The Progress Notes revealed documentation: Awaiting medication delivery from pharmacy. Pharmacy called twice. States will be delivered tonight. There was no documented evidence that the nurse advised the DON/Administration of the medication not available from the out of state pharmacy, ADU, or back up system. Review of the (MONTH) (YEAR) MAR, documented on 12/27/17, the 10:00 PM dose of [MEDICATION NAME] had a check mark with initials of LPN #1, to indicate [MEDICATION NAME] 20 mg was administered. On 12/31/17, the 2:00 PM dose had a check mark with initials to indicate [MEDICATION NAME] 20 mg was administered by LPN #1. A review of the Controlled Substance Accountability sheet, documented that two (2) [MEDICATION NAME] 5 mg tablets were signed out for administration on 12/27/17 at 11:50 PM. A handwritten note on the sign out page revealed that the ADU machine only had two (2) [MEDICATION NAME] 5 mg tablets, and Pharmacy was called. A separate Accountability Sheet documented that three (3) [MEDICATION NAME] 5 mg tablets were available and signed out on 12/31/17, at 2:00 PM, for Resident #3. Both Accountability Sheets were signed by LPN #1. This indicated incorrect dosages of the [MEDICATION NAME] were administered to Resident #3 at these times. Review of an ADU generated report revealed that [MEDICATION NAME] was dispensed for Resident #3 on the following dates and at the following strengths: 12/6/17 one (1) 5 mg tablet; 12/8/17 one (1) 5 mg tablet; 12/27/17 two (2) 5 mg tablets; 12/30/17 three (3) 5 mg tablets; 1/13/18 three (3) 5 mg tablets and 1/28/18 two (2) 5 mg tablets. There were no times documented to indicate when the [MEDICATION NAME] was dispensed, or if the correct doses were administered to Resident #3. A telephone interview on 02/13/18 at 3:10 PM, with LPN #1, revealed the [MEDICATION NAME] 20 mg was not available for the 10:00 PM dose on 12/27/17, for Resident #3, and was not administered. The LPN said the Pharmacy was located out of state, and that she called Pharmacy about not having the right dose. LPN #1 stated that she was not aware of a back-up Pharmacy, only to call the Pharmacy Provider. The LPN said the only strength available in the machine was [MEDICATION NAME] 5 mg and she administered it. The LPN acknowledged that the lesser strength could have potentially affected the resident's pain relief. The LPN said she administered the 5 mg because she thought, something was better than nothing. The LPN also acknowledged administering 15 mg of [MEDICATION NAME] on 12/31/17, because [MEDICATION NAME] 20 mg was not available. LPN #1 confirmed she did not follow physician's orders [REDACTED]. Review of a disciplinary action form revealed LPN #1 received a write up, dated 2/23/18, for the significant medication error; which read, Gross negligence in performance of job duties. An interview on 02/14/18 at 12:00 PM, with RN #4, revealed a significant medication error occurred when Resident #3 received the wrong dose, a lesser dose of [MEDICATION NAME]. RN #4 confirmed that Resident #3 was administered the wrong, a lesser dose of [MEDICATION NAME] on 12/27/17, and 12/31/17, instead of the [MEDICATION NAME] 20 mg, as ordered by the physician. An interview with the Medical Director (MD), on 03/02/18 at 2:00 PM, revealed Nurses should follow physician's orders [REDACTED]. The MD said if medications are not available, the nurse should call the physician or Nurse Practitioner (NP) for further instructions. The MD stated that nurses could not alter dosages or strength of a medication without a physician's orders [REDACTED].>Resident #9: Review of the facility's Face Sheet revealed Resident #9 was admitted on [DATE], and readmitted on ,[DATE] 7/17, with [DIAGNOSES REDACTED]. Review of the MDS, with an ARD of 11/15/17, revealed Resident #9 had a BIMS score of 14, which indicated the resident was cognitively intact. Interview on 02/13/18 at 8:10 AM, with Resident #9, revealed she had asked the Psychiatric NP, after an altercation with another resident, to give her something for her nerves because she felt like she needed it. Review of Resident #9's physician orders [REDACTED]. On 01/23/18, there were orders for an increase of the [MEDICATION NAME] to 150 mg two (2) times a day. There was no documented evidence to indicate the order for the increased [MEDICATION NAME] was transcribed to the MAR, or that the resident received the correct dose of the [MEDICATION NAME] as ordered, for 21 days. The failure of the nurses to match the orders with the MAR/medication, caused the medication error to occur for 21 days. Interview on 02/13/18 at 9:45 AM, with the Psychiatric NP, revealed she ordered the increase of Resident #9's [MEDICATION NAME] due to depression and to help control her compulsive behaviors. The NP confirmed the medication should have been administered as ordered and this was a medication error. Review of the Behavioral Health note, documented by the NP on 1/23/18, revealed the resident did not want to talk about the altercation with the other resident, but did admit to being anxious. Interview on 02/13/18 at 10:45 AM, with RN #1, revealed the order for Resident #9's increased [MEDICATION NAME] was never put into the system, therefore the medication was not administered to the resident. RN #1 acknowledged the medication error. Resident #10: The facility admitted Resident #10 on 01/25/18, from the hospital with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 02/01/18, revealed staff identified the resident with memory problems. An interview on 02/12/18 at 11:45 AM, with Resident #10, and the resident's Responsible Party (RP), revealed the RP had voiced prior concerns about Resident #10 not receiving medications as ordered when admitted . The RP said when Resident #9 was admitted , on 01/25/18, he did not receive some of his medication (med) for three (3) days. The RP said they were told the facility did not have all the medications, the meds had been ordered from an out of state pharmacy and would have to wait for them to be delivered before they could administer the medications. The RP knew about Resident #10 not receiving [MEDICATION NAME] for sure, but not sure what else the resident didn't receive. A review of a Customer Concern/Grievance Communication Form, dated 1/29/18, initiated by Social Services (SS), revealed that Resident #10 complained of not receiving his medications for three (3)days. The form documented that [MEDICATION NAME] doses were missed five (5) times. The form was signed by Registered Nurse #5, Regional Director of Clinical Systems and Quality Assurance, on 1/29/18, and signed by the Administrator on 2/03/18. No other medications were listed on the form as being missed. A review of Resident #10's physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR), revealed [MEDICATION NAME] 300 mg was not administered, as ordered by the Physician, at the following scheduled administration times: 01/26/18: 8:00 AM or 4:00 PM dose 01/27/18: 8:00 AM or 4:00 PM dose. 01/28/18: 8:00 AM dose. A review of progress notes documented that medications were not in stock, not available and/or orders had been refaxed to pharmacy. An interview on 03/05/18 at 8:45 AM, with RN #5, Regional Director of Clinical Systems and Quality Assurance, revealed she met with Resident #10 on 01/29/18, regarding the resident's grievance about missing doses of medication. RN #5 stated that Resident #5 had missed five (5) doses of [MEDICATION NAME] when first admitted . RN #5 stated that missed doses of [MEDICATION NAME] could have affected the therapeutic level of the medication and the resident's behaviors could have escalated. RN #5 confirmed this was a medication error. RN #5 confirmed she did not review the MAR for further medication omissions. During an interview, on 03/02/18 at 2:00 PM, the Medical Director stated that she expected residents to get the best care possible, including medicines given timely. The MD said that medications that require therapeutic levels should be available within 24 hours after admission. An interview with LPN #7, on 02/14/18 at 9:55 AM, revealed she encountered problems obtaining medications and/or medications being available. LPN #7 said the ADU would jam, and if the medication was not in the drawer or if there is not a delivery, then the resident didn't get the medicine. LPN #7 stated that she had not been told and was not aware of a back-up Pharmacy plan. She stated if the medication was not available in the drawer, or the ADU, the resident just didn't get the medication, thus a medication error would occur. An interview on 02/13/18 at 3:45 PM, with LPN #5, revealed she had encountered problems obtaining medications. LPN #5 said she was not aware of a back-up pharmacy plan or how to use it. The facility was asked to provide any in-service records regarding procedures for acquiring medications if they were not available. A review of in-service records dated 11/02/17, 11/17/17, 01/03/18, 01/23/18, and 02/08/18, revealed no documented evidence of any education on procedures of how to obtain medications from a back-up pharmacy or what to do if medications were not available. Review of a written response from the Senior Director of Clinical Operations, dated 4/6/18 at 11:23 AM, revealed: As part of our nursing standards of practice and our guidelines, we use evidenced based practice which states that 'communication with the interdisciplinary team (IDT) ensures that the six (6) rights of medication administration are followed.' Best practice guidelines for safe medication administration includes clinical decision-making competency, theoretic competency, and clinical practice competency. We expect and educate our staff to follow these guidelines. If the medication is not available, which is one of the six (6) rights, the expectation is to notify the IDT, which includes the physician or NP, for further instruction. The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ, prior to exit: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medication availability has continued on a daily basis and is being conducted by the medication and supervising nurses. Education was provided by the Director of Clinical Education (DCE) and Director of Nursing Services (DNS) to eight (8) Registered Nurses (RN) and 23 Licensed Practical Nurses (LPN) regarding medication administration on 2/8/18, through 2/22/18, and then started again 2/28/18, when surveyors identified further concerns. This education was provided by the DNS at times for all shifts. All nurses were also educated by DCE/DNS regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medications for all shifts. No staff member worked until this education was given. No agency staff is being utilized. All supervising and medication nurses, totaling eight (8) RNs and 23 LPNs, were educated regarding sliding scale accuchecks results and insulins and following MD orders with follow up regarding accucheck results on 2/8/18-2/22/18 by DCE/DNS. Education provided by the DNS and supervising nurses began again on 2/28/18 after surveyors returned. This education was provided at times for all shifts. No staff member worked until this education was given. No agency staff is being utilized. Systemic changes and monitoring have been developed, presented and approved by the Administrator, DNS, and Medical Director on 2/19/18, at 1:00 pm, during the Quality Assurance Performance Improvement (QAPI) meeting. The systemic changes and guidelines include algorithms for medication ordering, reordering and availability. These changes will be prepared for monthly reporting at QAPI. Education has been provided by the DNS/ADNS/DCE to all eight (8) RNs and 23 LPNs concerning the guidelines and changes on 2/22/18, and again after the immediate jeopardy identification on 2/28/18. This education provided for all shifts regarding the systematic changes includes: when new orders are received or orders for a new admission, the assigned medication nurse will review medication cart to assure medication is in center; should the medication not be available, the assigned medication nurse will notify the supervisor immediately as well as fax the order to the pharmacy; should the medication not arrive by administration time or within a two (2) hour timeframe, the physician will be notified by the nurse supervisor for follow-up orders. A pharmacy representative will be in the center at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability for at least 30 days and then two (2) times per week thereafter. A QAPI meeting was held on 2/19/18 at 1:00 pm. In attendance were the Administrator, DNS, ADNS, Medical Director, Social Workers, Unit Managers and other department leaders. Also, in attendance, were support resource members from the corporate office. Findings from the initial medication cart checks were discussed, along with the follow-up assignments, including medication cart match back, medication administration record monitoring for holes and missed accucheck follow up or medications and medication availability. Findings related to follow up for pain medication and sliding scale insulins were discussed with follow-up assignment to include monitoring of the medication administration record and nurses' progress note review. Another QAPI was completed on 2/28/18 at 7:00 pm w (TRUNCATED)

CI MS # Based on record review, staff interview, and policy review, the facility failed to ensure current professional standard of practice, according to the Mississippi Nurse Practice Law, were followed for providing and monitoring ordered medications. The facility failed to provide pharmacy services, due to frequent problems with acquiring medications from an out of state Pharmacy Provider, which was located in Atlanta, Georgia, approximately 373 miles from the facility, with a travel time of over five (5) hours, and without adequate provision of a back-up local pharmacy provider, per pharmacy contract. The contract specified arrangement for all new admission/routine orders to be delivered within a timely fashion, with a turn around time of no more than four (4) hours emergency basis, and/or provided by the back up pharmacy. The facility failed to ensure that medications from the out of state pharmacy and/or Automated Dispensing Unit (ADU) machine were available, accessible, and administered in the right strength, and at the right time. The ADU was located in the facility and furnished/stocked by the out of state pharmacy provider. The facility failed to ensure communication and complete shipments from the out of state pharmacy. Staff failed to match the medication against the Medication Administration Record (MAR) and physician's orders [REDACTED]. The facility failed to ensure knowledge/training of staff for obtaining medications through a back-up plan, or what to do when medications were not available. This affected Residents #1, #2, #3, #4, #9 and #10, for six (6) of 18 sampled residents, as evidenced by: Resident #1: Resident #1 was admitted to the facility on [DATE], from the hospital with physician's orders [REDACTED]. The facility failed to follow physician's orders [REDACTED]. Failure to follow the physician's orders [REDACTED]. Although the facility had no documented adverse effects of Hypo/[MEDICAL CONDITION] for Resident #1, the resident had a range in Blood Sugars from 128-501, and the Hemoglobin A1C (test of blood sugar over a period of time) was elevated at 11.8 (normal range 4.0-6.0). Resident #2: Resident #2 had a physician's orders [REDACTED]. The facility failed to follow the physician's orders [REDACTED]. The nursing staff failed to match the actual medication with the physician's orders [REDACTED]. The incorrect dosage could have resulted in increased Depression for the resident. Resident #3: Resident #3 was admitted to the facility on [DATE], with history of a [MEDICAL CONDITION] lower extremity. Resident #3 had a physician's orders [REDACTED]. The facility failed to administer the medication as ordered, due to unavailability. Staff administered a lesser dose, available in the ADU, potentially affecting relief of pain. Although the pharmacy provider was notified of the unavailability of the [MEDICATION NAME] 20 mg, the pharmacy failed to provide the correct dose of medication from the back up pharmacy. Tylenol was ordered, and administered for Resident #3's breakthrough pain, six (6) times from (MONTH) to (MONTH) (YEAR). During that time, Resident #3's pain level was 0-8 (on a pain scale of 0 being no pain, and 10 the worst pain). Resident #3 was discharged home, with medications, on 2/17/18. Resident #4: Resident #4 had physician's orders [REDACTED]. If the BG was greater than 400, staff was to give 12 units, recheck the BG in two (2) hours and call the physician. Resident #4 had elevated BG levels greater than 400, for 21 of 124 scheduled testing times. There was no evidence of rechecking the levels in two (2) hours or notifying the physician as ordered. On 11/2/17, Resident #3 had orders for a Tresiba Flextouch Sol Pen (Insulin): inject 22 units at bedtime. The Insulin pen was not available to be administered on 11/2/17, and 11/3/17, from the Pharmacy Provider or back up pharmacy. Resident #4's BG level was elevated to 571 at 4:00 PM and 8:00 PM on 11/3/17, and had to be given two (2) extra doses of [MEDICATION NAME]to bring the BG down. Resident #9: Resident #9 had a physician's orders [REDACTED]. Nursing Staff did not match the MAR and the physician's orders [REDACTED]. A Behavior Health Note, documented on 1/23/18, by the Psychiatric Nurse Practitioner, revealed Resident #9 did admit to feeling anxious at times. Resident #10: Resident #10 was admitted from the hospital, on 01/25/18, with physician's orders [REDACTED]. The [MEDICATION NAME] was not administered as ordered for five (5) doses, due to unavailability from the out of state and/or back up pharmacy, potentially affecting the therapeutic level of the medication. A complaint was filed by the resident/Responsible Party (RP), related to not having medications available, and was told by the facility staff the medications were being ordered from an out of state pharmacy, and they would have to wait for them to be delivered. The facility failed to ensure the availability of the [MEDICATION NAME], for Resident #10, for five (5) doses. This could have resulted in the risk of affecting the therapeutic level of the medication and escalation of behaviors. Resident #10 also had additional medications that weren't available on admission. Although the facility documented that Resident #10 showed no signs of depression or bazaar behaviors, the resident was admitted to the hospital for a fever, on 2/1/18, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The facility's failure to administer medications, per Nurse Practice Law and standards of practice, including to: A) ensure medications were accessible and available from a pharmacy provider, which was located in Atlanta Georgia, 373 miles away from the facility, and the ADU located in the facility, or provided by the back up pharmacy: B) match the medications with the MAR and physician's orders [REDACTED].#1, #2, #3, #4, #9 and #10, and other residents in the facility with orders to receive medications and/or monitoring for Diabetes, Pain, and medications requiring therapeutic levels. The situation was determined to be an Immediate Jeopardy (IJ), which began on 10/30/17, when Resident #1 was admitted and did not receive medications for Diabetes as ordered and the other identified residents did not receive medication and monitoring as ordered. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.21(b)(3)(i) F658 Services Provided Meet Professional Standards, was lowered to an E while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the Mississippi Nurse Practice Law, with an effective date of 7/1/10, revealed the practice of nursing means the performance for compensation of services which requires substantial knowledge of the biological physical, behavioral, psychological and sociological sciences and of nursing theory as the basis for assessment, diagnosis, planning, intervention and evaluation in the promotion and maintenance of health; management of individuals' response to illness, injury or infirmity; the restoration of optimum function; or the achievement of a dignified death. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen including the administration of medication and treatments prescribed by any licensed or legally authorized physician or dentist. A review of the facility's policy titled, Preparation and General Guidelines, Medication Administration-General Guidelines, revised (MONTH) 2014, documented as follows: Medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the prescriber. The policy included the following documentation: FIVE RIGHTS-Right Resident, right drug, right dose, right route and right times are applied for each medication being administered. A triple check of these five (5) rights is recommended at three (3) steps in the process of preparation of a medication for administration: (1) when the medication is selected. (2) when the dose is removed from the container and finally (3) just after the dose is prepared and the medication put away. If a medication with a current, active order cannot be located in the medication cart/drawer, either areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the night box/emergency kit. Medications are administered in accordance with written orders of the prescriber. Review of Mosbey's Pocket Guide to Nursing Skills and Procedures, Perry and Potter, 8th edition, page 321: Oral Medications: Select correct drug from the unit dose drawer or stock supply. Compare the name of the medication label with the Medication Administration Record (MAR) or computer printout. The rationale: Reading label first and comparing it against transcribed orders reduces errors. Review of an article from www.ihi.org/five rights of medication administration, revealed the five (5) rights of medication administration included the right individual, the right medication, the right dose, the right time and the right route. Check the five (5) rights three (3) times by reading the medication label information and comparing it to the medication sheet (MAR): when you remove the medication from the storage area, when you remove the medication from the original labeled container and just before you assist the individual to take the medication. A review of a contract agreement between the facility and the Pharmacy Provider, dated 10/01/16, revealed the following information: Delivery: Pharmacy shall arrange for all new admissions orders and routine reorders to be delivered by Pharmacy, or another Pharmacy within a timely fashion to meet the needs of the patient. Facility shall use reasonable efforts to aggregate, organize and plan all new admissions orders and routine reorders with Pharmacy to minimize the need for stat orders by Pharmacy or another pharmacy. Emergency Drug Services. Pharmacy will provide any prescriptions and supplies requested by Facility for its Patients, on an emergency basis or stat (statim) basis, within no more than four (4) hours of Pharmacy's receipt of such request. This emergency service will be provided 24 hours per day, seven (7) days per week. In the event Pharmacy cannot timely furnish an ordered medication due to circumstances beyond its control, Pharmacy will make arrangements with another pharmacy to provide such Pharmacy Product to Facility (a Back-Up Pharmacy) as soon as possible. This pharmacy provider was located approximately 373 miles from the facility, per map quest, and over five (5) hours from the facility in drive time. Review of a written statement, provided by the Chief Operating Officer, dated 3/28/18, identified that the facility's nurses' only point of contact was through the pharmacy provider located out of state. The decision and communication to a back up pharmacy comes from the Pharmacist at the dispensing pharmacy provider, located in Atlanta Georgia. Review of a complaint, MS # , received 2/2/18, revealed issues with medications not being given as ordered, blood sugars not being checked or rechecked as ordered, and reports of medications not being available due to the dispensing machine being broken. Resident #1: The Facility admitted Resident #1 on 10/30/17, with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) was not completed. A review of the Initial Nursing Assessment identified Resident #1 was admitted on [DATE], via ambulance, from the hospital, with a history of Insulin Dependent Diabetes Mellitus. Resident #1 was noted to be alert and oriented. A telephone interview with Resident #1, on 02/08/18 at 11:20 AM, revealed the resident was admitted to the facility on [DATE] at approximately 6:00 PM. Resident #1 said her medications were not given as ordered, especially the Insulin, and night time medications. Resident #1 said her Blood Sugars (BS), also known as Blood Glucose (BG) levels, were not checked before meals and at bedtime, as ordered. A review of the physician's orders [REDACTED]. Insulin [MEDICATION NAME], inject per sliding scale subcutaneously before meals and at bedtime for [MEDICAL CONDITION]. The sliding scale included directions for administration of Insulin, according to the results of the BG levels. Values of greater than 401, identified orders for the administration of 12 units of Insulin and notify the Physician. A review of the MAR for (MONTH) (YEAR), for Resident #1, revealed the [MEDICATION NAME] Insulin was not administered on 10/30/17 at 8:00 PM, or the 8:00 AM scheduled administration time on 10/31/17. Resident #1's BS on 10/30/17 at 8:00 PM was 233 and she was administered 4 units of Sliding Scale (SS)Insulin. The BS on 10/31/17 at 6:00 AM was 202 and 4 units of SS Insulin was administered. There was no documentation for the 11:00 AM BS check on 10/31/17. At 4:00 PM, on 10/31/17 the BS was 187 with 2 units of SS Insulin administered. A review of the MAR for (MONTH) (YEAR), documented scheduled times for checking Blood Glucose (BG) levels for Resident #1 as 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. The MAR revealed the resident had BG results of greater than 401 on four (4) of 10 days including the following: 11/02/17 at 11:00 AM-BG results 501; 11/04/17 at 11:00 AM-BG results 450; 11/05/17 at 8:00 PM-BG results 509; and 11/08/17 at 11:00 AM-BG results 449. Sliding Scale Insulin was documented as given, however, there was no documented evidence that the MD was notified as ordered for BG levels above 401, in order to have further instructions for Resident #1's [MEDICAL CONDITION]. A review of the (MONTH) (YEAR) MAR, and progress notes, revealed no results for BG checks on 10 scheduled administration times to indicate the BG had been checked and insulin administered if needed, as ordered. These times included the following dates: 10/31/17 at 11:00 AM, 11/01/17 at 6:00 AM; 11/02/17 at 6:00 AM, 4:00 PM and 8:00 PM; 11/03/17 at 4:00 PM and 8:00 PM; 11/04/17 at 6:00 AM; 11/07/17 at 6:00 AM; and 11/09/17 at 6:00 AM. A review of progress notes did not identify if the Physician had been notified about BG levels greater than 401, for Resident #1, or why BG results were not obtained and Insulin administered, if needed, for Resident #1. Review of a Nurse's Note, dated 11/8/17, with no time, documented Resident #1 had no signs or symptoms of Hyper/[DIAGNOSES REDACTED]. This was the only documentation of monitoring for signs and symptoms of Hyper/[DIAGNOSES REDACTED] during Resident #1's stay at the facility. During an interview on 02/12/18 at 1:45 PM, Resident #1's Physician said nurses are expected to follow doctor's orders because it is a standard of practice. Further interview with Resident #1's Physician on 3/2/18 at 2:00 PM, revealed giving insulin and not following up on BG levels, could lead to severe consequences including life-threatening situations of Hypo/[MEDICAL CONDITION]. The Physician stated she and the Nurse Practitioner (NP) were available at all times by phone. A review of a physician's orders [REDACTED]. A review of the (MONTH) (YEAR) MAR revealed no evidence of Resident #1 receiving the [MEDICATION NAME], as ordered, on 11/06/17. A Nurse's note, dated 11/9/17, revealed pending pharmacy delivery. The resident was discharged home on[DATE], without receiving the medication as ordered by the physician. Trazadone, ordered on [DATE], was not administered until 11/9/17. An interview on 03/01/18 at 2:30 PM, with the NP, revealed the [MEDICATION NAME] was ordered on [DATE], for Resident #1, in an attempt to level out the resident's BS. The NP said the resident's BS levels were changing from ranges of 168-500, and if Insulin was increased, the BS could bottom out. The NP said the significance of not administering the [MEDICATION NAME] and/or Insulin, as ordered, could have resulted in Ketoacidosis, a complication from [MEDICAL CONDITION]. Interview with LPN #11 on 3/5/18 at 11:15 AM, confirmed the [MEDICATION NAME] was not available on 11/9/17. She stated she called pharmacy to let them know the medication was not available. She stated that the blood sugar was not stable for Resident #1, and the [MEDICATION NAME] was to be used in conjunction with the insulin. She stated that she might not always document notification of the blood sugars because the NP was in the building five (5) days per week and they would discuss the blood sugars. Review of a laboratory report, for Resident #1, completed on 10/31/17, the day after admission, documented the Hemoglobin (Hgb) A1C, an indicator of blood glucose levels over a span of time, with results of 11.8. The lab slip documented normal range is from 4.0-6.0, with a target less than 7.0. The 11.8 value indicated that Resident #1's BS was not being controlled in the expected normal range. Resident #2: The facility readmitted Resident #2 on 10/19/16, with [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 12/05/17, identified the resident with a Brief Interview for Mental Status (BIMS) Score of 12, which indicated moderately impaired cognition. The resident required limited to extensive assistance with all Activities of Daily Living. Interview with Resident #2 on 2/8/18 at 10:10 AM, revealed she had not always received medications/treatments at times. She did not specify how often or which medications she didn't receive. A review of Resident #2's Active physician's orders [REDACTED]. The start date for the [MEDICATION NAME] was 04/15/16. During Med-pass observation, on 02/08/18 at 10:10 AM, LPN #3 prepared medications for administration for Resident #2. The LPN obtained an individual dose in a plastic pouch from the medication cart labeled with Resident #2's name, and identified the medication as [MEDICATION NAME] 20 mg for the 02/08/18 morning dose. The LPN said the strength documented on the MAR was for [MEDICATION NAME] 60 mg. LPN #3 attempted to get the medication from the ADU machine, without success. She stated the machine was, locked up and she would have to try to get someone to unlock the machine. Interview with LPN #3 on 2/8/18 at 3:15 PM, revealed during med pass on 2/8/18 at 10:10 AM, she discovered that the [MEDICATION NAME] was not the proper dose because the label didn't match the MAR. The LPN confirmed the label on medication should have the right dose, time, name of resident, medication and right route. She stated that nurses should compare the label to the MAR. She stated a medication error could have occurred if the nurse had not looked at the MAR. She stated the medications are printed from the ADU machine by a nurse at 1:00 PM, and once printed, the 3-11 or 11-7 nurse puts the medication in the carts, whoever has time. LPN #3 stated that there were from 800-900 medications printed daily. LPN #3 stated that there were no match backs when medications are put in the drawer, but when medications are administered, the nurses are to match the medication with the MAR at that time. During an interview on 02/13/18 at 2:10 PM, LPN #3 reviewed the MAR for (MONTH) and (MONTH) (YEAR), and acknowledged signing the MAR as administering [MEDICATION NAME] 60 mg to Resident #2. The LPN said she had been administering one (1) purple pill and if 20 mg was the only strength being sent, then 20 mg was being given, instead of 60 mg. She stated she didn't know when and if the strength had changed, she just knew it had been being a purple pill. The LPN also confirmed that only one (1) purple pill of [MEDICATION NAME] 20 mg was available on the medication cart, labeled for Resident #2, on 02/08/18. LPN #3 confirmed the dose was not accurate. A review of the MAR for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), documented [MEDICATION NAME] 60 mg had been administered to Resident #2 daily for the 8:00 AM dose, however, review of the Pharmacy Manifest, (medications that were sent from the out of town pharmacy in Atlanta Georgia), revealed [MEDICATION NAME] 20 mg had been dispensed from Pharmacy daily, for at least the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), for Resident #2. The MAR documented that [MEDICATION NAME] 20 mg had been administered by LPN #13 twice in (MONTH) (YEAR), and once in (MONTH) (YEAR). LPN #14 documented administration eight (8) times in (MONTH) (YEAR), and six (6) times in (MONTH) (YEAR). LPN #3 had documented administration 16 times in (MONTH) (YEAR), 21 times in (MONTH) (YEAR), and six (6) times of eight (8) days reviewed in (MONTH) (YEAR). Five (5) other nurses had documented one (1) to two (2) times from (MONTH) (YEAR)-February (YEAR), that they had administered [MEDICATION NAME] 60 mg for the 8:00 AM dose, for Resident #2. Review of the MAR documentation revealed staff were monitoring Resident #2 for adverse effects of anxiety, agitation, and crying, without any evidence of increase of anxiety. An interview with the Physician on 02/12/18 at 1:45 PM, revealed she had been made aware of a medication error, related to the incorrect administration of [MEDICATION NAME], for Resident #2. The Physician said the resident's order was for 60 mg, however, the resident would need to be re-evaluated before initiating the 60 mg, since the resident had actually been receiving the 20 mg without any problems. Resident #1's Physician said nurses are expected to follow doctor's orders because it is a standard of practice. The Physician stated that Resident #2 may or may not be reliable in an interview. Resident #3: The facility admitted Resident #3 on 12/04/17, with [DIAGNOSES REDACTED]. A review of the MDS, with an ARD of 12/11/17, identified Resident #3 with a BIMS score of 14, or cognitively intact. The resident required limited to extensive assistance with all Activities of Daily Living. A Pain Assessment on the MDS identified pain limiting day-to-day activities. Interview with Resident #3, on 2/8/18 at 2:00 PM, revealed problems with receiving medication when first admitted , but did not specify what medications. She stated that she was told they had to be ordered from an out of state pharmacy and it took a day and a half to get some of her medications. Resident #3 was alert and oriented. She stated there were no problems that she was aware of, was getting her pain medications, and was going home on Saturday and had no problems, except for when first admitted in getting her medications. A review of Resident #3's physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR), revealed the following: On 12/27/17, the 2:00 PM time of administration documented that [MEDICATION NAME] 20 mg was not administered. Progress notes revealed: Awaiting medication delivery from pharmacy. Pharmacy called twice. States will be delivered tonight. The facility used an out of state pharmacy that was located in Atlanta, Georgia, over 370 miles from the facility and over five (5) hours in travel time, per MapQuest. A review of the (MONTH) (YEAR) MAR, documented that LPN #1 administered [MEDICATION NAME] 20 mg for the 10:00 PM dose on 12/27/17, however, the Controlled Substance Accountability Sheet documented the 20 mg was not available and two (2) 5 mg tablets were signed out for Resident #3. On 12/31/17, the 2:00 PM dose was documented as 20 mg administered, however the Controlled Substance Accountability Sheet documented three (3) 5 mg tablets of [MEDICATION NAME] were signed out for Resident #3. Both Accountability Sheets were signed by LPN #1. A telephone interview, on 02/13/18 at 3:10 PM, with LPN #1, revealed the [MEDICATION NAME] 20 mg was not available for the 10:00 PM dose on 12/27/17, for Resident #3. The LPN said the only strength available in the ADU machine in the facility was a 5 mg [MEDICATION NAME] and she administered 5 mg. The LPN acknowledged that the lesser strength could have potentially affected the resident's pain relief. The LPN said she administered 5 mg because she thought, something was better than nothing. LPN #3 also acknowledged administering 15 mg on 12/31/17, because the 20 mg [MEDICATION NAME] was not available. The LPN confirmed she did not follow Doctor's orders or call the Doctor about the [MEDICATION NAME] 20 mg not being available. She acknowledged she'd only called the out of town pharmacy provider. An interview on 02/14/18 at 12:00 PM, with Registered Nurse #4, Director of Clinical Operations, revealed Resident #3 received the wrong dose, a lesser dose, of [MEDICATION NAME]. The RN said Resident #3 was administered the wrong dose of [MEDICATION NAME] on 12/27/17 and 12/31/17, instead of the 20 mg as ordered by the physician. Review of the nurse's notes revealed Resident #3 was administered Tylenol 325 mg for breakthrough pain on the following dates: 1/22/18, 1/24/18, 1/26/18, 2/3/18, 2/7/18, and 2/12/18. A review of physician's orders [REDACTED].#3: On 12/04/17: [MEDICATION NAME] 100 microgram (mcg) daily for [MEDICAL CONDITION], Carvedilol 12.5 mg-twice times daily related to Hypertension, [MEDICATION NAME] 300 mg-twice daily related to Low Back Pain, and [MEDICATION NAME] 4 mg every eight (8) hours as needed for nausea. On 12/07/17, orders for [MEDICATION NAME] 20 mg every eight (8) hours for pain; and on 12/21/17, [MEDICATION NAME] 500 mg was ordered twice daily for pain. A review of the MAR and progress notes for (MONTH) (YEAR), documented the 4:00 PM [MEDICATION NAME] dose was not administered on 12/16/17 and 12/22/17. [MEDICATION NAME] was not administered for the 4:00 PM dose on 12/22/17. The Progress notes documented the medications were not available. A review of Resident #3's MAR for (MONTH) (YEAR), revealed: [MEDICATION NAME] was not administered on 01/21/18, and 01/28/17. Carvedilol was not administered on 01/04/18, 01/07/18, 01/08/18, and 01/09/18. [MEDICATION NAME] was not administered on 01/04/18/, 01/08/18, 01/09/18. A review of the progress notes revealed the medications were not available. An interview with the Medical Director (MD) on 03/02/18 at 2:00 PM, revealed Nurses should follow physician's orders [REDACTED]. The MD said nurses cannot alter dosages or strength of medication without a physician's orders [REDACTED].>Review of the Nurse's Notes for Resident #3 revealed entries for 12/16/17, 12/22/17, 1/21/18, 1/23/18 and 2/3/18, of medications not available, with no documentation of Administrative staff being notified. Resident #4: The facility readmitted Resident #4 on 10/12/16, with [DIAGNOSES REDACTED]. The MDS with an ARD of 12/12/17, identified the resident with a BIMS of 15, or cognitively intact. Resident #4 required set up help only for Activities of Daily Living. The MDS identified the resident received Insulin Injections daily. A review of Resident #4's Active physician's orders [REDACTED]. A review of the MAR for (MONTH) (YEAR), revealed Resident #4 had elevated BG levels of greater than 400 on 21 of 124 scheduled testing times. The (MONTH) (YEAR) MAR documented BG checks were greater than 400 for four (4) of 32 scheduled times. Sliding Scale Insulin was administered as ordered for the elevated BG levels. There was no evidence of rechecking the BG levels in two (2) hours as ordered by the physician to assess for Hypo/[MEDICAL CONDITION]. Dates, times and BG levels are as follows: 01/01/18 at 6:00 AM-400, at 11:00 AM-432 01/02/18 at 11:00 AM-400 01/03/18 at 11:00 AM-443 01/04/18 at 11:00 AM-581 01/05/18 at 6:00 AM-400, at 11:00 AM-432 01/06/18 at 11:00 AM-463 01/12/18 at 4:00 PM-459 01/18/18 at 6:00 AM-400 01/19/18 at 6:00 AM-400, at 4:00 PM-415, at 8:00 PM-408 01/24/18 at 4:00 PM-434 01/25/18 at 8:00 PM-400 01/26/18 at 11:00 AM-439 01/27/18 at 8:00 PM-401 01/28/18 at 4:00 PM-489 01/30/18 at 6:00 AM-400, at 11:00 AM-512 01/31/18 at 8:00 PM-414 02/01/18 at 11:00 AM-487 02/03/18 at 4:00 PM-590 02/04/18 at 8:00 PM-500 02/08/18 at 11:00 AM-490 Review of a physician's orders [REDACTED].#4 had orders for Tresiba Flextouch Sol Pen (Insulin) 22 units at bedtime. Review of the (MONTH) (YEAR) MAR, revealed the Tresiba was not administered until 11/4/17, due to unavailability from the out of town pharmacy, ADU, or backup pharmacy. Review of the Progress Notes dated 11/2/17 at 10:21 PM, revealed, awaiting. The note on 11/3/17 at 9:43 PM, revealed, med in route from pharmacy. On 11/3/17 at 11:54 PM, the Progress Note revealed Resident #4's BS was elevated this shift to 571. The NP was notified and gave orders for 15 units of [MEDICATION NAME]and recheck in one (1) hour, with results of 543. The NP was notified again and another order was given for 15 more units of [MEDICATION NAME]and recheck in one (1) hour, with results of 525. The note documented: No signs of Hyperglycemic reactions noted, blood sugars decreasing, will continue to monitor. Review of the MAR revealed Resident #4's BG level on 11/2/17 at 11:00 AM was 597, at 4:00 PM the BG level was 439, and at 8:00 PM the level was 318. On 11/3/7 the 6:00 AM level was 249, the 11:00 AM level was 403, the 4:00 PM level was 571, and the 8:00 PM level was 571. Resident #4's

CI MS # Based on record review, interview and facility policy review, the facility failed to monitor the effectiveness of the administration of routine and as needed (PRN) medications, and without accurate monitoring, per Mississippi Nurse Practice Law, for Resident #1, Resident #4, and Resident #6, for three (3) of 18 sampled residents reviewed, for residents with diabetic and pain medications, as evidenced by: 1. Resident #1 received Insulin without consistent monitoring of Blood Glucose (BG) levels and administration of Sliding Scale Insulin, potentially resulting in severe consequences including Ketoacidosis or life threatening hypo/[MEDICAL CONDITION]. Resident #1 did not receive [MEDICATION NAME] as ordered, from the pharmacy provider located in Atlanta Georgia, which resulted in inadequate control/monitoring for BG levels. 2. Resident #4: Received PRN Insulin for elevated BG levels without monitoring the effectiveness of Sliding Scale Insulin, potentially resulting in severe consequences including Hypo/[MEDICAL CONDITION]. 3. Resident #6 received PRN medication for pain without consistent monitoring for the effectiveness of pain relief, which could result in ineffective or no pain relief. The failure to adequately monitor the effectiveness and use of insulin and pain medications for Residents #1, #4 and #6, resulted in the likelihood of serious injury, harm, impairment or death for the identified residents and other residents who received Insulin, pain medication, or other medications which required monitoring. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 10/30/17, when Resident #1 was admitted and did not receive pharmacy services and adequate monitoring of Diabetic medications as ordered. This also affected Resident #4 for Diabetic monitoring and Resident #6 for pain monitoring. The facility's Director of Clinical Operations and the Assistant Director of Nursing (ADON) was notified on 2/28/18 at 5:45 PM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on 3/3/18, in which the facility alleged the removal of the IJ on 3/3/18. The State Agency (SA) determined the IJ to be removed on 3/6/18, prior to exit. The scope and severity for the IJ at CFR 483.45 (d)(3) Unnecessary Drugs without adequate monitoring, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Preparation and General Guidelines, Medication Administration, reviewed (MONTH) 2014, included the following documentation: Medications are administered in accordance with written orders of the prescriber. When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration and if applicable the injection site; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted. Review of the facility's policy, Pain Management, dated (MONTH) (YEAR), revealed, Purpose: To provide guidelines for consistent evaluation, management and documentation of pain in order to provide maximum comfort and enhanced quality of life. Process: Ongoing pain monitoring and effectiveness of interventions is noted in the electronic medical record through the EMAR (electronic medication administration record) system and progress notes. A review of the information provided by the facility titled Diabetes Management Education, not dated, documented Monitoring Compliance: The following elements are in place for the center to demonstrate satisfactory compliance with the guide: Residents with a [DIAGNOSES REDACTED]. Review of the Mississippi Nurse Practice Law, with an effective date of 7/1/10, revealed the practice of nursing means the performance for compensation of services which requires substantial knowledge of the biological physical, behavioral, psychological and sociological sciences and of nursing theory as the basis for assessment, diagnosis, planning, intervention and evaluation in the promotion and maintenance of health; management of individuals' response to illness, injury or infirmity; the restoration of optimum function; or the achievement of a dignified death. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen including the administration of medication and treatments prescribed by any licensed or legally authorized physician or dentist. Resident #1: Resident #1 was admitted to the facility on [DATE], and discharged home on[DATE]. [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) was not completed. A review of the Initial Nursing Assessment identified the resident as alert and oriented. A telephone interview, on 02/08/18 at 11:20 AM, with Resident #1 and the Resident's Responsible Party (RP), revealed the resident had concerns about the lack of obtaining and/or monitoring the resident's Blood Sugars (BS), which is known as BG levels, and administration of medications. The RP said that he called the facility and spoke with a Social Worker (SW) regarding concerns of medications and/or checking BG levels during the first week of (MONTH) (YEAR). A review of Resident #1's physician's orders [REDACTED]. On 10/30/17: Insulin [MEDICATION NAME] Solution-Inject per sliding scale subcutaneously before meals and at bedtime for [MEDICAL CONDITION]; If the Blood Glucose level is 401 or greater, administer 12 units and notify the physician. An order on 11/06/17, revealed orders for [MEDICATION NAME] 500 milligrams (mg) ER (Extended Release) daily for Diabetes. Although the [MEDICATION NAME] was ordered for Resident #1, by the Nurse Practitioner (NP) on 11/06/17, related to elevated Blood Glucose (BG) levels, review of the Pharmacy Manifest revealed the medication was not dispensed from Pharmacy until 11/09/17, and the resident was discharged home on[DATE], without receiving any of the [MEDICATION NAME]. Resident #1's BG levels remained elevated, and were not consistently monitored by nursing to ensure the medication was administered to bring the BG levels down. Medication was not made available in the Automated Dispensing Unit (ADU) or from a back up pharmacy. A review of the Medication Administration Record (MAR) for (MONTH) (YEAR), for Resident #1, revealed the [MEDICATION NAME] Insulin was not administered on 10/30/17 at 8:00 PM, or on 10/31/17 for the 8:00 AM dose. A review of the (MONTH) (YEAR) MAR, documented the scheduled times for checking the BG levels for Resident #1 as: 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. Resident #1 had BG results of greater than 401 on four (4) of 10 days including the following: 11/02/17: BG results 501 at 11:00 AM. 11/04/17: BG results 450 at 11:00 AM. 11/05/17: BG results 509 at 8:00 PM. 11/08/17: BG results 449 at 11:00 AM. There was no progress note or documentation on the MAR to indicate the BG was monitored or rechecked after PRN insulin administration, to evaluate the effectiveness to lower the BG level. Resident #1 was not administered the [MEDICATION NAME] as ordered to lower the BG levels. A review of the (MONTH) (YEAR) MAR, and progress notes, revealed there were no results documented for BG checks for 10 scheduled administration times in (MONTH) to indicate the BG had been checked, evaluated, and PRN insulin administered if needed for the following dates and times: 10/31/17 at 11:00 AM, 11/01/17 at 6:00 AM 11/02/17 at 6:00 AM, 4:00 PM and 8:00 PM 11/03/17 at 4:00 PM and 8:00 PM 11/04/17 at 6:00 AM, 11/07/17 at 6:00 AM 11/09/17 at 6:00 AM Review of a HGB A1C, a test used to monitor BG levels over a period of months, dated 10/31/17, revealed normal ranges were between 4.0-6.0. Resident #1's level was elevated to 11.8. Review of a Nurse's Note, with no time, dated 11/8/17, documented Resident #1 had no signs or symptoms of Hyper/[DIAGNOSES REDACTED]. This was the only documentation related to monitoring Resident #1's signs and symptoms during her stay, from 10/30/17 through 11/10/17. An interview with Resident #1's Physician on 02/12/18 at 1:45 PM, revealed Nurses were expected to follow physician's orders [REDACTED]. The MD said checking the BS is especially important on residents who are unstable, have underlying conditions, or if the BS is running high on admit. The MD stated that repeating levels in two (2) hours, if the BS is over 400, is important: (a) to see if the BS is coming down, (b) to see if the resident needs more insulin (c) to see what is going on with the resident. The MD said the only way to monitor the effectiveness of Sliding Scale Insulin is to recheck the BS and/or obtain the BS. The Physician confirmed being on call and available by phone and nurses should call if there is a question. During an interview, on 02/14/18 at 9:35 AM, the Assistant Director of Nursing (ADON) said nurses should notify the physician of Blood Sugar results, because there is an order and expectation to follow up with the BS. The ADON acknowledged ineffective monitoring of BS for Resident #1. An interview on 03/01/18 at 2:30 PM, with the Nurse Practitioner (NP) revealed Resident #1's BS had ranged from 168 to 500, and if Insulin was increased, the BS could bottom out. The NP said the [MEDICATION NAME] was ordered on [DATE], for Resident #1, in an attempt to level out the resident's Blood Sugar (BS). The NP said the significance of not administering the [MEDICATION NAME], and monitoring of the BS, could have resulted in Ketoacidosis, which is a complication of not controlling Diabetes, including further [MEDICAL CONDITION]. The NP confirmed ineffective monitoring of the BG levels for Resident #1. An interview with the Medical Director on 03/02/18 at 2:00 PM, revealed that giving insulin and not checking BS could lead to severe consequences with diabetic residents, including life threatening situations of Hypo/[MEDICAL CONDITION]. An interview with the Director of Nurses (DON), on 03/02/18 at 2:55 PM, revealed if Blood Sugars are not monitored and assessed and/or reassessed for response to Insulin, it could place residents at risk for life threatening complications. Although Resident #1 had MD notification parameters in place, the facility had no evidence of consistently monitoring the resident's BG to assess for Hypo/[MEDICAL CONDITION] and reporting results of 401 or greater to the MD as ordered. The facility also failed to administer Resident #1's [MEDICATION NAME] as ordered for unstable BG levels, and monitor the resident's response to see if the BG stabilized. Interview with the Social Service (SS) personnel on 2/8/18 at 12:15 PM, and 2/12/18 at 1:00 PM, revealed they were not aware of Resident #1's complaint of BS monitoring. There was no documentation of a complaint for Resident #1's BG concerns. Resident #4: The facility readmitted Resident #4 on 10/12/16, with [DIAGNOSES REDACTED]. The MDS, with an ARD of 12/12/17, identified the resident with a BIMS Score of 15, or cognitively intact. The resident required set up help only for Activities of Daily Living. The MDS identified the resident received Insulin Injections daily. A review of Resident #4's physician's orders [REDACTED]. If 400 or greater, give 12 units, recheck the BG in two (2) hours, and if still 400 plus, call the physician. A review of the MAR for (MONTH) (YEAR), revealed Resident #4 had elevated BG levels of 400 plus on 20 of 124 scheduled testing times. There was no evidence that staff rechecked the levels in two (2) hours, as ordered by the physician, or evaluated the effectiveness of the Sliding Scale insulin administration, on the following dates and times: 01/01/18 at 6:00 AM-400, at 11:00 AM-432 01/02/18 at 11:00 AM-400 01/03/18 at 11:00 AM-443 01/04/18 at 11:00 AM-581 01/05/18 at 6:00 AM-400, at 11:00 AM-432 01/06/18 at 11:00 AM-463 01/12/18 at 4:00 PM-459 01/18/18 at 6:00 AM-400 01/19/18 at 6:00 AM-400, at 4:00 PM-415, at 8:00 PM-408 01/24/18 at 4:00 PM-434 01/25/18 at 8:00 PM-400 01/26/18 at 11:00 AM-439 01/27/18 at 8:00 PM-401 01/28/18 at 4:00 PM-489 01/30/18 at 6:00 AM-400, at 11:00 AM-512 01/31/18 at 8:00 PM-414 Review of the Nurse's Notes, dated 1/17/17, no time, revealed no signs of Hyper/[DIAGNOSES REDACTED]. This was the only documented note for Resident #4's diabetic monitoring during the above mentioned dates where the BG levels were not checked/rechecked. Review of Resident #4's Hemaglobin (HGB) A1C, dated 2/13/18, revealed a result of 8.1, with normal range being 4.0-6.0, which indicated Resident #4's level was high. A review of the MAR for (MONTH) (YEAR), revealed Resident #4 had BG levels of 400 plus on four (4) of eight (8) days reviewed, with no documentation of evaluating the effectiveness of the insulin received or re-checking the BS, on the following dates: 02/01/18 at 11:00 AM-487 02/03/18 at 4:00 PM-590 02/04/18 at 8:00 PM-500 02/08/18 at 11:00 AM-490 An interview with Resident #4's Physician on 02/12/18 at 1:45 PM, revealed if the order stated to recheck BG in two (2) hours if the level is more than 400, then the BS should be re-checked. The MD said repeating the level in two (2) hours determines if the BS is coming down, if the resident needs more insulin, or if the BS is going up. The MD said monitoring the BG is especially important on residents who are unstable, have underlying conditions, or if the BS is running high for the newly admitted residents. The MD stated if the BS was not coming down, this could indicated infection and the BS needed to be repeated to see what was going on. An interview with the Nurse Practitioner (NP) on 02/14/18 at 9:30 AM, revealed that it was important to recheck the BG in two (2) hours, specifically for Resident #4. She said rechecking the BS in two (2) hours, for the BS of 400 or more, is to make sure the BG levels are going down to keep the resident out of the hospital. The NP said if the BS is greater than 400, the resident is into the danger zone and the monitoring is necessary to keep the resident from going into Ketoacidosis. The NP said Resident #4 had a swing in BG levels from 89 to 590. The NP confirmed it was important to call and report BS values, and she could always be reached by phone. Resident #6: Review of the facility's Face Sheet revealed Resident #6 was admitted on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS, with an ARD of 12/29/17, revealed Resident #6 had a BIMS score of 15, which indicated Resident #6 had no cognitive impairment. Interview with Resident #6 on 2/13/18 at 2:30 PM, revealed she was alert and oriented to person, place and time. She stated she had received [MEDICATION NAME] ([MEDICATION NAME]) about 20 times in (MONTH) (YEAR). She stated it controlled her pain about as much as it was going to, that she did not expect to get total pain relief with her neck pain. She stated she mainly took the medication at night to help her sleep, and occasionally during the day. Review of physician's orders [REDACTED]. Review of Resident #6's MAR revealed Resident #6 received five (5) [MEDICATION NAME]-[MEDICATION NAME] 5-325 milligrams (mg) tablets during the month of January, 1/9/18 at 9:10 PM, 1/10/18 at 9:30 PM, 1/20/18 at 11:38 PM, 1/22/18 at 8:56 PM, and 1/24/18 at 8:10 PM. However, Review of the Controlled Substance Accountability Sheet revealed Resident #6 received [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablets 20 times during the month of January. There was no documented evidence that the pain level was evaluated for Resident #6 for the other 15 times the resident was administered pain medication. The following days [MEDICATION NAME] was signed out as administered to Resident #6 without adequate monitoring of pain: 1/8/18, 1/11/18, 1/15/18, 1/16/18, 1/17/18 x 2, 1/18/18, 1/19/18 x 2, 1/21/18, 1/22/18, 1/23/18, 1/25/18 and 1/27/18 x 2, mostly at night. Interview on 02/13/18 at 1:45 PM, with RN #1, revealed the nurses did not document the administration of Resident #6's pain medication on the MAR, or in the nurse's notes consistently, during the month of January. RN #1 confirmed the nurses failed to assess the effectiveness of the pain medication that was administered, and document whether the resident got relief. RN #1 stated it is important to monitor the effectiveness of the medication because, as a nurse, you want to ensure the resident receives effective pain relief. Interview on 02/14/18 at 8:45 AM, with LPN #7, revealed when a medication is administered, it should be documented on the MAR, and staff should assess pain level and follow up with the resident 30 minutes to one (1) hour after administration, to assess effectiveness. LPN #7 stated if the medication was not effective, the physician would need to be notified. Interview with LPN #15, on 3/6/18 at 7:25 AM, revealed pain was assessed by using the pain scale of 0-10, with 0 being no pain 10 the worst pain. The non-verbal resident may use signs to indicate the pain level. LPN #15 stated after administration of the pain medication, the nurse should document the time, and follow up for the effectiveness, documenting on the MAR. She stated the importance of assessing the resident's pain, was so the physician and nursing staff knew the resident's level of pain and what care was provided. Interview with the Administrator on 2/14/18 at 10:45 AM, revealed it was important to monitor pain medications and their effectiveness to ensure pain relief. Review of a written response from the Senior Director of Clinical Operations, dated 4/6/18 at 11:23 AM, revealed: Best practice guidelines for safe medication administration includes clinical decision-making competency, theoretic competency, and clinical practice competency The facility submitted an acceptable Allegation of Compliance (AoC) on 3/3/18, for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to removed the IJ, prior to exit: The state agency conducted a complaint investigation at the facility beginning 2/8/18. An Immediate jeopardy was called regarding noncompliance on 2/28/18 at 4:45 pm. Noncompliance with regulations related to pharmacy services was identified for failure to have medications available and accessible for Residents #1, #2, #3, #9 and #10 on 2/14/18. Noncompliance related to pharmacy services also pertained to follow up of effectiveness of pain medication for Resident #6 and effectiveness of sliding scale insulin administration and monitoring for Residents #1 and #4. Failure to administer medications and delays in obtaining medications led to significant medication errors. Lack of obtaining medications for administration and then monitoring those medications could have potentially led to [DIAGNOSES REDACTED], [MEDICAL CONDITION] and/or death. Immediate actions were taken to care for the residents identified in jeopardy. Resident #1 had her Hbg (Hemoglobin) A1C drawn for the Medical Director's review on 10/31/17, the day after her admission. Hbg A1C results were 11.8, and reviewed by the Medical Director prior to the resident's discharge on 11/10/17. Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order was clarified. Resident #3 had her pain assessed by the medication nurse prior to routine pain medication being administered on 2/8/18, with 0/10 on the pain scale. Resident #4 had Hgb A1C drawn on 2/13/18, with results of 8.1. Resident #6 was assessed by the medication nurse for pain on 2/8/18, with a 0/10 on the pain scale. On 2/10/18, pain scale was 0/10 and 2/11/18, the pain was assessed as 5/10 on the pain scale and [MEDICATION NAME] was given and evaluated by the medication nurse as effective. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] clarified. Resident #10 had his [MEDICATION NAME] order reviewed by the Medical Director. [MEDICATION NAME] level was drawn on 3/1/18, and results were 1.5, which indicated normal range. Other immediate actions taken to assure no other residents were in jeopardy include the following actions. A 100% match back was completed on all medication carts on 2/10/18, 2/11/18, 2/15/18 and 2/16/18, by the medication and supervising nurses. Beginning on 2/14/18, after exit with the surveyors, all medication carts were checked by the medication nurses and medication availability was compared to any new orders that had been received on the prior shift. This cart check process is conducted by the medication nurses every shift since 2/14/18. On 2/15/18, the medication nurses reviewed all resident charts at the beginning of the next shift for any new medication orders or new admission orders [REDACTED]. Based upon a 2-hour window of being in the cart, if the drug was not available, the pharmacy was notified by the medication nurses or the supervisor by telephone. This process of monitoring and verifying medication availability has continued on a daily basis and is being conducted by the medication and supervising nurses. Education was provided by the Director of Clinical Education (DCE) and Director of Nursing Services (DNS) to eight (8) Registered Nurses (RN) and 23 Licensed Practical Nurses (LPN) regarding medication administration on 2/8/18, through 2/22/18, and then started again 2/28/18, when surveyors identified further concerns. This education was provided by the DNS at times for all shifts. All nurses were also educated by DCE/DNS regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medications for all shifts. No staff member worked until this education was given. No agency staff is being utilized. All supervising and medication nurses, totaling eight (8) RNs and 23 LPNs, were educated regarding sliding scale accuchecks results and insulins and following MD orders with follow up regarding accucheck results on 2/8/18-2/22/18 by DCE/DNS. Education provided by the DNS and supervising nurses began again on 2/28/18 after surveyors returned. This education was provided at times for all shifts. No staff member worked until this education was given. No agency staff is being utilized. Systemic changes and monitoring have been developed, presented and approved by the Administrator, DNS, and Medical Director on 2/19/18, at 1:00 pm, during the Quality Assurance Performance Improvement (QAPI) meeting. The systemic changes and guidelines include algorithms for medication ordering, reordering and availability. These changes will be prepared for monthly reporting at QAPI. Education has been provided by the DNS/ADNS/DCE to all eight (8) RNs and 23 LPNs concerning the guidelines and changes on 2/22/18, and again after the immediate jeopardy identification on 2/28/18. This education provided for all shifts regarding the systematic changes includes: when new orders are received or orders for a new admission, the assigned medication nurse will review medication cart to assure medication is in center; should the medication not be available, the assigned medication nurse will notify the supervisor immediately as well as fax the order to the pharmacy; should the medication not arrive by administration time or within a two (2) hour timeframe, the physician will be notified by the nurse supervisor for follow-up orders. A pharmacy representative will be in the center at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability for at least 30 days and then two (2) times per week thereafter. A QAPI meeting was held on 2/19/18 at 1:00 pm. In attendance were the Administrator, DNS, ADNS, Medical Director, Social Workers, Unit Managers and other department leaders. Also, in attendance, were support resource members from the corporate office. Findings from the initial medication cart checks were discussed, along with the follow-up assignments, including medication cart match back, medication administration record monitoring for holes and missed accucheck follow up or medications and medication availability. Findings related to follow up for pain medication and sliding scale insulins were discussed with follow-up assignment to include monitoring of the medication administration record and nurses' progress note review. Another QAPI was completed on 2/28/18 at 7:00 pm with discussion surrounding the immediate jeopardy and continuing plans for correction. After the 2/28/18 QAPI monitoring of medication carts and medication availability continued, along with medication administration documentation and follow up of accucheck results. Education continued to the staff and medication nurses. Participants in this meeting were the Administrator, DNS, ADNS, Nurse Consultant, and Medical Director. NOTE/ADDENDUM : The facility sent documentation, dated 3/5/18, which advised the Out of State pharmacy of termination of the pharmacy contract. On 03/06/18 the State Agency (SA) validated through record review and interview with staff, the Director of Nursing Service (DNS) and the Director of Clinical Operations (DCO) that the facility had implemented the following measures to remove the Immediate jeopardy, prior to exit: A: Resident #1: Validated a HgbAIC was obtained on 10/31/17 on Resident #1 and reviewed by the Medical Director. The resident was discharged on [DATE]. b. Resident #2: Validated Resident #2 was assessed by the psychiatric nurse practitioner and the [MEDICATION NAME] order clarified on 02/12/18. c. Resident #3. Validated Resident #3 had pain monitoring assessments by the medication nurse on 02/08/18. Resident #3 was assessed with [REDACTED]. d. Resident #4: Validated Resident #4 had a HgbAIC level completed on 02/13/18 with the results being 8.1 (H) and reviewed by the Nurse Practitioner. e. Resident #6: Validated pain monitoring assessments by the medication nurse for pain on 02/08/18, 02/10/18, 2/11/18. Validated pain assessment was evaluated by the medication nurse as effective. f. Resident #9: Validated by review of physician's orders [REDACTED]. Resident #9 was assessed by the nurse practitioner and medication order for [MEDICATION NAME] was clarified on 02/13/18. f. Resident #10: Validated Resident #10 had a [MEDICATION NAME] Level drawn on 03/01/18. The results were 1.5 and reviewed by the Medical Director. The SA validated through record review and interview on 03/06/18, with the DCO, that a 100% match back was completed on all medication carts beginning on 02/10/18, 02/11/18, 02/15/18 and 02/16/18. Interviews with two (2) Registered Nurses (RN) and six (6) Licensed Practical Nurses (LPN) validated the match backs were completed. The SA validated through record review and interview on 03/06/18, with the DCO that med carts were checked daily by medication nurse and verified by the DNS and ADNS that performance was completed daily. Interviews with 2 RNs and 6 LPNs validated daily checks of the med carts. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the Director of Clinical Education (DCE)/DNS beginning 02/08/18 through 02/22/18, and again on 02/28/18, for eight (8) RNs and 23 LPNs regarding medication pass, the importance of all ordered medications being given and instructions for lack of availability of medication for all shifts. Interviews from three (3) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO, of sign in sheets of education by the DCE and DNS for eight (8) RNs and 23 LPNs on 02/08/18 through 02/22/18, and 02/28/18, regarding sliding scale accucheck results and insulins and following MD orders with follow up regarding accucheck results. Interviews with two (2) RNs and six (6) LPNs validated attendance and knowledge of in-services. The SA validated through record review and interview on 03/06/18, with the DCO of systemic changes and monitoring guidelines, including medication ordering, reordering and availability, being developed, presented and approved by the Administrator, DNS, and Medical Director on 02/19/18. Interviews with the DNS, Administrator, Senior Director of Clinical Operations and Medical Director validated the systemic changes of monitoring of sliding scale insulin and pain assessments. The SA validated through record review and interview on 03/06/18, with the DCO of sign in sheets of education provided to eight (8) RNs and 23 LPNs on 02/22/18, and 02/28/18, by the DNS/ADNS/DCE of education regarding the systematic changes regarding ordering, reordering and availability of medications. Interviews with three (3) RNs and six (6) LPNs validated attendance and knowledge of in-service. The SA validated through record review and interview with the DCO on 03/06/18, of sign-in sheets of education beginning 02/28/18, provided to all staff by the DNS/ADNS for eight (8) RNs and 23 LPNs regarding Med cart match back, ordering medication, availability, administering medications, monitoring and documentation of Sliding Scale Insulin and pain medication. Interviews with three (3) RNs and six (6) LPNs validated attendance and knowledge of in-service. The SA validated through interview on 03/06/18, including the DCO and Pharmacy Representative on 03/06/18, of the pharmacy representative being in the facility at least three (3) days per week to communicate and receive feedback from the nursing team regarding medication availability. Interviews with one (1) RNs and three (3) LPNs validated training by the Pharmacy representative on obtaining medications. The SA validated through record review and interviews on 03/06/18, including the Senior Director of Clinical Operations (SDCO), Director of Clinical Systems (DCS), DNS, ADNS, DCO, Maintenance Director, Social Services Designee of a QAPI meeting on 02/19/18. Interviews validated that areas of concern discussed included medication availability, Insulin Administration, Following physician's orders [REDACTED]. The SA validated through record review and interview with DCO on 03/06/18, that a QAPI meeting was conducted on 02/28/18, and attended by the Administrator, Medical Director, DNS, ADNS and DCO. The QAPI meeting discussed corrective actions which included immediate interventions initiated for residents with the potential to be affected, system changes/modified and continued quality assurance audits and monitoring. Interviews with the Medical Director, DNS, ADNS and Corporate Support validated attendance of QAPI meeting on 02/28/18. The SA validated during survey, through 100% matchback, that diabetic medications were available for Residents who required the medication.