Every finding on record at Elizabethtown Nursing and Rehabilitation Center

Based on interview and review of the facility's Payroll Based Journal Data Report, the facility failed to ensure there was a Registered Nurse (RN) on duty at least 8 consecutivc hours a day, 7 days a week. There was no documented evidence there was a RN working at the facility on 07/12/2025, 07/20/2025, 09/06/2025, and 09/07/2025.The findings include:Review of the document signed by the Administrator, dated 01/29/2026, revealed, The facility does not have a specific policy on staffing.Review of the facility's Payroll Based Journal (PBJ) Data Report, for the timeframe from 07/01/2025 to 09/30/2025, revealed no Registered Nurse (RN) hours were submitted for 07/12/2025, 07/20/2025, 09/06/2025, and 09/07/2025.During an interview, on 01/31/2026 at 9:12 AM, the Payroll Manager stated she submitted the PBJ hours for all the facility's employees. The Payroll Manager stated there were four days in the previous quarter when she could not record any RN hours because there was not an RN available to work a shift during those days. The Payroll Manager further stated, the Director of Nursing (DON) at the time may have worked those days on an on-call basis, but she did not submit those hours as RN coverage to the PBJ reporting because being available on an on-call basis was already part of the DON's job description.During an interview, on 01/31/2026 at 9:26 AM, the current DON, who started working at the facility in November 2025, stated there were four weekend days prior to her date of hire where the facility did not have RN coverage per the PBJ report. The DON further stated she expected there to be an RN available to cover the required eight hours, and if there was not an RN available, she would come in and work as an RN on the floor to fulfill the minimum staffing requirement.During an interview, on 01/31/2026 at 9:42 AM, the Administrator stated the previous DON did work at some point during the days in question, but they did not know how to code the hours correctly. The Administrator stated she expected there to be an RN working in the facility eight hours per day, seven days a week, to fulfill the minimum RN requirement. The Administrator further stated it was important to have an RN available because there were some nursing tasks that only an RN could complete in order to provide proper care for the residents.

Based on observation, interview, and review of facility policy, the facility failed to prepare, distribute and serve food in accordance with professional standards for food safety. Observation on 01/30/2026 revealed Cook1 failed to remove soiled gloves and wash hands when appropriate while preparing and serving food. Further, Cook1 failed to use tongs to place bread on the meal trays, and instead handled the bread with his gloved hands.The findings include:Review of the facility policy titled, Food: Preparation, revised 02/2023, revealed, All foods are prepared in accordance with the FDA [Food and Drug Administration] Food Code. Procedures - 1. All staff will practice proper hand-washing techniques and glove use. 2. Dining Service Staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.Observation on 01/30/2026 at 11:00 AM, revealed while Cook1 blended vegetables, he touched his beard covering with his gloved hands. After touching his beard covering, Cook1 then failed to remove his gloves and wash his hands and continued to prepare the pureed vegetables.Observation on 01/30/2026 beginning at 11:25 AM, revealed Cook1 donned oven mitts over black gloves, pulled a pan of baked fish out of the oven, and removed the oven mitts. Cook1 then failed to wash his hands and don new gloves before pulling serving utensils out of the drawers and placing them on the steam table. While wearing the same soiled gloves, Cook1 then pulled his beard cover up, but failed to remove his soiled gloves and wash his hands before he retrieved serving utensils for the steam table.Further observation during the same meal service, revealed Cook1, while wearing the same soiled gloves, again donned oven mitts before removing a pan of fish from the oven, and then removed the mitts. Cook1 then failed to remove the soiled gloves and wash his hands before placing five servings of fish in a small pan, and placing the fish on the steam table.Additional observation during the same meal service, revealed while wearing the same soiled gloves, Cook1 retrieved a cutting board, and then failed to remove his soiled gloves and wash hands before removing the remaining fish from the tray, placing the fish on the cutting board, and chopping the fish for the mechanical soft diets using a large knife. Once the fish was fully chopped, Cook1 placed the fish in a pan, and placed the pan on the steam table.Continued observation during the same meal service, revealed Cook1 again donned oven mitts over the same pair of soiled gloves, and removed a tray of fish from the oven. While wearing the oven mitts, he tipped the tray to place the fish into a pan to place on the steam table. Cook1 then placed the dirty pan in the dishwashing area, removed his soiled gloves and washed his hands. Continued observation during the same meal service, revealed Cook1 donned new black gloves, opened a loaf of bread, and with his gloved hand placed a slice of bread on each meal tray instead of using tongs to plate the bread. Cook1 touched his beard cover and adjusted his ball cap while plating the bread, but failed to remove his gloves and wash his hands before continuing to plate the bread with his gloved hand.Additional observation during the same meal service, revealed when Cook1 ran out of fish on the steam table, he placed oven mitts over his soiled gloved hands, pulled a tray of fish out of the oven, and removed the fish from the pan. Cook1 then removed his gloves and, without using any soap, rinsed his hands, dried them, donned new gloves, and returned to the steam table to continue the meal service.During an interview, on 01/30/2026 at 1:10 PM, Cook1 stated he should have washed his hands a little more often than he did during the meal service. Cook1 stated he was to wash his hands upon entering the kitchen, anytime he changed gloves, and when there was a risk for cross-contamination. Cook1 further stated he should change gloves anytime he went from one product to another, anytime he touched himself, and anytime he handled food. Further, Cook1 stated he would consider the gloves soiled if they were inside oven mitts. Cook1 stated the oven mitts were washed every other day, but he could see how failing to wash his hands after handling the oven mitts could result in cross-contamination.During an interview, on 01/31/2026 at 9:31 AM, the District Manager stated Cook1 should have used tongs to plate the bread. The District Manager stated he expected staff to immediately change gloves and wash hands when the gloves became soiled.During an interview, on 01/31/2026 at 10:05 AM, the Director of Nursing (DON) stated, if staff was preparing food, once they touched something dirty, they should remove the soiled gloves and wash their hands. The DON further stated staff should wash their hands and change gloves after they touched their face, hair, or person.During an interview, on 01/31/2026 at 10:20 AM, the Administrator stated kitchen staff needed to wash their hands at appropriate time to prevent cross-contamination. She stated kitchen staff should wash their hands after each task. The Administrator further stated kitchen staff should wash hands and change gloves after using the mitts and then proceed with what they were doing with the food.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failure had the potential to affect all 59 residents in the building. The facility failed to ensure fit testing for employees. Fit testing refers to a mandatory Occupational Safety and Health Administration (OSHA) regulated procedure that verifies a tight-fitting respirator (such as an N95 mask) properly seals to an employee's face in order to minimize contaminants entering the mask through gaps between the seal and the skin. Additionally, observations on 01/28/2026 and 01/29/2026, revealed staff entered Resident (R)29's room, who was diagnosed with COVID-19, without wearing the appropriate personal protective equipment (PPE). Furthermore, R37, who was R29's roommate, was not tested for COVID-19, after R29 tested positive for COVID-19.The findings include: Review of the facility policy titled, Infection Control, revised October 2018, revealed, This facility'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. The policy revealed, . 4. All personnel will be trained on our infection control policies upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.1. During an interview on 01/30/2026 at 12:18 PM, the Staff Development Coordinator (SDC)/ Infection Preventionist (IP) stated she was unable to find a policy regarding staff fit testing for N95 respirators.Additionally, the facility was unable to provide documented evidence of annual N95 fit testing.During an interview, on 01/30/2026 at 12:08 PM, the SDC/IP stated the facility currently did not have the needed supplies to conduct fit testing for employees, so she visually inspected the mask and seal to ensure proper fit.During an interview, on 01/30/2026 at 10:47 AM, the Director of Nursing (DON) stated she was not aware fit testing had not occurred. She further stated it was her expectation that fit testing for employees be completed upon hire and annually.During an interview, on 01/30/2026 at 10:57 AM, the Administrator stated the last time fit testing was conducted was in 2022. Additionally, she stated after she became aware fit testing had not been done, she ordered all the supplies for the testing, and the facility would conduct fit testing as soon as the supplies arrived.2. a. Review of the facility policy titled, Isolation- Categories of Transmission-Based Precautions, revealed, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Once initiated, the resident is placed in isolation for the designated time frame, with services provided in the resident room versus communal areas. [sic] (such as nursing care, therapy, dining, activities, etc. [et cetera; and so forth]. The policy revealed, Droplet Precautions included, 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets that can be generated by the individual coughing, sneezing, talking, or by performance of procedures such as suctioning); . 3. Masks will be worn when entering the room; and 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. The policy revealed, Airborne Precautions included, 1. Airborne precautions are indicated when and [sic] individual is infected with a pathogen that is very small and can be transmitted long distances through the air. The policy further revealed, . 4. Any individuals who enter the room of a resident placed on airborne precautions must wear approved respiratory protection.Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, revised 01/23/2026, revealed, HCP [healthcare personnel] who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 [COVID-19] infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health]-approved particulate respirator with N95 filters or higher, gowns, gloves, and eye protection (i.e. [id est; that is], goggles or a face shield that covers the front and sides of the face.Review of R29's admission Face Sheet revealed the facility admitted the resident on 12/22/2025 with a diagnosis of a stroke with residual hemiplegia and hemiparesis (weakness and/or paralysis to one side of the body).Review of R29's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of 10 out of 15, which indicated moderate cognitive impairment.Review of R29's nursing Misc [Miscellaneous] note, dated 01/21/2026, revealed the resident had been coughing and congested. The note indicated facility staff contacted the Advanced Practice Registered Nurse (APRN) and obtained orders for a respiratory panel to be sent to the laboratory. Per documentation, the specimen was obtained and placed for laboratory staff to pick up. Review of R29's Careplan Report included a problem statement initiated 01/24/2026, that indicated the resident tested positive for COVID-19.Review of R29's nursing Misc note, dated 01/24/2026, revealed the resident's respiratory panel was positive for COVID-19. The note indicated the resident was placed on droplet precautions for five days.Review of R29's Physician's Order Form As Of 01/28/2026 revealed an order dated 01/24/2026 for the resident to be on droplet precautions, with staff instructions to wear a gown and gloves when entering the resident's room.Observation on 01/28/2026 at 9:52 AM, revealed a sign above R29's room placard indicating the resident was on droplet precautions, with instructions that indicated everyone must clean their hands upon entering and leaving the room and ensure their eyes, nose, and mouth were fully covered prior to entry. The sign indicated everyone was to remove face protection before exiting the room. There was a three-drawer plastic storage unit below the signage on the floor with N95 respirators, KN95 respirators, surgical masks, face shields, gowns, and gloves available. There was also a wall unit beside the door placard with gloves and gowns available.Further observation on 01/28/2026 at 9:52 AM, revealed Certified Nurse Aide (CNA)2 donned a gown, a surgical mask, and gloves and entered R29's room, closing the door behind her. CNA2 did not put on a face shield or an N95 respirator prior to entering the room.During an interview, on 01/29/26 at 3:37 PM, CNA2 stated she wore a gown, gloves, and surgical mask, but not a face shield to provide care to R29.Observation on 01/28/2026 at 12:14 PM, revealed CNA3 delivered R29's meal tray and assisted with setting it up. CNA3 wore a gown and gloves. She did not wear any face shield, eye protection, or N95 respirator. The droplet precaution sign was present above the placard, and the storage bin was still present.During an interview, on 01/28/2026 at 12:14 PM, CNA3 stated she did not wear a mask or face shield while delivering and setting up R29's meal.During an interview, on 01/29/2026 at 8:58 AM, the Staff Development Coordinator (SDC)/ Infection Preventionist (IP) stated if a resident tested positive for COVID-19, staff was expected to wear a face shield or goggles, an N95 respirator, gown, and gloves. She stated staff was trained in the use of personal protective equipment (PPE) and she expected staff to know when to wear it.During an interview, on 01/30/2026 at 2:43 PM, the Director of Nursing (DON) stated she expected staff to follow the pictures on the signage and don the appropriate PPE. She stated using an N95 respirator and following the rest of the pictures on the signage for R29, was the same as abiding by airborne precautions.During an interview on 01/30/2026 at 3:27 PM, the Administrator stated it was her expectation the facility staff follow CDC guidance for transmission-based precautions.2. b. Review of the CDC guidance titled, Infection Control Guidance: SARS-CoV-2, dated 06/24/2025, revealed, Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5.Review of R37's admission Face Sheet revealed the facility admitted the resident on 01/02/2026. R37 was R29's roommate.Review of R37's admission MDS, with an ARD of 01/07/2026, revealed the R37 had an active diagnosis of a right femur (thigh bone) fracture. The MDS further indicated the facility assessed the resident as having a BIMS score of 12 out of 15, which indicated moderate cognitive impairment.The facility was unable to provide documented evidence of a COVID-19 test for R37 after R29 tested positive.During an interview, on 01/30/2026 at 10:42 AM, the SDC/IP stated she believed R37 was tested for COVID-19 with one of the facility's rapid tests.During an interview, on 01/30/2026 at 2:43 PM, the DON stated the facility staff tested R37 on day one with negative result or symptoms. She stated R37's symptoms had improved after testing on day 1. She further stated she expected the residents to be tested for COVID-19 according to CDC guidance.During an interview, on 01/30/2026 at 12:37 PM, the Advanced Practice Nurse Practitioner (APRN) stated she expected the facility staff to follow CDC guidance related to COVID-19 testing.During an interview, on 01/30/2026 at 3:27 PM, the Administrator stated she expected the facility staff to have completed testing on R37 per the CDC guidance.

The facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. Gnats were observed in common areas and resident rooms throughout the survey process. Interview with residents indicated this had been an ongoing issue, with multiple resident reporting concerns with gnats getting on their food or drinks at meal times (R3, R9, R10, R15, R42, R45, R48). The findings include: Interview with Maintenance Director on 08/29/2024 at 10:45 AM and Administrator on 08/29/2024 at 3:37 PM revealed facility did not have a pest control plan or policy. A Pest Control Agreement was requested, but not provided during survey. Review of the Homelike Environment Standard of Practice, dated 10/2020, revealed the purpose of the policy was to ensure residents are provided with a safe, clean, comfortable and homelike environment, with the facility responsible for maximizing cleanliness and order. Review of a facility Work Order #2059, created on 03/14/2024, noted broken tiles around dish machine, holding water, causing water to attract gnats. Further documentation noted Regional is supposed to bring some spare tile from another facility. Floor being cut out 05/20/24 to 05/22/24 for new plumbing in dish washing area. Review of a Customer Service Report from Ecolab pest control dated 06/07/24 revealed the facility was treated for large flies, with gluboards checked and replaced. Glueboards were documented as 25% full. Sanitation Issues were identified in the kitchen, specifically the floor under cook/steam line was observed in need of cleaning. Drains need to be cleaned pipes need to be cleaned out [AGE] years worth of small fly larva, and pipe. Please clean regularly. Material Applied: Ecolab Drain Cleaning Gel, targeting small flies. Review of a Customer Service Report from Ecolab pest control, 07/12/24 revealed the facility was treated for large and small flies, with glueboards checked and replaced. Glueboards were documented as 50% full. Review of a Customer Service Report from Ecolab pest control, 08/28/24 the facility was treated for large and small flies, with glueboards checked and replaced. Documentation goes on to reveal pest activity was found in the kitchen area, with small flies noted during service throughout the kitchen. Area was inspected and serviced. Observation on 08/25/24 at 10:45 AM revealed several gnats swarming around R42's overbed table. Resident had no open food items or other items in area that would be attracting gnats. Resident had a covered thermos-style cup on overbed table. Observed two gnats on resident's thermos. Counted six gnats on ceiling in area to the side and above resident bed. No gnats were observed around sink or anywhere else in resident area. Interview with R42 on 08/25/2024 at 10:45 AM revealed when he finished his breakfast that morning and put the napkin down over his plate, in just a matter of seconds there were a dozen gnats all over it. He shared the only thing he has concerns about regarding his care here is the gnats, states they are everywhere. Continued observation, returned to R42's room on 08/25/2024 at 12:30 PM following lunch service. Resident had his eyes closed, observed three gnats on resident napkin placed over his plate. Observation on 08/25/2024 at 1:10 PM revealed a gnat flying around R45's tray. Interview with R45 at that time revealed he sees gnats often. Interview on 08/25/2024 at 1:10 PM with R45 stated he sees gnats often around his tray, and won't eat his food when gnats are swarming around it. During resident council on 08/26/2024 at 2:30 PM, R9, R10, R3, R15, and R48 all complained of seeing gnats on their food or on their drink cups. R48 stated if gnats land in her food, she doesn't eat because of it. R9 stated if gnats land in her coffee cups or cokes, she doesn't drink them when that happens. On 08/29/24 at 10:20 AM surveyor observed bug attracting lights with glue paper filled mostly with gnats on small hallway beyond [NAME] Lane. Interview on 08/29/24 at 10:34 AM with the Housekeeping Supervisor (HS) from another facility here to assist as this facility housekeeping supervisor recently quit, stated maintenance handles pest control, works with eco lab, treats for gnats. The HS stated there are some rooms that gnats are more prevalent in, including one resident on [NAME] Lane, whose refusals for room cleaning and personal hygiene may contribute to the gnat problem. We have deep cleaned that room, offered to deep clean yesterday, but resident refused. When we go to clean, roommate asks us to do as much as possible. No other areas come to mind, but I'm not extremely familiar with this building either. Interview on 08/29/24 at 10:45 AM with the Maintenance Director (MD) stated there is a plumbing issue contributing to the gnat problem, we have an outside vendor coming to redo plumbing to seal off one of the drains in the kitchen. The MD stated Ecolab was here yesterday and treated for gnats, but didn't replace all the glue strips in the lights. The MD stated the gnat issue has improved, but we still have more to do to eliminate them. The MD stated gnats have been an issue for about three weeks, with the MD being newly employed as MD as of 5 weeks ago. The MD stated he has replaced the troubled part of the drain line, that got rid of a lot of them, but have an outside vendor coming in to replace the part where it goes into the floor. Observation with MD on 08/29/2024 at 10:50 AM revealed one of four bug light stations had glue strips which had not been replaced, the one at the end of the small hallway beyond [NAME] Lane which surveyor noted earlier. MD was able to replace with an extra glue strip from another bug light station. Interview on 08/29/2024 at 3:37 PM with the Administrator stated when she came to the facility as Administrator at the end of June 2024, she did see their were gnats. She stated the facility started working on it, started calling pest control, consulted a plumber. She stated her goal was to find the root cause, and fix it. She was not aware of any resident complaints specific to gnats. She stated her expectation is to be pest free, including gnats, and if something arises we figure it out and get it fixed.

The facility failed to protect resident dignity related to a catheter bag cover for four of four sampled residents. Observation of R7, R8, R14, and R11 during survey revealed the catheter urine bag did not have a privacy cover and contained liquid. Observation of R7 included lunch time in the dining room with other residents present. R11 and R14 expressed they would prefer to have their catheter covered. R8 was vulnerable and catheter without dignity bag was visible from the doorway. The findings include: Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility would protect and promote the rights of each resident. The policy included the resident had a right to a dignified existance. Review of the facility policy Resident Rights Under Kentucky Law not dated, revealed residents were treated with recognition of his/her dignity and included privacy in treatment and in care for his/her personal needs. Review of the clinical record for Resident (R) 7 revealed the facility readmitted the resident on 09/10/2023. Resident diagnoses included Obstructive and Reflex Uropathy, and Other Specified Disorders of Kidney and Ureter. Review of the resident's Minimum Data Set (MDS) dated [DATE] revealed the facility assessed R7 as cognitively intact with a Brief Interview of Mental Status (BIMS) of 15. The MDS also identified the resident had an indwelling catheter. Review of the resident care plan for impaired bladder elimination, dated 06/09/2020, revealed the resident had a suprapubic catheter. An intervention included use of a dignity cover for the catheter drainage bag, dated 06/09/2020. Observation on 08/26/2024 at 12:40 PM, revealed R7 in the dining room eating his/her meal independently. The resident's catheter bag was on his/her left side of the wheelchair (w/c). The drainage bag was visible with liquid. Other residents were also in the dining room. In Interview on 08/27/2024 at 10:01 AM, R7 stated his/her (urine) drainage bag was changed the previous night and the bag was then covered. R7 stated he/she wanted the bag covered. The resident stated he/she liked having the bag covered and felt different without the cover on the bag. In interview on 08/28/2024 at 2:29 PM, Certified Nurse Aide (CNA) 6/ Staff Scheduler stated R7 had a urinary catheter when she began employment at the facility on 04/24/2024. She stated catheter drainage bags were to have a privacy bag over it. She also stated the privacy covers were in the supply room behind the nurse's station. The CNA stated the purpose of the cover for the resident's dignity. CNA 6 also stated the bags should not be seen or noticeable and she would report to the nurse if a cover was missing. On 08/28/2024 at 2:42 PM interview with CNA 5 revealed she took R7 his/her meal tray in the dining room. She stated catheter bags were supposed to be covered for a resident's dignity and privacy. She also stated it could be embarassing for the resident and hurt his/her feelings if the bag was not covered. CNA 5 stated she was unaware of R7's bag uncovered. In interview on 08/28/2024 at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated she did not see R7's catheter bag without a cover. She stated the purpose of the cover was for the resident's dignity. She further stated without the cover the bag was easy to spill when knocked and could burst easier. Interview on 08/29/2024 at 1:10 PM, with the Unit Manager (UM) revealed catheter bags were expected to have a privacy bag for the resident's dignity. She stated the purpose of the cover was so others would not know there was urine in the bag. She stated she checked residents urine bags had covered. The UM also stated resident's should not come out of their rooms without the cover on the bag. She further stated it was not good for other residents in the dining room to see R7's bag during the meal time. In interview on 08/29/2024 at 1:54 PM, the Director of Nursing (DON) stated she expected urinary catheter bags were covered. She stated the purpose of the cover was for the resident's dignity and for those around the resident. She also stated the cover helped residents feel comfortable. The DON stated every resident should have a dignity cover on the drainage bag. The DON stated she was unaware R7 did not have a cover on the bag. She further stated if the resident did not have a cover, the resident did not have his/her dignity. In interview on 08/29/2024 at 3:37 PM, the Administrator stated she was an LPN and was in her position as Administrator since June 2024. She stated the catheter unire bag should be covered to uphold the resident's dignity. She also stated she expected the nursing staff watched for covers in place. The Administrator stated the purpose of the cover was for the resident's dignity and to make the best situation they can for the resident. She stated if the cover was missing, the resident could feel insecure which could impact his/her dignity. 49267 Review of facility's policy titled, Resident Rights Standard of Practice, dated 04/2024, revealed the purpose was to ensure each resident is treated with respect and dignity, and care for in a manner that promotes maintenance or enhancement of his/her quality of life. Further review revealed the resident has the right to be treated with respect and dignity. The facility did not have a policy specific to catheter care. 1. Review of R8's, Admission Face Sheet, revealed the facility admitted the resident on 01/09/2015 with diagnoses including Alzheimer's disease, aphasia and dysphagia following a stroke, and congestive heart failure (CHF). Review of R8's, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. Observation on 08/25/2024 at 11:27 revealed R8 in bed A with the door open. Further observation revealed R8's catheter drainage bag was visible from the hallway and was without a dignity cover. Additional observation on 08/27/2024 at 8:40 AM revealed R8's catheter drainage bag still without a dignity cover. 2. Review of R14's, Admission Face Sheet, revealed the facility admitted the resident on 10/12/2023 with diagnoses including Parkinson's disease, quadriplegia, and type 2 diabetes. Review of R14's, MDS with an ARD of 08/10/2024, revealed the resident had a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Observation on 8/25/2024 at 10:51 AM revealed a catheter drainage bag secured to the right side of the bed with no dignity cover in place. In an interview with R14 on 8/25/2024 at 10:51 AM, he stated he was unsure why his catheter bag was not covered, and no one had ever asked. He further stated he wished to have a dignity cover, so the urine was not visible. 3. Review of R11's MDS with an ARD of 10/19/2023, revealed the facility admitted the resident on 01/16/2020 with diagnoses including non-traumatic spinal cord dysfunction, neurogenic bladder (a condition where normal bladder function is disrupted due to nerve damage), dementia, and CHF. Review of R11's, MDS with an ARD of 07/05/2024, revealed the resident had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Observation of R11's catheter drainage bag on 08/28/2024 at 9:31 AM, revealed the absence of a dignity cover. In an interview with R11 on 08/28/2024, she stated she wished they would put something over her catheter bag because she did not like the bag visible to people. In an interview with Certified Nursing Assistant (CNA) 5 on 08/28/2024 at 9:14 PM, she stated all residents with catheters should have a dignity bag, but they did not. She further stated she was not exactly sure why but thought maybe it was because they did not have enough at the facility. In an interview with CNA 8 on 08/28/2024 at 3:17, she stated some of the residents had dignity covers over their catheter drainage bags and some did not, but she was unsure why. In an interview with the central supply clerk on 08/28/2024 at 3:29 PM, she stated the facility had an ample supply of catheter dignity bags. Observations on 08/28/2024 at 3:29 PM in supply closet behind the nurse's station revealed one opened box that contained one dignity bag and two unopened boxes of 20. In an interview with CNA10 on 08/28/2024 at 9:55 AM, she stated all catheter drainage bags should be covered with a dignity bag to protect residents' privacy. In an interview with Licensed Practical Nurse (LPN) 5 on 08/29/2024 at 10:24 AM, she stated every resident with a catheter should have a dignity cover over the drainage bag. She further stated, Nobody wants you looking at their urine. In an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM, she stated all residents with catheters should have a dignity cover over their catheter drainage bag for privacy and respect. In an interview on 08/29/2024 at 2:28 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), she stated every resident with a catheter should have a dignity cover over the drainage bag. She further stated it was important for the bag to be covered because it protected the resident's privacy. In an interview with the Director of Nursing (DON) on 08/29/2024 at 3:03 PM, she stated it was her expectation any resident with a catheter had dignity cover in place over the drainage bag. In an interview with the Administrator on 08/29/2024 at 3:55 PM, she stated it was her expectation nursing ensured all residents with a catheter had a dignity cover over the drainage bag. She further stated no one wanted a catheter and they should make the situation the best scenario possible. The Administrator stated failure to provide a dignity cover resulted in potential impact to a resident's dignity and feelings of insecurity.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for ten (Resident (R) 9, R14, R25, R26, R35, R39, R40, R42, R108, and R254) of 21 sampled residents. Residents did not receive regularly scheduled showers and/or baths, and grooming/hygiene, including nail care, as needed. The findings include: Review of a facility policy, titled Activities of Daily Living (ADLs), dated 10/2020, revealed the facility would work to provide care and services to residents that were person-centered, and honor and support each resident's preferences, choices, values, and beliefs. The policy stated the facility protocol would be to provide the resident the appropriate care and services to maintain or improve his/her ability to carry out the ADLs. The facility would provide care and services for the following ADLs: hygiene (bathing, dressing, grooming, oral care) and any resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the facility did not include specifics related to the provision of these services. 1. Review of R9's Admission Face Sheet revealed the facility admitted the resident on 11/04/2016 with diagnoses including multiple sclerosis (MS), morbid obesity, and type 2 diabetes. Review of R9's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident was dependent on staff for bathing and had no refusals of care. Review of the resident's care plan revealed the resident required two-person assistance with the use of a mechanical lift. Review of the resident's shower/bath schedule revealed the resident was supposed to receive a shower twice a week. Per the shower sheet, each day was to be documented that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. Review of R9's shower sheets from 11/01/2023 through 01/31/2024 revealed no documented showers, baths, or refusals between 11/12/2023 and 11/20/2023; between 12/04/2023 and 12/10/2024; between 12/15/2023 and 12/22/2023; between 12/24/2023 and 01/05/2024; or between 01/07/2024 and 01/21/2024. During an interview with R9 on 08/26/24 at 08:37 AM, she stated her showers were often not provided on her shower day because of staffing issues. She further stated it was very depressing when she did not receive a shower. During an interview with Certified Nursing Assistant (CNA) 3 on 08/27/24 at 07:49 PM, she stated R9 required two people for her care and preferred her shower during the day. CNA3 stated R9's showers were not always provided on her scheduled shower day because there were not enough people to help on the floor. 2. Review of R14's Admission Face Sheet revealed the facility admitted the resident on 10/12/2023 with diagnoses including Parkinson's disease, quadriplegia, and type 2 diabetes. Review of R14's MDS, with an ARD of 08/10/2024, revealed the resident had a BIMS score of 12/15, which indicated the resident was moderately cognitively impaired. Per the MDS, the resident was dependent on staff for Activities of Daily Living (ADLs) and did not refuse case. Review of R14's care plan, with a date of 10/12/2023, revealed the resident would be provided ADL assistance per assessment. The resident's shower schedule was twice weekly. Review of R14's shower sheets from 05/26/2024 through 08/24/2024 revealed documentation of partial or total bed baths, but no showers. Further review revealed no documentation of any bath hygiene between 06/21/2024 through 06/30/2024; 07/23/2024 through 07/31/2024; or 08/07/2024 through 08/13/2024. Observation on 08/26/24 at 9:39 AM revealed R14's fingernails were approximately one to one and a half inches long; were yellowed in color; and dirt was observed underneath all ten fingernails. During an interview with R14 on 08/26/2024 at 9:39 AM, he stated he was not sure the last time his nails were trimmed. He further stated he liked to have his nails trimmed and clean. Further interview with R14 revealed that yesterday (08/25/2024) was the first time in about six months he was offered a bath. 3. Review of R26's Admission Face Sheet revealed the facility admitted the resident on 04/05/2024 with diagnoses including legal blindless, right below the knee amputation (BKA), and type 2 diabetes. Review of R26's MDS, with an ARD of 07/04/2024, revealed the resident had a BIMS score of 14/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing/showering, and did not refuse care. Review of the care plan, dated 04/04/2024, revealed the resident would be provide the level of assistance required with ADLs. The resident's shower schedule was twice weekly. a. During interview with R26 on 08/27/24 at 8:36 AM, he stated he had not received a shower last month. Review of R26's shower sheets from 05/27/2024 through 08/24/2024 revealed no documented showers, baths, or refusals between 07/07/2024 and 08/09/2024. During an interview with CNA5 on 08/28/2024 at 9:14 AM, she stated R26 was scheduled for a shower yesterday, but it was missed because she did not have time or help. b. Observation on 08/27/2024 at 8:36 AM revealed R26's fingernails were approximately one to one and a half inches long, yellow in color, brittle, and dirty underneath. During an interview with R26 on 08/27/2024 at 8:36 AM, he stated he wanted to have his nails trimmed and cleaned. He further stated he had a visual impairment and frequently used his hands when he ate finger type foods. During an interview with CNA 10 at 08/29/2024 at 9:55 AM, she stated the CNAs trimmed residents' fingernails unless the resident was a diabetic. If the resident was diabetic, then nursing staff was responsible for nail care. CNA 10 further stated it was important fingernails were kept trimmed and cleaned because of cleanliness, especially when the resident ate. 4. Review of R25's Admission Face Sheet revealed the facility admitted the resident on 03/20/2019 with diagnoses including left sided paralysis following a stroke and contracture of left hand and left wrist. Review of R25's MDS, with an ARD of 08/06/2024, revealed the resident had a BIMS score of 14/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing/showering and did not refuse care. The resident's care plan, dated 11/08/2019, noted the resident had a self-care deficit and required assistance with ADLs. Review of R25's shower sheets from 05/26/2024 through 08/25/2024 revealed no documented showers, baths, or refusals between 07/06/2024 and 08/05/2024. Observation on 08/25/24 at 11:47 AM revealed R25's hair was dirty, greasy, and matted to the resident's head. During interview with R25 on 08/25/2024 at 11:47 AM, he expressed concern about the frequency of baths and stated it had been about a month since he received a shower or bath. In an additional interview with R25 on 08/27/2024 at 8:48 AM, he stated he still had not received a shower. He further stated he wanted a bath because he felt dirty. 5. Review of R35's Admission Face Sheet revealed the facility admitted the resident on 01/06/2023 with a diagnosis of left sided paralysis following a stroke. Review of R35's MDS, with an ARD of 08/20/2024, revealed the resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident was dependent on staff for showers/bathing and did not refuse care. The care plan, dated 01/17/2023, noted the resident had a self-care deficit and staff were to provide ADL assistance per the MDS assessment. The resident's shower schedule was twice weekly. Review of R35's shower sheets from 05/26/2024 through 08/25/2024 revealed no documented showers, baths, or refusals between 07/19/2024 and 07/31/2024 or between 08/11/2024 and 08/25/2024. During an interview with R35 on 08/25/2024 at 11:15 AM, she stated her scheduled showers were not always provided. Observation during this interview revealed the resident had dirty, uncombed hair. 6. Review of R40's Admission Face Sheet revealed the facility admitted the resident on 08/18/2022 with diagnoses including, acute and chronic respiratory failure, type 2 diabetes, and stroke. Review of R40's MDS, with an ARD of 07/31/2024, revealed the resident had a BIMS score of 15/15, which indicated the resident was cognitively intact. Per the MDS, the resident required assistance with bathing and did not refuse care. The resident's care plan, dated 08/18/2022, noted the resident required assistance with ADLs per their assessment. The resident's shower schedule was twice weekly. Review of R40's shower sheets from 11/01/2023 through 01/31/2024 revealed no documented showers, baths, or refusals between 11/08/2023 and 11/13/2023 or between 01/03/2024 and 01/10/2024. Review of R40's shower sheets from 05/26/2024 through 08/24/2024 revealed no documented shower, bath, or refusals between 07/19/2024 to 07/31/2024 or between 08/11/2024 to 08/25/2024. No observation or interview was conducted as the resident was out to the hospital during the survey. 7. Review of R108's Admission Face Sheet revealed the facility admitted the resident on 10/17/2023 with diagnoses including paraplegia and type 2 diabetes. Per this closed record, the resident's discharge date was 05/08/2024. Review of R108's MDS, with an ARD of 04/03/2024, revealed this resident required assistance with bathing. Per the care plan, dated 10/16/2023, the resident had a self-care deficit and ADL assistance was to be provided as required per assessment. Review of R108's shower sheets from 11/01/2023 through 01/31/2024 revealed one documented entry on 12/01/2023 for a shower. 8. Review of R254's Admission Face Sheet revealed the facility admitted the resident on 12/04/2023 with diagnoses that included paralysis following a stroke, dementia, and congestive heart failure (CHF). Per this closed record, the resident's discharge date was 01/11/2024. Review of R254's shower sheets from 12/04/2023 through 01/10/2024 revealed no documented showers, baths, or refusals between 12/04/2023 and 12/10/2023. 9. Review of a face sheet revealed the facility admitted R39 on 02/15/2024 with diagnoses including cognitive communication deficit, history of transient ischemic attack (TIA) and cerebral infarction, and unspecified dementia with other behavioral disturbance. Review of a Quarterly MDS, with an ARD of 08/21/2024, revealed the facility assessed R39 to have a BIMS score of 3/15 indicating the resident had severe cognitive impairment. Per the MDS, the resident needed staff assistance with bathing and did not refuse care. Review of R39's shower sheets from 05/27/2024 through 08/28/2024 revealed no documented showers, baths, or refusals from 07/07/2024 through 08/05/2024. 10. Review of a face sheet revealed the facility admitted R42 on 10/17/2022 with diagnoses including cervical disc disorder with myelopathy, major depressive disorder, and neurogenic bowel. Review of a Quarterly MDS, with an ARD of 07/28/2024, revealed the facility assessed R42 to have a BIMS score of a 15/15 indicating the resident was cognitively intact. Per the MDS, the resident needed staff assistance with bathing and did not refuse care. Review of R42's shower sheets from 05/27/2024 through 08/28/2024 revealed no documented showers, baths, or refusals from 07/04/2024 through 07/12/2024, 07/15/2024 through 07/22/ 2024, and 08/15/2024 through 08/26//2024. During an interview with R42 on 08/29/2024 at 1:10 PM, he stated he did not receive showers regularly. R42 stated he has had to wait several days between showers due to a lack of staff to assist. R42 stated he had waited up to a week in the past. R42 stated he did like to take his showers and it was frustrating to him when he could not receive a shower. R42 further revealed there had been many times that staff wouldn't even ask him if he wanted a shower because they did not have enough help. During an interview with CNA5 on 08/28/2024 at 9:14 AM, she stated that typically, four to five showers were completed on day shift, and she was unsure about night shift. CNA5 stated sometimes they had a shower aide, but lately the facility was short staffed. She further stated when they had one aide per hall and the mechanical lift required two staff, it was hard to get showers completed. CNA5 stated residents had complained to her about missed showers. She further stated residents had missed outside appointments because they told her they felt dirty. During an interview with CNA10 on 08/29/2024 at 9:55 AM, she stated residents were usually showered twice a week; however, some residents had complained to her their showers were missed. During an interview with CNA9 on 08/28/2024 at 1:57 PM, she stated if a shower aide was not scheduled to work, the CNA on the floor was responsible for showers and she found it difficult to give showers on top of her other assigned duties. CNA9 stated she often worked without a shower aide scheduled and they were short staffed. During an interview on 08/29/2024 at 10:24 AM with Licensed Practical Nurse (LPN) 5, she stated residents had complained their showers were not received. She further stated some days they had a shower aide and that helped, but other days there was not enough staff to make certain all showers were completed. During an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM, she stated there should not be any reasons showers were not provided unless a resident refused. During an interview with the Director of Nursing (DON) on 08/29/2024 at 2:37 PM, she stated residents have assigned shower days twice a week. The DON stated she expected the facility to be staffed appropriately to be able to provide the care the residents required, and she thought the facility had been. Further interview with the DON, on 08/29/2024 at 3:03 PM, revealed she had no concerns with the overall hygiene of residents. She further stated it was her expectation nurses helped with ADL's if needed. During an interview with the Administrator on 08/29/2024 at 3:39 PM, she stated she was aware there was work to be done, and the facility was working on an action plan related to showers. The Administrator stated she wanted to ensure a shower aide was staffed at least three days a week. She stated showers should not be missed and the CNA working the floor was responsible to ensure the resident received their shower or bath. The Administrator stated their goal was to ensure all scheduled showers were given, adding that there should never be a day a resident did not receive their scheduled shower. 49267

Based on observation, interview, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (six) of 21 sampled residents (R8, R11, R30, R31, R36, R45). Observation on 08/26/2024 at 2:23 PM revealed R45's catheter bag on the floor. Additionally, observation of a unit manager not donning a gown prior to entering R9's room, which was in contact precautions. The findings include: Review of a facility policy titled, Isolation-Categories- Transmission-Based Precautions, not dated, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or had a laboratory confirmed infection; and was at risk of transmitting the infection to other residents. Contact Precautions specify that staff and visitors would wear a disposable gown upon entering the room and remove before leaving the room. Review of Appendix PP in the State Operations Manual (SOM) revealed, Contact precautions were intended to prevent transmission of pathogens that were spread by direct (e.g., person-to-person) or indirect contact with the resident or environment, and required the use of appropriate Personal Protective Equipment (PPE), including a gown and gloves before or upon entering (i.e., before making contact with the resident or resident ' s environment) the room or cubicle. Review of a facesheet revealed the facility admitted Resident #9 (R9) on11/04/2016 with diagnoses to include: Carrier of carbapenem-resistant Enterobacterales, chronic candidiasis of vulva and vagina, and neuromuscular dysfunction of bladder, unspecified. Review of a facesheet revealed the facility admitted Resident #45 (R45) on 07/28/2024 with diagnoses to include: Benign prostatic hyperplasia with lower urinary tract symptoms, exocrine pancreatic insufficiency, and peripheral vascular disease. Observation on 08/26/2024 at 2:20 PM, R45's catheter bag was laying on the floor while the housekeeping staff swept and mopped around the bag. The housekeeper exited the room and proceeded to the next room without notifying nursing staff the catheter bag was laying on the floor. Observation on 08/27/2024 at 2:40 PM revealed Unit Manager (UM) #1 answered R9's call light. A sign was posted on R9's door alerting staff and visitors that R9 was placed on Contact Precautions. Prior to entry, the UM donned gloves, reached for a gown from the PPE bin but did not remove a gown and entered R9's room without a gown on. During an interview on 08/26/2024 at 2:23 PM with Housekeeper (HK) #1, she stated she should have notified a Certified Nursing Assistant or a Nurse that the catheter bag was laying on the floor. HK1 stated she cleaned around the catheter bag on the floor instead of notifying staff that it was laying on the floor. During an interview on 08/27/2024 at 3:35 PM with Unit Manager (UM) #1, she stated staff should wear a gown and gloves prior to providing care for residents on Contact precautions. UM1 read the sign on R9's door and stated she should have put on gloves and a gown everytime she entered the room if a resident was on contact precautions. UM1 stated it was important to follow the precautions put in place to prevent the spread of infection throughout the facility. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated catheter bags should always be secured to a bed or chair. The DON stated she expected non-clinical staff to notify nursing staff immediately so it could be corrected. During an interview on 08/29/2024 at 3:39 PM with the Administrator, she stated a catheter bag should never touch the floor because of cleanliness and positioning could impact the flow of urine in the tubing. She stated if someone saw a catheter bag on the floor they should always let a nurse know. 49267 Review of the facility's policy titled, Policies and Practices - Infection Control, revised 10/2018 revealed the objective is to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the facility's undated policy titled, Isolation - Categories of Transmission-Based Precautions revealed staff and visitors will wear gloves (clean, non-sterile) when entering room. Further review revealed staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The State Survey Agency (SSA) Surveyor requested a respiratory/oxygen policy on 08/27/2024 at 3:16 PM and a catheter care policy on 08/28/2024 at 8:20 AM. The Administrator stated the facility did not have a catheter care policy. The Administrator further stated the facility followed physician orders related to oxygen tubing because they did not have a specific respiratory and/or oxygen policy. 1. Review of R8's, Admission Face Sheet, revealed the facility admitted the resident on 01/09/2015 with diagnoses including Alzheimer's disease, aphasia and dysphagia following a stroke, and congestive heart failure (CHF). Review of R8's, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) of 00 out of 15, which indicated the resident was severely cognitively impaired. Review of R8's, Physician Order Form, dated as of 08/29/2024 revealed an order in place for oxygen at two liters. Further review revealed no orders in place related to resident's oxygen tubing. a. Observation on 08/25/2024 at 11:27 revealed R8 in bed A with the door open. Further observation revealed R8's catheter drainage bag was visible from the hallway. An additional observation revealed R8's catheter drainage bag positioned on the floor. During an interview with Certified Nursing Assistant (CNA) 5 on 08/28/2024 at 9:14 AM, she stated a resident's catheter drainage bag should not be placed on the floor because of infection concerns. During an interview with CNA8 at 08/28/2024 at 3:17 PM, she stated she worked at the facility as a CNA since May of this year and received training during orientation related to infection control and prevention. CNA8 stated catheter bags should never be left where they touched the floor because of the risk for infection. During an interview with Housekeeper #1 on 08/29/2024 at 9:45 AM, she stated resident rooms were cleaned daily. Housekeeper #1 stated if she found a resident's catheter bag or oxygen tubing on the floor, she stopped and notified the nurse or the aide. She further stated it was not acceptable to sweep or mop around a catheter bag or oxygen tubing on the floor because it was dirty and increased the chances for infection. During an interview with Licensed Practical Nurse (LPN) 5 on 08/29/2024 at 10:24 AM, she stated if she observed a resident's catheter drainage bag on the floor, she replaced it with a new bag. She further stated catheter drainage bags should not be on the floor because of infection risks. During an interview with the Unit Manager (UM) on 08/29/2024 at 10:48 AM she stated catheter drainage bags should not be on the floor because of contamination risks. The UM stated she performed rounds and room checks every morning. She further stated she had observed catheter drainage bags on the floor when she made rounds and provided immediate education to staff. During an interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 08/29/2024 at 2:28 PM, she stated she had been in her role for only two weeks but had started work on a new IP training program for both orientees and current employees. She further stated she planned for more skills checks, yearly check offs and return demonstrations. The ADON/IP stated she currently monitored for compliance with infection control practices through random audits. The ADON/IP stated catheter drainage bags should not be on the floor because of infection control concerns, The ADON/IP stated she had not observed any breaks in infection since she started at the facility. During an interview with the Administrator on 08/29/2024 3:52 PM, she stated catheter drainage bags should not touch the floor because of cleanliness and if positioned incorrectly affected urine flow. She further stated she expected staff to follow the facility's policies and procedures related to infection control and that included location of catheter drainage bags. b. Observation on 08/27/2024 at 8:40 revealed R8 with oxygen in use at two liters. Further observation revealed oxygen tubing contained no label or date. 2. Review of R11's MDS with an ARD of 10/19/2023, revealed the facility admitted the resident on 01/16/2020 with diagnoses including non-traumatic spinal cord dysfunction, neurogenic bladder (a condition where normal bladder function is disrupted due to nerve damage), dementia, CHF. Review of R11's, MDS with an ARD of 07/05/2024, revealed the resident had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Observation on 08/26/2024 at 9:43 AM revealed R11's oxygen tubing dated 08/09/2024. 3. Review of R31's, MDS, with an ARD of 02/14/2024 revealed the facility admitted the resident on 07/08/2020 with diagnoses including unspecified neurological condition and depression. Review of R31's, MDS with an ARD of 06/24/2024, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Observation on 08/25/2024 at 11:38 AM revealed R31 with oxygen in use. Further observation revealed R31's oxygen tubing dated 08/09/2024. 4. Review of R30's, MDS, with and ARD of 07/26/2024 revealed the facility admitted the resident on 07/26/2024 with diagnoses including CHF and chronic obstructive pulmonary disease (COPD). Review of R30's, MDS with an ARD of 07/29/2024, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R30's, General Order Form with an original date of 07/26/2024 and a renewed date of 08/01/2024, revealed an order to change oxygen tubing, humidification, and filter every 14 days. Observation on 08/25/2024 at 11:18 AM revealed oxygen in use at three and a half liters. Further observation revealed tubing was not labeled or dated. 5. Review of R36's, MDS, with an ARD of 12/08/2023 revealed the facility readmitted the resident on 12/04/2023 with diagnoses of stroke, CHF, and pneumonia. Review of R36's, MDS with an ARD of 06/09/2024, revealed the resident had a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Review of R36's, General Order Form with an original date of 08/23/2023 and a renewed date of 08/01/2024, revealed an order to change oxygen tubing, humidification, and filter every 14 days. Observation on 08/25/2024 at 11:21 AM revealed R36 with oxygen in use at two liters. Further observation revealed R36's oxygen tubing was not dated. An interview was attempted with CNA 12 on 08/28/2024 at 9:01 PM. CNA12 was not reached and the (SSA) surveyor was unable to leave a message. An interview was attempted with CNA 13 on 08/28/2024 at 9:03 PM, but the number provided by the facility was incorrect. An interview was attempted with LPN6 on 08/28/2024 at 9:06 PM. The (SSA) surveyor left a message, but a return call was not received. During an interview with LPN5 at 08/29/2024 at 10:24 AM, she stated she did not know how often oxygen tubing was changed, but thought it was changed by night shift. LPN5 stated it should be changed on a regular basis because over time the tubing became dirty and posed a risk for infection. During an interview with the UM on 08/29/2024 at 10:48 AM, she stated oxygen tubing should be changed as needed or at least monthly because of infection risks. During an interview with the ADON/IP on 08/29/2024 at 2:28 PM, she stated oxygen tubing should be changed every seven days or per physician's order. During an interview with the Staff Development Coordinator (SDC) on 08/29/2024 at 2:41 PM, she stated she did not know if the facility had a policy related to how often O2 tubing was changed. She further stated, it should be changed regularly because of the risk for infection. During an interview with the Director of Nursing (DON) on 08/29/2024 at 3:03 PM, she stated it was her expectation staff followed facility policies and procedures related to infection. She further stated oxygen O2 tubing should be changed weekly. During an interview with the Administrator on 08/29/2024 at 3:52 PM, she stated it was her expectation staff followed the facility's policies and procedures related to infection control. The Administrator stated they did not have a specific oxygen policy and the facility followed the physician's orders related to how often oxygen tubing was changed but stated it should be changed regularly for cleanliness purposes.

The facility failed to ensure CNAs received 12 hours of yearly training for two of three sampled CNA personnel files. The facility did not provide the required 12 hours of yearly training for the three CNAs reviewed. The findings include: Review of personnel files for Certified Nurse Aide (CNA) 10 revealed the facility hired the CNA on 05/12/2017. Review of the personnel file for CNA 13 revealed the facility hired the CNA on 12/10/2015. The facility did not provide the required 12 hours of annual training for revie for both CNAs. In interview with the Staff Development Coordinator (SDC) on 08/29/2024 at 1:43 PM, the SDC stated she worked at the facility for 3 weeks and was still looking for the CNA training hours. She stated her expectation was the training hours were completed monthly and within 1 year of the CNA's hire date. She further stated the facility had a lot of new staff and the trainings would be completed face-to-face and online. The SDC stated the purpose of the yearly training was to keep the CNAs up to date with what was going on in care. Additionally, she stated the trainings were a refresher on various topics including the facility abuse policy, resident rights, blood borne pathogens, use of the mechanical lifts, safety awareness, emergency preparedness. The SDC stated the CNAs may not be able to complete their shift until their training was up to date. On 08/29/2024 at 1:54 PM interview with the Director of Nursing (DON) revealed she was the DON for 2 weeks, although she was employed at the facility since 04/29/2024. She stated the SDC was responsible for most of the staff education. The DON stated she was unaware the SDC was unable to find any CNA training hours in the 2 weeks since she (the SDC) was hired. She stated the purpose of the yearly training hours for the CNAs was to show they received continuing education in their field to be up to date in their knowledge as a CNA. The DON stated if the CNAs did not receive the yearly training, they would not be up to date on their knowledge as a CNA and possibly not be able to renew their certification. In interview on 08/29/2024 at 3:37 PM, the Administrator stated she was employed at the facility since June 2024. She stated she was first aware of the lack of the CNA training hours during the survey. The Administrator stated the SDC was new in the last 2 to 3 weeks and filled a vacant position. She further stated the purpose of the yearly training hours was to nensure the CNAs skills and knowledge were where they needed to be . She stated if the CNAs did not have the yearly training, the CNAs may not know what they need to do which could directly impact the care they provide.

The facility failed to update the electronic clinical record to reflect resident code status per signed advanced directive for two of five sampled residents, R38 and R45. The Advanced Directives forms were signed for CPR, however, the electronic record revealed DNR. The findings include: 1. Review of the facility policy Advance Directive Standard of Practice reviewed ,d+[DATE], revealed it was the resident's right to formulate an Advance Directive. The facility would determine if the resident had executed an Advance Directive on admission to the facility and copies would be in the resident's medical record and scanned into the electronic medical record (EMR). If the resident was determined to not have decision making capabilities, the facility would approach the legal representative or health care proxy for the resident in regards to Advance Directives. Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility would protect and promote the rights of each resident. Residents had the right to create Advance Directives in accordance with state law. Review of the clinical record for Resident (R) 38 revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The resident's diagnoses included Congestive Heart Failure (CHF) and Mild Neurocognitive Disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 11 out of 15. Review of R38's Cardiopulmonary Resuscitation Consent (CPR) form dated [DATE] revealed the resident and his/her POA both signed to choose CPR be performed in the event of cardiac arrest. Review of the care plan, dated [DATE], for R38's Advance Directive revealed on [DATE] the resident was a Full Code status and the resident had a Power of Attorney (POA). The care plan also revealed on [DATE] the resident was Do Not Resuscitate (DNR) upon return from the hospital. An intervention included the resident would have his/her health care wishes/ advance directives honored. Review of R38's Advance Directives Order Form dated [DATE] revealed a physician order for DNR. In interview on [DATE] at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated the nurse completing a resident admission obtained the resident's code status. She stated the purpose of the Advance Directive was to know if the resident wanted CPR in case his/her heart stopped. The LPN stated if there was a question on a resident's status, staff would look in the electronic health record as she did not have access to the signed paper copy. She further stated she was unsure how the discrepancy with R38's Advance Directive occurred. She stated if the computer was different from the signed form, there was the potential for staff to do what they are not supposed to do. In interview on [DATE] at 9:20 AM, the Admissions Director (AD) stated she completed the admission packet for the resident, however if the resident entered the facility after 5:00 PM the nurse on duty would complete the resident's code status. She stated she was only involved for a resident re-admission if the resident's code status changed. The AD stated she did not recall R38's code status on return from the hospital, however she stated the hospital mentioned comfort measures with the family and palliative car services saw the resident in the hospital. She further stated the purpose of the Advance Directive was in case the resident's heart stopped, the facility knew what the resident's wishes were. She also stated the nurse would refer to the directive in the computer which came from the physician's order entered into the system. She further stated if the resident's heart stopped, staff would follow the order for DNR. The AD stated staff would not perform CPR on R38 and he/she could pass away. In interview on [DATE] at 1:10 PM, the Unit Manager (UM) stated she began employment at the facility on [DATE]. She stated when a resident returned from the hospital as a new admission, the resident's code status was reviewed and changed if needed. The UM stated code status was reviewed by the Interdisciplinary Team (IDT). She stated the nurse did not have access to the paperwork and the computer record was the resource for staff to know a resident's code status. The UM stated if there was a discrepancy between the computer record and the paperwork, staff would not perform CPR as the computer said DNR. On [DATE] at 1:54 PM interview with the Director of Nursing (DON) revealed a resident's Advance Directive was not completed when he/she returned from the hospital. She stated residents with a DNR status were reviewed in the IDT clincical meeting. The DON stated she did not recall reviewing R38's code status upon return from the hospital. She stated if there was a discrepancy between the computer and the paperwork, the resident's wishes would not be followed and CPR would not be provided. In interview on [DATE] at 3:37 PM, the administrator stated the facility audited resident admissions for the Advance Directive when a resident returned to the facility. She stated no one at the facility identified R38's code status did not match what was in the computer. She stated the purpose of the Advance Directive was to make a resident's wishes and choice if he/she wanted CPR or progress a natural course. The Administrator stated if there was a discrepancy the resident's wishes may not be followed and would not receive CPR. 2. Review of the facility policy Advance Directive Standard of Practice reviewed ,d+[DATE], revealed the resident had the right to formulate an Advance Directive. The facility determined if the resident had an Advance Directive upon admission to the facility and copies would be in the resident's medical record and scanned into the electronic medical record (EMR). If the facility determined the resident did no have decision making capabilities, the the legal representative or health care proxy for the residentwas approached in regards to Advance Directives. Review of the facility policy Resident Rights Under Federal Law not dated, revealed the facility protected and promoted the rights of each resident. Residents had the right to create Advance Directives in accordance with state law. Review of the clinical record for Resident (R) 45 revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The resident's diagnoses included Congestive Heart Failure (CHF) and Left Ventricular Failure. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) of 10 out of 15. Cardiopulmonary Resuscitation (CPR) Consent form signed on [DATE] revealed R45 chose CPR in the event of cardiac arrest. Review of the Advance Directioves Order From dated [DATE] revealed the physician order for Do Not Resuscitate (DNR). Review of R45's care plan dated [DATE] for Advance Directives revealed the resident had a DNR status with an onset date of [DATE]. In interview, on [DATE] at 8:42 AM, R45 stated he/she wanted to be let go if found unresponsive and did not want chest compressions. The resident stated yesterday the facility also asked him/her. In interview on [DATE] at 3:14 PM, Licensed Practical Nurse (LPN) 5 stated the resident's code status was completed by the nurse completing the resident admission. She stated the purpose of the Advance Directive was to know if the resident wanted CPR in case his/her heart stopped. The LPN stated staff looked in the electronic health record as she did not have access to the signed paper copy. She stated if the computer was different from the signed form, there was the potential for staff to do what they are not supposed to do. In interview on [DATE] at 9:20 AM, the Admissions Director (AD) stated she completed the admission packet for the resident, unless the resident entered the facility after 5:00 PM and the nurse on duty would complete the resident's code status. She stated she was only involved for a resident re-admission if the resident's code status changed. The AD stated R45's code status was follwed by what was in the computer from the physician order. She further stated the purpose of the Advance Directive was in case the resident's heart stopped, the facility knew what the resident's wishes were. She also stated the nurse would refer to the directive in the computer which came from the physician's order entered into the system. She further stated if the resident's heart stopped, staff would follow the order for DNR and would not perform CPR on R45 who could pass away. In interview on [DATE] at 1:10 PM, the Unit Manager (UM) stated the resident's code status was reviewed and changed if needed when a resident returned from the hospital as a new admission. The UM stated code status was reviewed by the Interdisciplinary Team (IDT). She stated the nurse did not have access to the paperwork and the computer record was the resource for staff to know a resident's code status. The UM stated R45 returned to the facility this month and would not receive CPRas the computer noted DNR and staff would not have the paperwork. On [DATE] at 1:54 PM interview with the Director of Nursing (DON) revealed the Advance Directive for a resident was not completed upon return from the hospital. She stated residents with a DNR status were reviewed in the IDT clincical meeting. The DON stated if there was a discrepancy between the computer and the paperwork, the resident's wishes would not be followed and CPR would not be provided. In interview on [DATE] at 3:37 PM, the administrator stated the facility audited resident admissions for the Advance Directive when a resident returned to the facility. She stated She was sure R45's code status was discussed and reviewed. The Administrator stated the purpose of the Advance Directive was to make a resident's wishes and choice if he/she wanted CPR or progress a natural course. The Administrator stated if there was a discrepancy the resident's wishes may not be followed and would not receive CPR.

Based on observation, interview, and facility policy review, the facility failed to ensure the resident(s) right to be free from abuse and neglect for one of one sampled resident. (R9) R9 stated staff left the room while providing her a shower, which made her feel scared. R9 was a quadriplegic and unable to call for help. The findings include: Review of a facility policy titled, Abuse Prohibition Standard of Practice, dated 11/2016 and revised 07/2022, revealed the facility would prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property and to ensure reporting and investigating of alleged violations in accordance with Federal and State laws. Review of a facility policy titled, Safety and Supervision Standard of Practice, dated 07/2020 and revised 02/2021, revealed the facility strived to make the environment as free from accident hazards as possible and resident safety and supervision were facility-wide priorities. Review of a facesheet revealed the facility admitted R9 on 11/04/2016 with diagnoses to include: lymphedema, not elsewhere classified, morbid obesity (severe) due to excess calories, and Multiple sclerosis. Review of the resident's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of a 15 out of 15, indicating the resident was cognitively intact. Review of a grievance form dated 07/16/2024 at 3:00 PM, revealed R9 stated she was being given a shower by CNA14. R9 stated she asked CNA14 twice to raise her arm and wash under it. CNA 13 replied with I am, threw down the hose and stated she was done and going to get another aide, leaving R9 in the room naked, soaked and unattended to. Section II documented action taken was education was provided to staff, as well as coaching and counseling. The State Survey Agency (SSA) Surveyor was unable to interview the nurse whom provided the education as she was out of the facility on medical leave. During an interview on 08/26/2024 at 8:37 AM with R9, she stated on 07/16/2024, CNA14 was helping her with a shower in the shower room and kept reaching across her body covering her face. R9 stated she was claustrophobic and kept telling the staff member to stop. R9 stated the staff member became angry, throwing the shower nozzle to the floor and walking out of the shower room , leaving her on the shower table alone with the water still running. R9 stated she began to yell for help but nobody could hear her and she felt scared. R9 stated she felt like she laid there forever however it was about fifteen minutes in reality. R9 further stated two other staff members entered the room and stated CNA14 told them R9 kicked CNA14 out of the shower room. During an interview on 08/28/2024 at 5:43 PM with Certified Nursing Assistant (CNA) #14, she stated she was giving R9 a shower and R9 kept complaining that she wasn't doing it correctly and to get out and find someone else. CNA14 stated she did leave the room to find another staff member to take over and left R9 laying on the shower table. CNA14 stated she should have stopped the shower, cover R9 with a sheet and pull the cord to alert other staff she needed assistance. CNA14 stated R9 could have fell off of the table and it was not appropriate to have left the resident alone. CNA14 stated she had only been employed at the facility a few weeks at the time and was reeducated by a nurse. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated a resident should never be left alone in the shower room. The DON stated CNA14 should have used the pull cord in the shower room and waited until someone could relieve her before leaving the room. The DON stated CNA14 was reeducated immediately. During an interview on 08/29/2024 at 3:39 PM with the Administrator she stated, the facility does not want staff to leave anyone unattended in the shower room. The Administrator stated R9 was unable to call for help and it was a safety concern. The Administrator further stated CNA14 should have used the emergency pull cord or stuck her head out of the door and yelled for someone to come help her.

The facility failed to ensure performance evaluations were completed for two of two sampled CNAs. The facility did not provide evaluations for CNAs employed over one year and trained based on those evaluation results. The findings include: Review of the personnel files for Certified Nurse Aide (CNA) 10 and CNA 13 revealed they did not have annual performace evaluations completed. The facility hired CNA 10 on 05/12/2017, the last performance evaluation completed was signed on 08/28/2018. The facility hired CNA 13 on 12/10/2015, and the last completed evaluation was signed 04/06/2021. In interview on 08/29/2024 at 9:57 AM, the Human Resource (HR) and Payroll Manager stated she worked at the facility 5 yeas and began as the HR Manager in December 2023. She stated employee performance evaluations were completed once a year based on their anniversary date. The HR Manager stated she places the completed evaluation into the employee's file, which she was responsible to maintain. She also stated the facility used a computer program to enter the employee hire date and the computer auto-populated when an evaluation was due. She stated when this occurred, she had to dismiss the autopopulated alert as it did not automatically go away. She stated when an employee's evaluation was due, she informed the Administrator. The HR Manager further stated the computer program did not flag if an evaluation was overdue. She stated she was unsure the reason CNA 10 and CNA 13 did not have their evluations completed. In interview on 08/29/2024 at 1:54 PM, the Director of Nursing (DON) stated she began employment at the facility in April 2024, and as the DON about 2 weeks ago. She stated the purpose of the employee performance evaluation was to ensure the employee did his/her job appropriately and provided good resident care. The DON stated the CNA evaluations were completed by the HR Manager. She further stated she completed the nurses evaluations, and the nurses were responsible to supervised the CNAs. The DON stated she was unsure if the nurses provided input into the CNA evaluations. She also stated she wanted to know if a CNA evaluation was not compelted, as she oversees the clinical department. The DON stated if the evaluation was not completed the facility was not able to follow up on theemployee's job performance. On 08/29/2024 at 3:37 PM, interview with the Administrator revealed she started employement at the facility at the end of June 2024. She stated she was not aware how far back employee performance evaluations were not completed until the survey. The Administrator stated she or the DON were responsible to complete the CNA evaluations. She stated the HR Manager received notifications from a computer program when evaluations were due. She further stated she asked the HR Manager to inform her when she (the HR Manager) sees them. The Administrator stated if the evaluations were not completed, employees had less information of what they did that was, good or where they needed to improve or areas to work on.

The facility failed to ensure daily nursing staffing was posted in the facility for two of five days during the survey. The last posted daily staffing 08/27/24. The findings include: Observation of the posted staffing on 08/29/2024 at 3:16 PM revealed the last posted date was 08/27/2024. In interview on 08/29/2024 at 3:24 PM, the Director of Nursing (DON) stated the Staff Scheduler/Certified Nurse Aide (CNA) 6 was responsible to post staffing in the morning during the week. The DON stated she did not check on this morning to see if the daily staffing was posted. She further stated the purpose of posting staffing information was so everyone knew the facility had adequate staffing to provide patient care. The DON stated if the information was not posted, the facility would have a hard time proving the staffing for the day. She also stated if the Scheduler was out during the week, she, the DON, would post the information. In interview on 08/29/2024 at 3:28 PM, the Staff Scheduler/CNA 6 stated she was responsible to post the daily staffing sheets and she did not post the sheet for this day. She stated when she came to work this day, she knew she would work as a CNA and was worried about resident care. The Scheduler also stated the day before (08/28/2024) the Administrator told her she would find someone to post the staffing for the day. The Scheduler further stated she posted in the morning when she comes in to work, however she worked as a CNA yesterday and this day. She stated the purpose to post daily staffing was to know how many staff to residents ratio. She stated without the posting, it was possible the facility would not have proper staffing available to provide resident care. On 08/29/2024 at 3:37 PM, interview with the Administrator revealed the Scheduler was responsible to post daily staffing. She stated the purpose to post was for transparency so others would know the facility had staff. The Administrator further stated the Scheduler worked as a CNA on 08/28/2024 and 08/29/2024, and the Unit Manager was the backup to post. She also stated the Scheduler worked as a CNA about once per week. The Administrator stated if the staffing was not posted daily, whomever looked for staffing posting would not have the information he/she was looking for.

Based on observation, interview, and record review, the facility failed to ensure one (Resident (R) 203) of 21 sampled residents was free from a significant medication error. R203 was sent to the hospital for pain control after not receiving her routinely ordered controlled pain medication for over two days after admission. The findings include: Review of a facility policy titled, Medication Administration Standard of Practice, dated 10/2020, revealed medications would be administered in a safe and timely manner, and as prescribed. 1. Observation on 08/26/2024 at 2:06 PM revealed R203 ambulating on Heritage Hall in her wheelchair. The resident was yelling out for help to use the bedpan and stating she was in pain. Interview at this time with R203 revealed she was admitted to the facility on the night of 08/23/2024. R203 stated she had taken Oxycodone (a controlled opioid medication used to treat moderate to severe pain) and Lyrica (medication used for nerve and muscle pain) for at least four years prior to admission. However, she continued, she had not received her scheduled pain medication since admission because the facility staff told her the physician had not sent in a prescription and they had not received her medication. R203 stated she had requested to be transferred to the emergency room for pain control. Additional observation on 08/26/2024 at 2:17 PM revealed three Emergency Management personnel transporting R203 to the hospital via ambulance. The resident was evaluated and treated in the emergency room but was not admitted , to the hospital, and returned to the facility around 3:00 AM on 08/27/2024. Review of a face sheet revealed the facility admitted R203 on 08/23/2024 with diagnoses including chronic migraine without aura, a displaced trimalleolar fracture of the left lower leg, chronic pain, muscle wasting and atrophy, and rheumatoid arthritis. Review of the resident's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated the resident was cognitively intact. Review of physician orders for R203 revealed routine orders for Lyrica (Pregabalin) 100mg (milligrams) one capsule twice a day and Oxycodone 10mg tablet one tablet every eight hours with a start date of 08/23/2024. In addition, the resident had orders for Tylenol 325 mg, two tablets as needed (PRN) for pain, as well as Tylenol 650 mg rectally PRN for pain. Although the resident was admitted on [DATE], review of the 08/01/2024 - 08/27/2024 Medication Administration Record (MAR) revealed the first dose of Lyrica 100 mg was not documented as given until 08/24/2024 at 7:00 PM (one day after admission). Per the MAR, the resident did not receive the first dose of Oxycodone 10mg tablet until 08/24/2024 at 11:00 PM (over a day after admission) Review of the MAR revealed these medications were documented as being administered by Licensed Practical Nurse (LPN) 8. During an interview with LPN8 on 08/28/2024 at 7:10 PM, he stated he did not administer Oxycodone or Lyrica on 08/24/2024 and if the MAR reflected that, it must have been a documentation error. Further interview with LPN8 revealed that he did not administer the medications because they had not yet arrived at the facility. Although the MAR documented that the medications were given on 08/24/2024, review of a packing slip confirmed the facility did not receive R203's Oxycodone 10mg tablets and Pregabalin 100mg capsules until 08/26/2024. The Oxycodone and Pregablin were not administered until 08/27/2024 at 7:00 AM, after the resident returned from the hospital. Further review of the 08/01 - 08/27/2024 MAR revealed that the PRN Tylenol was not administered during the two+ days from admission on 08/23/2024, till hospital transfer on 08/26/2024, and review of the resident's Progress Notes revealed no evidence of pain. Review of an inventory list from the facility's emergency Cubex supply (E-kit) revealed the facility had six Oxycodone-Acetaminophen 10/325mg tablets in stock/available for use. However, review of the transaction log, dated 08/23/2023 through 08/27/2024, revealed staff failed to remove the medication from the Cubex and administer the ordered Oxycodone to R203. During an interview on 08/27/2024 at 9:30 AM, Registered Nurse (RN) 1 stated she was an agency nurse. RN1 stated LPN5 was responsible for admitting R203. Although there was a physician's prescription on 08/23/2024 for the Oxycodone and Lyrica. LPN5 did not obtain the needed hard copy to order the pain medications from the pharmacy. RN1 stated she called the medical director on 08/24/2024 to request a prescription be sent to the pharmacy and the physician replied with Thank you. RN1 stated she did not work on 08/25/2024 and when she returned on 08/26/2024, R203's pain medication was still not stocked in the medication cart. RN1 stated she called the medical director again and he instructed her to notify his office and it would be taken care of. RN1 stated she did call the medical director's office to request the prescriptions be sent to the pharmacy. Although there was no evidence in the clinical record that the resident experienced pain on 08/23 - 08/25/2024, RN1 stated that on 08/26/2024, R203 began to complain of increased pain and asked to be sent to the hospital for an evaluation. RN1 stated typically the resident would admit with their pain medication with them or a written prescription. RN1 stated if the resident did not have a prescription, the admitting nurse was responsible to obtain the prescription and fax the prescription to the pharmacy. RN1 stated the pharmacy usually delivers the medication on the same day they receive the prescription. RN1 further stated if the resident had not received their medication, a nurse could pull medication from the Cubex; however, she did not know if this had been done for R203. RN1 confirmed that the facility ultimately did receive R203's medication during the time she was in the emergency roiagnom on [DATE]. During an interview on 08/29/2024 at 3:02 PM with LPN5, she stated she worked through an agency and had worked regularly at the facility since 03/2024. LPN5 stated she was responsible for R203's admission on 08/23/2024. LPN5 stated R203 did not have a hard copy of the prescriptions for Oxycodone or Lyrica, and it was her error, adding she should have asked someone what to do. LPN5 further stated she placed R203's admission papers in the tray for the administration team to review and assumed they would order R203's medications. LPN5 stated she misunderstood the process and should have asked someone since she did not know, and she should have called the medical director or ensured the sending facility had actually sent a prescription with the resident. LPN5 stated the normal process would be to obtain a hard copy of the prescriptions and fax it to the pharmacy, but she was tired and had several admissions that day. During an interview with LPN8 on 08/28/2024 at 7:10 PM, LPN8 stated he had worked on 08/24/2024 and R203's medications had not been received, so he called the pharmacy and was made aware they had not received a prescription. LPN8 stated he assumed the admitting nurse had not faxed the prescription, so he called the medical director. LPN8 stated the medical director replied with Thank you, and he did not hear anything back the remainder of the evening. He stated on 08/25/2024 when he reported to work, R203 still did not have her medications so he again called the medical director, who responded with Thanks, I'll take care of it LPN8 stated the admitting nurse should have ensured a hard copy of the resident's prescriptions had been faxed to the pharmacy so the resident would have had her medication. An attempt to conduct a telephone interview with the medical director (MD) on 08/28/2024 at 7:30 PM was unsuccessful and the MD did not return the telephone call. During an interview on 08/29/2024 at 2:37 PM with the Director of Nursing (DON), she stated she was not made aware until 08/27/2024 that R203 had not received her scheduled pain medications. The DON stated the admitting nurse was responsible for obtaining all orders for the resident. The DON stated on 08/27/2024, they learned that the physician had initially sent R203's prescription to an incorrect pharmacy. The DON stated that once R203 complained of increasing and uncontrolled pain on 08/26/2024, it was necessary to send the resident to the emergency room . The DON stated she expected nursing staff to obtain orders and send the prescription to the pharmacy during the admission process. The DON further stated she expected to be notified immediately so a decision could be made in a timelier manner and the resident could receive their prescribed medications. During an interview with the Administrator on 08/29/2024 at 3:39 PM, she stated she expected medications to arrive from the pharmacy in a timely manner and staff should ensure they had received the appropriate orders. The Administrator stated there should have been better communication with the staff, physician, and pharmacy to ensure R203's medications were received.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to immediately inform the resident's physician and guardian when there was a significant change in the resident's physical status for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's diet was downgraded by the Speech Therapist (ST) to a pureed diet with nectar thick liquids. Record review revealed the resident did receive a pureed diet beginning 01/09/2024; however, there was no evidence to support the physician or the resident's guardian were notified, or a physicians order written for the diet change. Further review revealed the facility did not notify the physician and guardian each time Resident #1 refused medications or meal/fluid intake. The findings include: Review of the facility's policy, titled Change of Condition Standard of Practice, dated 07/2020, revealed it was the facility's purpose to ensure all interested parties were informed of the resident's change in health status so a treatment plan could be developed which was in the best interest of the resident. Further review revealed the facility would immediately (as soon as possible/no longer than twenty-four (24) hours) inform the resident, consult the resident's physician, nurse practitioner or physician assistant, and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Depending on the nursing assessment, appropriate notification could range from immediately to forty-eight (48) hours. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 01/02/2024 with diagnoses which included unspecified severe protein-calorie malnutrition, vascular dementia, aphasia, and weakness. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete the interview. In addition, the facility assessed Resident #1 to require partial/moderate assistance with eating. Continued review of the MDS revealed the facility had assessed the resident to have coughing or choking during meals and/or swallowing medications and complaints of difficulty or pain with swallowing. Review of Resident #1's Medication Administration Record for 01/04/2024, revealed the resident refused his/her medications on 01/02/2024, 01/04/2024, 01/05/2024, 01/06/2024, 01/11/2024, 01/12/2024, 01/13/2024, 01/15/2024, 01/17/2024, 01/20/2024, 01/21/2024, and 01/23/2024. However, there was no documented evidence to support the physician or guardian were notified the resident had refused medications on those dates. Review of Resident #1's Note dated 01/06/2024 at 1:48 PM, entered by Licensed Practical Nurse (LPN) #3, revealed the resident had refused vital signs. However, there was no documented evidence to support the physician or guardian were notified the resident refused vital signs. Review of Resident #1's Note, dated 01/06/2024 at 12:37 AM, entered by LPN #2, revealed Resident #1 had refused all nighttime medications. However, there was no documented evidence to support the physician or guardian were notified the resident refused medications. Review of Resident #1's Diet Requisition Form, dated 01/09/2024, entered by the Speech Therapist (ST), revealed a diet change request for a dysphagia pureed diet with nectar thick liquids. However, there was no documented evidence to support the physician or the resident's guardian had been notified of the change in the residents diet. Review of Resident #1's Nutrition Assessment, dated 01/09/2024 at 9:47 AM, entered by the Dietician, revealed the resident's weight was one hundred six (106) pounds, and was likely malnourished. Further review revealed the Dietician recommended the resident have fortified foods with meals to aid with meeting nutritional needs, to monitor nutritional parameters, and to notify the Dietician as needed. However, there was no documented evidence to support the physician or guardian were notified of this recommendation. Review of Resident #1's Note, dated 01/11/2024 at 5:27 PM, entered by Registered Nurse (RN) #1, revealed Resident #1 had coarse lung sounds with a cough and was presumed to have Covid-19 related to his/her roommate was Covid positive and resident refused to allow staff to test him/her. Further review revealed the resident was refusing to drink/eat much and the physician was notified with orders received to start on Paxlovid (a prescription medication used to treat Covid symptoms) and Albuterol (a medication used to treat wheezing and shortness of breath) inhaler, obtain a chest x-ray. However, there was no documented evidence to support the resident's guardian was notified of the changes in the residents medical condition, the refusal to test for Covid, the residents refusal to eat or drink, or that the resident had been started on Paxlovid to treat Covid. Review of Resident #1's Note, dated 01/15/2024 at 5:30 AM, entered by LPN #5, revealed Resident #1 refused having vital signs obtained. However, there was no documented evidence to support the physician or guardian were notified the resident refused vital signs. Review of Resident #1's Note, dated 01/17/2024 at 2:25 PM, entered by LPN #4, revealed Resident #1 refused vital signs and medications, Power of Attorney (POA) aware and Advanced Practice Registered Nurse (APRN) aware; social services addressed on 01/10/2024 and are aware of behaviors. However, review of the Social Services Director (SSD) note dated 01/10/2024 revealed no documented evidence to support the physician, APRN, or guardian were notified the resident refused vital signs or medications. Review of Resident #1's Note, dated 01/23/2024 at 8:41 PM, entered by LPN #2, revealed Resident #1 had refused all medications and the Medical Director was aware. However, there was no documented evidence to support the resident's guardian was notified the resident refused all medications. During an interview with Resident #1's Guardian on 02/04/2024 at 6:49 PM, she stated she had received notification on 01/12/2024 the resident was refusing medications and meal intake. She stated she went to the facility on that date and was able to get the resident to take his/her medications and allow staff to care for him/her while the guardian was in the building. She further stated she asked the facility to notify her in the future if the resident refused care, medications, or meal intakes, as the resident was anxious in new situations and did not yet feel comfortable in his/her new environment. She continued to state she was not made aware of any further refusals until she received a call on 01/24/2024 notifying her the resident was being sent to the hospital. During an interview with the Staff Development Coordinator (SDC) on 02/04/2024 at 7:10 PM, she stated nursing staff should have notified the physician for any signs or symptoms of nutrition or hydration problems or if the resident refused meals, fluid intake, medications, vital signs, or weights to determine if the physician wanted to change any orders. She further stated, refusals in any of those areas would trigger the facility to monitor the resident more closely to determine if a therapy referral was needed to observe for feeding assistance, weighted utensils, or if the resident did not like the food offered. During an interview with the Dietician on 02/05/2024 at 10:11 AM, she stated she did not write physicians orders directly, but instead gave her recommendations to the administrative nursing staff and the nursing staff were responsible for notifying the physician of the dietary recommendations, and obtaining orders if the physician agreed with the recommendations. During an interview with the Speech Therapist on 02/05/2024 at 10:51 AM, she stated she was responsible for assessing residents with swallowing difficulties, and she wrote orders based on any difficulties she found. She further stated after assessing Resident #1 on 01/03/2024 , she determined the resident required a diet change from a regular diet to a mechanical soft diet due to coughing with meal intake and signs that he/she was having difficulty swallowing. She continued to state the resident was scheduled for a modified barium swallow on 01/09/2024 but was unable to attend the appointment, and she downgraded his/her diet to pureed with nectar thick liquids due to his/her continued swallowing difficulties and risk for aspiration. Additionally, she stated she completed the Diet Requisition Form and gave a copy to the nursing staff and the dietary department on 01/09/2024, but was unsure why a physicians order was not written. She further stated she did not notify the physician or guardian of the diet change. Additionally, she stated she or the nursing staff should have talked with the resident's guardian and physician to make them aware the resident had increased swallowing difficulty because the resident was at increased risk for aspiration. During an interview with LPN #1 on 02/05/2024 at 2:55 PM, she stated if a resident refused medications, weights, meals, or fluid intake, it should be reported to the physician or APRN because the facility should monitor for significant weight loss or medication refusals and the physician/APRN may need to change the orders for the resident based upon the refusal. She further stated the family should be notified of any changes with the resident so they were aware of his/her care needs. During an interview with LPN #2, on 02/05/2024 at 3:10 PM, she stated the physician should be notified of any resident refusals to monitor for any weight loss or gain, to see if dietary or therapy needed to be referred to see the resident, or if the physician needed to change any orders based on the refusals. She further stated the resident's guardian should have been notified when the resident refused care so she could have assisted in getting the resident to accept care. During an interview with Advanced Practice Registered Nurse (APRN) #1 on 02/06/2024 at 9:25 AM, she stated it was important the physician or APRN be notified of any resident refusals so they could make appropriate referrals to dietary or therapy or make any necessary recommendations or order changes based upon the resident refusals. She further stated it was her expectation the facility staff notify her or the physician or other APRN of any resident refusals when they occurred so she could intervene as necessary to prevent weight loss, organ starvation, or death from the resident refusing medications, meals, and fluids. During an interview with APRN #2, on 02/06/2024 at 9:44 AM, she stated it was her expectation to be notified of any resident refusals so she could make any necessary changes to the resident's orders. She stated she was aware Resident #1 sometimes refused medications but was not notified of any refusals of care from 01/12/2024 to 01/24/2024. She further stated she was asked to see Resident #1 on 01/04/2024 and assessed the resident to have an oxygen saturation of seventy-seven percent (77%) at that time and ordered him/her sent to the emergency room . During an interview with the Medical Director (MD) on 02/06/2024 at 10:46 AM, he stated it was important that he be notified of any refusals, and if he was not notified of refusals, he could not get an accurate picture of the resident. He continued to state when he was notified of a resident's refusal of care, he made a mental note to watch that resident for any patterns of refusals and make adjustments to orders as necessary. He further stated it was his expectation all staff followed all facility policies. During an interview with the Director of Nursing on 02/06/2024 at 11:40 AM, she stated it was her expectation that staff accurately document any resident refusals and notify the physician or APRN and the guardian of any refusals. She further stated the notification would ideally be any time a resident refused care, but, as some residents have multiple refusals, the physician and guardian should be notified of refusals at least every shift so adjustments could be made to the resident's plan of care as needed. She continued to state it was her expectation staff followed all facility policies. During an interview with the Administrator on 02/06/2024 at 2:45 PM, he stated it was his expectation for staff to follow the policies of the facility, and document and report care as given or refused so the resident's care plan could be changed if needed. He further stated if Resident #1's guardian had been notified of the resident's continued refusals, after 01/12/2024, she might have been able to get the resident to eat/drink more and take his/her medications.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain medical records on each resident that was complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). On 01/09/2024, Resident #1's Nutrition Assessment revealed a recommendation from the Dietician for the resident to have fortified foods; however, there was no evidence this recommendation was relayed to the physician and an order obtained for fortified foods. On 01/09/2024, the Speech Therapy downgraded Resident #1's diet to a pureed diet with nectar thick liquids; however, there was no evidence an order was obtained from the physician regarding the diet change. In addition, record review and interview revealed the facility did not document Resident #1's weights, meal intake/output, and bowel and bladder incontinence care per the physician orders. The findings include: Review of the facility's policy, titled Medication Administration Standard of Practice, dated 10/2020, revealed if a drug was withheld, refused, or given at a time other than the scheduled time, the individual who administered the medication must document it in the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR), and the individual who administered the medication must sign the resident's MAR/TAR after giving each medication, along with any additional prior or follow up requested information. Review of the facility's policy, titled Weight Process Standard of Practice, dated 07/2020, revealed the Director of Nursing (DON) or designee was responsible to see weights were obtained regularly for all residents and recorded in the medical record. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 01/02/2024 with diagnoses which included unspecified severe protein-calorie malnutrition, vascular dementia, aphasia, and weakness. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was unable to complete the interview. In addition, the facility assessed Resident #1 to require partial/moderate assistance with eating. The facility further assessed the resident to have coughing or choking during meals and/or swallowing medications and complaints of difficulty or pain with swallowing. Review of Resident #1's January 2024 Medication Administration Record (MAR) revealed the facility's nurse's responsible for administering Amlodipine 10 milligrams (mg) daily (a blood pressure medication), had not signed to indicate the medication had been offered, administered, or refused on 01/15/2024 and 01/17/2024. In addition, the resident's pain level had not been documented on the MAR on 01/14/2024, 01/17/2024, 01/18/2024, and 01/20/2024. Review of Resident #1's January 2024 Treatment Administration Record (TAR) revealed the facility's nurse's responsible for obtaining vital signs had not signed to indicate the Blood Pressure had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, 01/17/2024, and 01/20/2024; the Pulse Rate had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, 01/17/2024, and 01/20/2024; the Respiratory Rate had been obtained on 01/10/2024, 01/13/2024, 01/14/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024 and 01/20/2024; the Temperature Results had been obtained on 01/10/2024, 01/13/2024, 01/15/2024, and 01/17/2024; or the Oxygen Saturation Results had been obtained on 01/10/2024, 01/13/2024, 01/14/2024, 01/15/2024, 01/16/2024, 01/17/2024, 01/19/2024, and 01/20/2024. Continued review revealed the resident's weight had not been documented on 01/09/2024 or 01/23/2024. In addition, the resident's pain level had not been documented on the MAR on 01/14/2024, 01/17/2024, 01/18/2024, and 01/20/2024. Review of the Diet Requisition Form, dated 01/09/2024, entered by the Speech Therapist, revealed a diet change request for a Dysphagia pureed diet with nectar thick liquids. However, there was no documented evidence to suppot the physician or the resident's guardian were notified. In addition, the was no documented evidence to suppot a physicians order had been written for the diet change. Review of Resident #1's Note, dated 01/11/2024 at 5:27 PM, entered by Registered Nurse (RN) #1, revealed Resident #1 had coarse lung sounds with a cough and was presumed to have Covid-19 related to his/her roommate was Covid positive. Continued review revealed Resident #1 refused to allow staff to test him/her for Covid-19. Further review revealed the resident was refusing to drink/eat much and the physician was notified with orders received to start on Paxlovid (a medication used to treat Covid symptoms) and Albuterol (a medication used to treat wheezing and shortness of breath) inhaler, and obtain a chest x-ray. However, there was no documented evidence to suppot the chest x-ray had been obtained. During an interview with the Speech Therapist, on 02/05/2024 at 10:51 AM, she stated she assessed residents for any swallowing difficulties and wrote orders based on any difficulties she found. She further stated Resident #1 was changed from a regular diet to a mechanical soft diet on 01/03/2024 due to coughing with meal intake and signs that he/she was having difficulty swallowing. She continued to state the resident was scheduled for a modified barium swallow on 01/09/2024 but was unable to attend the appointment and she downgraded his/her diet to pureed with nectar thick liquids due to his/her continued swallowing difficulties and risk for aspiration. Additionally, she stated she completed the Diet Requisition Form and gave a copy to the nursing and dietary departments on 01/09/2024, but was unsure why a physicians order had not been written. During an interview with Advanced Practice Registered Nurse (APRN) #1, on 02/06/2024 at 9:25 AM, she stated it was important for nursing staff to document accurate information in the medical record so the physician or APRN could determine if referrals should be made to dietary or therapy or make any necessary recommendations or order changes based upon the resident's vital signs, weight results, and medication refusals. She further stated it was her expectation the facility staff document complete and accurate information in the residents medical record. During an interview with APRN #2, on 02/06/2024 at 9:44 AM, she stated it was her expectation staff document all vital sign results, medication administration, and refusals appropriately in order to make any necessary changes to his/her orders. She further stated she was asked to see Resident #1 on 01/04/2024 because his/her breathing was more rapid and the nurse thought he/she might be having an anxiety attack. She stated she assessed the resident to have an oxygen saturation of seventy-seven percent (77%) at that time and ordered him/her sent to the emergency room . However, review of the Progress Note for 01/24/2024 revealed the resident had an oxygen level of 99%, and there was no evidence to support staff had documented vital signs on the MAR/TAR for 01/24/2024. During an interview with the Medical Director (MD), on 02/06/2024 at 10:46 AM, he stated it was important for each residents information be documented accurately and completely because he needed a complete picture of the resident in order to make informed decisions regarding the care of the resident. He further stated he expected the nursing staff to maintain a complete and accurate medical record for each resident. During an interview with the Director of Nursing, on 02/06/2024 at 11:40 AM, she stated it was her expectation that staff accurately document complete and accurate information on the resident's MAR/TAR per physician orders. She further stated it was ultimately her responsibility to ensue the information was documented and the facility had identified any issues with documentation and she stated she was working to educate staff on accurately documenting complete information each shift. During an interview with the Administrator, on 02/06/2024 at 2:45 PM, he stated it was his expectation staff follow the policies of the facility and document and report care as given or refused so the resident's care planning could be changed if needed.

Based on interview, record review, and policy review, it was determined the facility failed to document administration of medications on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Interview with Resident #8, on 03/02/2021 at 11:00 AM revealed a concern that his/her B 12 injections (B 12 is a vitamin) were not given in a timely manner. Review of the facility's policy and procedure titled, Medication Dispensing System, dated 01/01/2019 revealed all medications were prepared and administered in a manner consistent with the general requirement outlined in the policy. After Medication Administration staff documented necessary medication administration/treatment information on the appropriate forms. The facility admitted Resident #8 on 11/04/2016. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) signed and dated 12/21/2020 revealed the facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) exam score of fifteen (15) and determined the resident was interviewable. Review of the Physicians Orders revealed an order, dated 08/05/2019, for [MEDICATION(S)] Injection Solution (B 12 Vitamin) one-thousand (1000) micrograms (MCG) per milliliter (ML) one (1) ML Intramuscularly every month between 7:00 AM and 7:00 PM on day two of the Month. Review of the January, 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a written statement dated 03/03/2021, untimed, revealed Registered Nurse (RN) #1 administered the Cyanobalamin Injection as ordered to Resident #8 on 01/02/2021. Review of the February 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a written statement dated 03/03/2021, untimed, revealed RN #1 did not have the Cyanobalamin Injection Solution in the facility on 02/02/2021, and the medication was ordered from the pharmacy and was delivered and administered to Resident # 8 on 02/03/2021. However, review of the 02/2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Telephonic interview with RN #1 on 03/03/2021 at 10:30 AM revealed she administered Resident #8's Cyanobalamin Injection in January 2021, but could not state why she failed to document the medication as administered. She continued to state she had also administered Resident #8's Cyanobalamin Injection in February 2021 but could not state why she failed to document the medication as administered. She revealed once staff administered medications to a resident, the nurse should sign off the medications as administered on the MAR. Interview with Licensed Practical Nurse (LPN) #1, on 03/03/2021 at 11:17 AM, revealed it was the facility's expectation, and policy that staff administer medications to the residents as ordered by the physician, and then sign off on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed staff were expected to review their residents' medication documentation for accuracy prior to leaving their shift. 2. Closed record review revealed the facility admitted Resident #4 on 09/15/2020 at 3:44 PM, and the resident left the facility against medical advice (AMA) on 09/15/2020 at 10:41 PM. Admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Closed record review of the Progress Note, dated 09/15/2020 at 9:53 PM and signed by the Director of Nursing revealed Resident #4 complained of pain to the left lower extremity. Staff contacted the pharmacy for an access code to pull the medication from cubex with prescriptions sent to the pharmacy and an access code supplied to pull from the Emergency Drug Kit (EDK). Review of Resident #4's MAR, dated September 2020, revealed the following physician order, [MEDICATION(S)]-Acetaminophen Oral Tablet 10/325 MG one (1) tablet by mouth as needed, however, there was no documentation of administration to confirm that the resident had received the medication. Interview with the Director of Nursing, on 03/03/2021 at 1:12 PM, revealed he signed out and administered the [MEDICATION(S)]-Acetaminophen tablet to Resident #4 but he did not know why he did document the administration on the MAR. He stated he just did not. Continued interview with the DON revealed staff should document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 03/03/2021 at 1:30 PM, revealed there was a system in place to identify any discrepancies in the residents' medication via a daily report. She revealed it was facility policy and expectation that staff documented medications as administered on the MAR.

Based on interview, review of grievance forms and logs, and facility policy review, it was determined the facility failed to report the findings and actions of the facility to the Resident Council. Interviews with resident council members revealed the monthly meetings with the facility representative, the Activity Director (AD), did not include review of the previous grievances, and the facility resolution. In addition department heads responsible for the grievance review, investigation and resolution did not meet the next month with the resident council members to discuss findings, resolution and to follow up on the facility continued audit of the grievance. The finding include: Review of the facility policy, Grievance/Concern Standard of Practice, revised 03/2019, revealed the administrator of the facility was the grievance officer. The facility administrator or assigned designee was to notify the party within five (5) working days unless an extension was needed. The resident council members were able to verbalize a grievance at the council meeting. The grievance was to be documented on the facility grievance form, recorded and tracked, assigned to the department manager as it applied, review root cause and resolution, and log the resolution to the grievance log. Furthermore the name and date of when and whom the resolution was provided to be included with the process. Review of the facility Grievance/Concern Form, undated, revealed the bottom of the form contained the area for notification of resolution. The area included date of notification, name of the person who was notified by the facility, method of notification, if a written response was requested, date the response was provided and the signature of the person who completed the notification. Interview with Resident Council Members, on 09/11/19 10:01 AM, revealed Residents #7, #8, #10, #20, #30, #32, #33,#44, and #53 were in attendance for interview. Resident #7 stated the council filed complaints on staff shortages, food, and Internet connection for the facility residents. Resident #7 stated the council requested absentee ballots to vote in the Kentucky elections because residents were not able to go vote. Resident #7 stated the facility did not respond to the council for any filed grievances. Resident #7 stated the Activity Director (AD) wrote the grievance on the grievance form. The members of the council verbally agreed the facility was not responsive. Review of the facility Grievance Tracking Log, dated 6/28/19, revealed resident council reported a grievance on garbage pickup, food trays not picked up after meals, and interruptions during care. Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concerns over the meal tray pick up times. The form was completed by the Activity Director (AD). Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concern staff were not removing trash after staff removed wound dressings and placed the soiled dressings into the resident's trash. The form was completed by the AD. Review of the facility Grievance Form, dated 6/28/19, revealed resident council voiced concern staff were not removing trash after staff removed wound dressings and placed into the resident's trash and the form was completed by the AD. Review of the Resident Council Notes, dated 07/26/19, revealed the facility notes of the meeting lead by the AD did not include follow-up notes or discussion for the complaints of 06/28/19. Review of the facility Grievance Tracking Log, dated 7/26/19, revealed the resident council filed complaints for dietary food temperatures, the date of the meal of the month, dishes were not clean, and night snacks were not timely. Review of the facility Grievance from, dated 7/26/19, revealed three (3) forms completed by the AD. The facility did not complete or identify the staff person who investigated the concern on the three (3) forms. Further review revealed the facility did not complete the area of the grievance form for the date of notification as well as all other areas in the section and the facility staff who completed the notification was blank. Review of the facility Resident Council Notes, dated 08/30/19, revealed the AD read the notes of the last resident council notes aloud to the members who attended to the meeting but did not review results of previously filed greivances. Interview with Licensed Practical Nurse (LPN) #1, on 09/13/19 at 3:26 PM, revealed the facility staff completed a grievance form when a resident complained. LPN #1 stated the resident was to have follow up with the department head responsible for the grievance and she was unsure of a time limit for the response from the facility. Interview with the AD, on 09/13/19 at 03:36 PM, revealed she wrote up grievance forms for the resident council meetings. She stated she gave the department head a copy of the concern and gave the original to the Administrator. She stated the Administrator was the grievance officer for the facility. Additionally, the AD stted she did not bring completed grievance forms with her to the next resident council meeting for review with the council. She stated she was unaware she was to review the grievance results with the resident council at the next scheduled meeting. She stated the Administrator ensured the complaint was addressed and the facility discussed the concern and the actions the facility completed to address the concern. She stated the person who addressed and completed the grievance was to complete the form. She stated as the facility representative for the resident council she reviewed the notes from the last meeting however the results of the grievances were not included. Interview with the Unit Manager (UM), on 09/13/19 at 04:02 PM, revealed as UM she did not participate in grievance. She stated she filled out grievances and gave the form to the DON or administrator for follow through. She stated the facility was required to respond to the grievance within five (5) days . She stated the person who completed the grievance was to follow through with the person who filed the grievance to ensure the resident was knowledgeable as to what was done and completed. Interview with the Assistant Director of Nursing (ADON), on 09/13/19 at 04:33 PM, revealed grievances were to be written on the facility form and given to the department head. She stated the administrator logged the grievance and follow through to ensure it was addressed and completed. She stated the facility was to complete and report to the residents within 5 days. The person in the facility who was addressed the concern was to complete the form to ensure the process was completed. She stated concerns which were identified with the resident council meeting were to be reported back to the resident council at the next meeting. Interview with the DON, on 09/13/19 at 05:06 PM, revealed the facility grievance policy required the person who received the complaint to fill out the grievance from and pass it to the department head and to the administrator. He stated the facility investigated and followed up with the concern. The DON stated grievances from the resident council were to be handled in the same manner as if it were an individual resident. The DON stated to his knowledge the AD did not review the findings of a completed grievance with the resident council at the next meeting. He stated if the grievance form was not completely filled out then the grievance was not completed. He stated the grievance process was to ensure the residents' needs were met and to make the facility better as it addressed resident concerns which could impact all residents. Interview with the Administrator, on 09/13/19 at 07:02 PM, revealed the facility followed the grievance per the policy. She stated when the facility staff completed a grievance form a copy was given to her to track and ensure the concern was resolved. She stated when the department manager completed the process they returned the form to her and she logged it onto the grievance log. She stated if the concern required further follow through the facility would implement a Quality Assurance (QA) plan. She stated the facility department head was to complete the process by follow through with the person and or entity who requested a grievance form to be written. She stated the facility required five (5) days for follow through with grievances. She stated the AD was to follow through with resident council and get feedback from the residents. The DON follows through with the resident council president. She stated if the department head didn't follow through with the resident council members she was unable to provide an answer when the members of the resident council were notified of what was found and done to resolve the issues. She further stated the facility was to follow through with the findings of the grievance with the resident council at the monthly meeting.

Based on observation, interview and facility policy review it was determined the facility failed to ensure a resident was treated in a dignified and respectful manner for one (1) of thirty-two (32) sampled residents, Resident #7. Observations revealed the Director of Nursing (DON) conversed with Resident #7 at the resident's bedside. Interview with Resident #7 revealed the resident cried because he/she was angry and stated he/she felt the DON was rude and was treated the resident as a child. The findings include: Review of the facility policy, Quality of Life-Dignity, revised 10/2009, revealed the facility was to care for a resident in a manner which promoted respect. The facility was to treat residents with dignity and respect at all times. The staff were to speak to the resident respectfully at all times. Review of the facility policy, Resident Rights Standard of Practice, reviewed 09/17, revealed the facility's standard of practice included the right to a dignified existence which included communication with persons inside of the facility. Review of the facility resident admission packet, undated, revealed a form titled, Resident Rights under Federal Law, revealed item number three (3) indicated the resident was to have the right to a dignified existence. Review of the DON's Orientation Packet, dated 06/15/15, the DON signed the Resident Rights to acknowledge to have read and understand the rights of facility residents. The DON's signature was dated 02/07/16. Review of Resident #7's clinical chart revealed the facility admitted the resident on 11/04/16 with the [DIAGNOSES REDACTED]. Review of Resident #7's Quarterly Minimal Data Set (MDS), dated [DATE], revealed the facility evaluated Resident #7's cognition with the Brief Interview for Mental Status (BIMS) exam, dated 09/07/19, and assessed the resident with a score of fifteen (15) and determined the resident was interviewable. Observation, on 09/12/19 at 11:16 AM, revealed the DON entered Resident #7's room and the door to the room was not shut. The DON and Resident #7 discussed the requirement of moving to a room further up the hallway to have better Internet connectivity. The DON stated to Resident #7 in order to acquire better internet connectivity, as the Administrator had already discussed with him/her, it would require a change of rooms. The DON asked Resident #7 if he/she wished to change his/her room and the resident stated no. Observation, on 09/12/19 at 11:18 AM, revealed Resident #7 was red in the face and appeared to be upset. Interview with Resident #7, on 09/12/19 at 11:18 AM, revealed the DON came across in the discussion as so forceful he/she was taken aback by the whole attitude. Resident #7 stated he/she cried because he/she was angry with the DON's tone of voice. Resident #7 stated he/she was admitted to the room he/she was in and he/she was a large person and the items needed to take care of him/her would not fit in a double occupancy room. Interview with the DON, on 09/12/19 at 11:39 AM, revealed he expected staff to approach residents in a professional manner which included speaking to the resident with respect. He further stated he would not want to be spoken to in a rude and demeaning tone or manner and he stated Resident #7 did not have a reaction while he was conversing with the resident. The DON stated he was not aware his approach and demeanor to the resident was received as forceful. He stated treating a resident with dignity included the way you spoke to a resident and staff were to be respectful to residents at all times. Further interview with Resident #7 on, 09/13/19 at 10:38 AM, revealed he/she told the administrator he/she cried yesterday after the DON left the room because he/she was in shock as to how he/she was spoken too. The resident stated he/she told the administrator the DON came at him/her forcefully, spoke to him/her like a child, and it was demeaning. Resident #7 stated he/she was still in shock from yesterday. Interview with Staff Development Director, on 09/12/19 at 02:21 PM, revealed staff were trained on resident dignity and respect and staff were to treat residents with respect and dignity as they would treat their parents at home. She stated staff were to show respect and dignity by tone of voice and body language and speak to residents in a calm and collected voice. She stated speaking to residents in any other manner it could be considered disrespectful and undignified. She stated the DON was not educated by her on respect and dignity. Interview with the Administrator, on 09/12/19 at 3:06 PM, revealed Resident #7 stated to her he/she was hurt and the DON was very rude. She further stated facility staff were to follow policy and procedure in regard to resident rights.

Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for one (1) resident out of thirty-two (32) residents, Resident #9. Resident #9 had behaviors of entering resident's room without consent and watching them sleep. Resident #9's comprehensive care plan was not updated to reflect this behavior. The findings include: Record review of the facility policy titled, Comprehensive Care Plan Standard of Practice, with revised date of 11/2017, revealed a comprehensive person-centered care plan for each resident, consistent with resident right, include measureable objective and time frames to meet a resident's medical, nursing, and mental and psychosocial need are identified in the resident's comprehensive assessment. The policy further revealed each comprehensive care plan would reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and quarterly Minimum Data Set (MDS) assessment. Record review of the clinical record for Resident #9 reviewed the facility admitted the resident on 04/11/19 with [DIAGNOSES REDACTED]. Record review of the admission MDS, dated [DATE], revealed Resident #9 had a Brief Interview of Mental Stats (BIMS) of ten (10) out of fifteen (15), which indicated the resident was moderately cognitive impaired and interviewable. Resident #9 was assessed to not be a wanderer, needed limited assistance for bed and transfers. Resident #9 used mobility devices of a walker and a wheelchair. Review of Psychiatric note, dated 08/08/19, revealed Resident #9 to be mildly confused, had memory borderline, mood was labile, unorganized thought process, and impaired psychomotor activity along with impaired impulse control. Review of the Comprehensive Care Plan (CCP), initiated 04/17/19, revealed the resident exhibited alteration in mood/behavior as evidenced by: at times resident had aggression and verbal behavior symptoms toward others. Interview with Licensed Practical Nurse (LPN) #4, on 09/12/19 at 3:05 PM, revealed Resident #9 was found in Resident #1's room at the foot of Resident #1's bed, while the resident was sleeping. She stated Resident #9 only went into Resident #1's room and thought Resident #9 just wanted to see the resident. Further review of the CCP revealed there was no evidence the CCP was updated for Resident #9's conduct. Interview with Resident #1, on 09/12/19 at 11:17 AM, revealed she/he felt afraid at night because Resident #9 would enter his/her room and watch him/her sleep without his/her consent. Resident #1 stated he/she did not want Resident #9 watching him/her sleep because it was creepy. Resident #1 reported the incident to the nursing staff and staff would re-directed Resident #9 out of his/her room; however, it continued to occur. Resident #1 stated, Resident #9 was not his/her significant other, and was old enough to be his/her parent. Observations of Resident #9, from 09/11/19 through 09/13/19, revealed resident was either sleeping in bed, in the dining area, or self-propelling down the hallway. Observations of Resident #9, on 09/11/19 at 3:28 PM, revealed he/she was in bed with eyes closed. Observation of Resident #9, on 09/12/19 at 10:20 AM, revealed self-propelling to the dining area alone and sat with others. Interview with Resident #9's daughter, on 09/12/19 at 11:00 AM, revealed she was the Power of Attorney (POA) for the resident and had attended each care plan meeting. However, during these meeting there was no mention of resident wandering into other resident's rooms or re-directed from resident's rooms. Interview with Minimum Data Set (MDS) Coordinator, on 09/13/19 at 2:49 PM, revealed she was not aware of Resident #9's behavior of entering Resident #1's room while he/she was sleeping and watching him/her sleep. She stated care plans were created and updated to represent resident's individual needs. Furthermore, nursing staff could update the care plan at any time, with interventions for resident safety. The interdisciplinary team (IDT) met five (5) days per week at the clinical morning meeting to review the interventions on the care plan for appropriateness. If a resident report having concerns about being scared of another resident, the resident's care plan intervention should be updated. Interview with the Unit Manager (UM), on 09/13/19 at 4:02 PM, revealed she was aware Resident #9 went into Resident #1's room without his/her consent at night. However, had not followed up to ensure the plan of care was revised to meet Resident #1's care needs. She stated care plans painted a picture of the resident for the nursing staff to follow their care needs. The UM expected staff to follow the care plan so each resident would have the proper care and if not, the resident could have an adverse effect, such as behaviors. She reported she did not conduct audits on care plans; but assumed the Director of Nursing completed audits. Interview with Assistant Director of Nursing (ADON), on 09/13/19 at 4:10 PM, revealed stated if Resident #1 was sleep and Resident #9 tried to enter the room, Resident #9 would be asked to leave due to lack of consent. However, she was unaware of Resident 39's behavior of entering Resident #1's room without consent. She stated the care plans were to provide individual care to the resident, and should reflect the care for nursing staff to refer back to the intervention. The ADON states the CNAs conveyed resident behaviors to the nursing staff, who documented the behaviors in the nursing notes.Furthermore, if the behaviors were a safety concern, any nurse could update the care plan, at any time. She went on to explain, care plans were to be update immediately when a care need was identified with a new intervention or treatment for [REDACTED]. The ADON reported if the care plan was not updated with a new intervention, it could lead to harm and the staff would not be aware. Interview with Advanced Practice Registered Nurse (APRN), on 09/13/19 at 5:26 PM, revealed he was not aware of the allegation of sexual abuse between Resident #1 and Resident #9. APRN state if Resident #1 reported a problem such as sexual abuse against another resident, the concern needed to be care planned. He stated the purpose of the care plan was to provide the facility with a strategy for staff to follow, which would influence the resident's safety and dignity. Interview with Director of Nursing, on 09/13/19 at 5:06 PM, revealed care plans were developed for residents everyday care needs with the expectation for nursing staff to follow at all times. If the care plans was not follow or updated, it could lead to a negative outcome for the resident. Furthermore, at the IDT meeting, the care plans were reviewed and updated as needed. Interview with the Administrator, on 09/13/19 at 7:02 PM, revealed Care Plan meetings were significant to gain information from the resident, resident's representative and the interdisciplinary team in developing and revising the care plan. Further, the care plan served as a guideline for staff in caring for the residents.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide accessible water to encourage hydration for one (1) of thirty-two (32) sampled residents, Resident #7. Observations for four (4) of four (4 ) survey days revealed no camel water container within access for Resident #7. The findings include: The facility did not provide any policy related to resident hydration. Review of the clinical record revealed the facility admitted Resident #7 on 11/04/16 with [DIAGNOSES REDACTED]. Review of the comprehensive care plan for Resident #7 revealed the problem, potential for constipation related to immobility with the intervention resident prefers camel pack to left shoulder. Observation and interview of Resident #7, on 09/10/19 at 10:43 AM, revealed no camel pack near the resident. Continued observations revealed a camel pack on the other bed in the resident's room. Resident #7 stated he/she was a full assist and relied on staff to provide hydration when the camel pack was not in place. Observation of Resident #7's room, on 09/11/19 at 3:28 PM, revealed the camel pack appeared full and lying on the refrigerator, out of the resident's reach. Observation of Resident #7's room, on 09/12/19 at 10:10 AM, revealed the camel pack lying on top of the refrigerator, across the room from the resident. Observation of Resident #7's room, on 09/13/19 at 10:26 AM, revealed the camel pack lying on top of the refrigerator, across the room from the resident. Interview with Certified Nursing Assistant (CNA) #4, on 09/13/19 at 3:06 PM, revealed she was aware Resident #7 utilized a camel pack for hydration but stated we don't use it. CNA #4 stated a resident who did not receive enough fluids could become dehydrated which could affect the residents bowels. Interview with Licensed Practical Nurse (LPN) # 1, on 09/13/19 at 3:12 PM, revealed she was aware Resident #7 utilized a camel pack for hydration. LPN # 1 stated Resident #7 also had a cup with straw at the bedside but added the resident could not access the cup and straw without assistance. She stated Resident #7 could also call for assistance if he/she wanted some water. LPN # 1 stated a resident without adequate hydration could become constipated. Interview with the Unit Manager (UM), on 09/13/19 at 4:02 PM, revealed staff assisted with resident hydration needs by passing ice water and assisting with fluids when residents requested assistance. The UM stated the facility care planned a camel pack for Resident #7 to have at all times, but staff provided the camel pack when requested. The UM stated if Resident #7 did not receive adequate hydration the resident could suffer from constipation and added staff should insure the camel pack was in reach of Resident #7 at all times. Interview with the Assistant Director of Nursing (ADON), on 09/13/19 at 4:33 PM, revealed the facility care planned Resident #7 to have a camel pack at his/her head daily and to remove only per resident' request. The ADON stated if the camel pack is not at the resident's head then the facility needed to educate staff as the camel pack provided hydration for Resident #7. Interview with the Director of Nursing (DON), on 09/13/19 at 5:06 PM, revealed staff assisted Resident #7 with all meals and hydration needs. The DON stated the facility care planned a camel pack for Resident #7 to allow the resident to receive hydration without waiting for staff assistance. Interview with the Administrator, on 09/13/19 at 7:02 PM, revealed the facility had not identified concerns regarding resident hydration concerns.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure an effective system was in place to identify and report diversion of medications for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #5, #6) and two (2) of two (2) unsampled residents (Unsampled Residents A and B). The facility failed to identify and report misappropriation of resident property, and diversion of medications/narcotics when staff found tape on the back side of narcotic blister packs, and the narcotics ([MEDICATION NAME]/narcotic [MEDICATION NAME]) were replaced with other unidentified medications. In addition, staff borrowed [MEDICATION NAME] (anti-anxiety), [MEDICATION NAME] (anti-depressant), for other residents' use, even though staff had been trained in June 2014 not to borrow medications. (Refer to F431) On 08/31/14, during shift change (7:00 PM - 7:00 AM) review of Resident #1's narcotic blister packs revealed [MEDICATION NAME] (narcotic pain medication) tablets were missing, and/or the pack was opened with a small slit. The [MEDICATION NAME] tablets were replaced with tablets that were a different size and the pack was then taped back. Licensed Practical Nurse (LPN) #2 and LPN #6 recognized there was tape on the back side of the whole narcotic blister pack, but they failed to report this immediately to a supervisor. The staff made copies of the narcotic blister packs and gave them to the Director of Nursing (DON) under her office door. Review of Resident #1's narcotic count sheet revealed they continued to administer six (6) doses of the unknown tablets, that were in the blister pack of [MEDICATION NAME] 15 milligrams (mg), for Resident #1. The DON revealed Resident #1's [MEDICATION NAME] had been replaced with a different medication of which the resident was not ordered. On 09/05/14, LPN #3 and Registered Nurse (RN) #4 discovered Resident #1 received three (3) doses of [MEDICATION NAME], 15 mg, on 09/04/14 which was not Resident #1's normal pattern for taking this medication. Review of LPN #3's note provided to the DON revealed the resident's normal pattern was one tablet at night time. It was also determined Resident #1 had eighteen (18) tablets available on one medication card (this card had tape on the back and the [MEDICATION NAME] had been replaced) yet RN #1 documented she removed doses from Resident #1's untampered pack of [MEDICATION NAME]. Interview on 09/26/14 at 1:29 PM, with the DON, revealed she was not sure if someone had tampered with the [MEDICATION NAME] 1 mg, and the [MEDICATION NAME] 5 mg. The DON stated she was instructed by pharmacy on 09/09/14 to destroy these medications. However, these medications were not destroyed until 09/15/14, after Resident #5 had received three (3) doses of these medications on 09/10/14, 09/11/14 and 09/13/14. In addition, Resident #2 had two (2) [MEDICATION NAME], 2.5 mg, narcotic sheets and two blister packs. The second [MEDICATION NAME] 2.5 mg narcotic blister pack had paper tape behind more than half of the blisters. Resident #3's physician order [REDACTED]. Review of the first narcotic sheet, dated 08/01/14, and a second narcotic sheet dated 08/06/14, revealed RN #1 removed three (3) narcotics on 08/03/14 at 10:00 AM, 12:00 PM and 2:00 PM. RN #1 documented this medication was removed from the blister pack every two (2) hours instead of every (4) hours as ordered. Resident #6 was ordered to receive [MEDICATION NAME], 50 mg, at night. Review of the Medication Administration Record (MAR) documentation revealed multiple missed doses or the medication was not available to administer. However, the pharmacy was sending the medication routinely. Unsampled Resident A received or was documented as given six (6) doses of [MEDICATION NAME] 5/325 mg, in a six (6) hour period instead of every two (2) hours as ordered. RN #1 had documentation on the two (2) narcotic count sheets for Unsampled Resident B's [MEDICATION NAME] 5 mg as being removed from the narcotic blister packs at the same time on the same date. The facility's failure to ensure an effective system was in place to identify and report misappropriation/drug diversion and tampering of resident medications and controlled substances placed residents at risk in a situation that has caused or was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/02/14 and determined to exist on 08/31/14. The facility provided an acceptable Allegation of Compliance on 10/09/14 that alleged removal of the Immediate Jeopardy on 10/09/14. However, the State Survey Agency determined the Immediate Jeopardy was removed on 10/11/14, after training of facility staff was verified completed 10/10/14, at 42 CFR 483.13 Resident Behavior and Facility Practices (F224) with a scope and severity lowered to an "E" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy titled "Recognizing Signs and Symptoms of Abuse", revised April 2011, revealed the facility would not condone any form of resident abuse. To aid in abuse prevention, all personnel were to report any signs and symptoms of abuse to their supervisor, or to the Director of Nursing Services immediately. Signs of actual physical neglect would be improper use/administration of medications. Review of the facility's policy, "Inventory Control of Controlled Substances", revised 01/01/13, revealed the facility would ensure staff immediately reported suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation and timely follow-up in accordance with facility policy. Upon receipt of such a report, the facility would ensure the appropriate facility personnel confirmed the discrepancy and followed facility policy and applicable laws regarding documentation of the incident. The facility would also conduct an investigation to determine: if a dose was in fact administered; and, if so, the reason the administration was not charted and if a dose was refused. Review of the facility's "Loss and Theft" policy effective 12/01/07, revealed when facility staff suspected theft or loss of medications, the facility staff would take such actions as required by applicable laws and facility policy. Appropriate actions may include: immediately reporting suspected theft or loss of drugs to a supervisor/manager or the Director of Nursing for appropriate investigation and follow-up. Investigating and reconciling discrepancies and notifying the appropriate facility Administrator of the controlled substance discrepancies and if such discrepancies were not reconciled, notifying the appropriate law enforcement agencies according to applicable laws and facility policy. 1. Review of Resident #1's [MEDICATION NAME] IR (immediate release), 15 mg, narcotic blister pack with a quantity of thirty (30) tablets, revealed tablets number twenty-four (24) through thirty (30) were empty, tablet number twenty-one (21) was also empty; and, blister number one (1) through twenty (20), twenty-two (22) and twenty-three (23) were full. Review of the 08/31/14 documentation on the [MEDICATION NAME] IR 15 mg narcotic count sheet, revealed LPN #2 and LPN #6 had signed and verified blister #21 was missing a pill. Review of a photo copy of the back of the [MEDICATION NAME] IR, 15 mg blister pack revealed all thirty (30) tablets' foil backing had been cut with a tiny slit, the tablets removed, and replaced with an unknown medication and taped across the back of the card. Continued review of the photo copy revealed two (2) [MEDICATION NAME] IR 15 mg blister packs. One (1) of the blister packs was ordered on [DATE] with a remaining correct count of eighteen (18) tablets. The second [MEDICATION NAME] blister pack was ordered on [DATE] with a remaining correct count of twenty-seven (27) tablets. Post survey interview with the Pharmacy General Manager (GM), on 11/05/14 at 9:30 AM, revealed if the facility was reordering the medication through the computer system Pharmacy would not know if it was reordered too soon. The facility had an automated system which generated a fax to the facility notifying the facility the medication was reordered too soon. However, per interview, if the DON signed the fax Pharmacy would fill the reorder without question. Interview with the DON, on 09/25/14 at 2:18 PM, revealed she did sign the too soon reorder notices to get the medications delivered. Further interview with the DON, on 09/24/14 at 3:48 PM, revealed the two (2) [MEDICATION NAME] IR blister packs were destroyed on 09/10/14 because she suspected someone had tampered with the medications. 2. Review of the Narcotic count sheets revealed two (2) of Resident #5's [MEDICATION NAME] 1 mg liquid and one (1) of [MEDICATION NAME] ([MEDICATION NAME]), 5 mg, liquid had been destroyed on 09/15/14 for fear the medication had been tampered. Interview with the DON, on 09/26/14 at 1:29 PM, revealed the DON asked the pharmacy consultant if there was any other possible narcotics that could be tampered with and the pharmacist stated in the refrigerator. RN #1 had documented she administered this medication and the DON and the pharmacist could not tell if the liquid had been replaced with another liquid. Although pharmacy had instructed the DON to destroy this medication on 09/09/14, the facility administered three (3) more doses of these medications on 09/10/14, 09/11/14, and 09/13/14 to Resident #5. However, post survey interview with the DON, on 11/04/14 at 2:07 PM, revealed she could not remember when the pharmacist told her to destroy these medications and thought it was on 09/15/14 the day she destroyed the medications. 3. Observation of Resident #2's [MEDICATION NAME] 2.5 mg, narcotic blister packs revealed there were two (2) narcotic cards. The first [MEDICATION NAME] 2.5 mg, revealed Resident #2 had received a total of twelve (12) of thirty (30) half tablets that had no evidence they were tampered. The second [MEDICATION NAME] 2.5 mg, narcotic card, had paper tape behind more than half of the blisters. It was determined Resident #2 did not receive any of these narcotic because the blister pack still had unknown tablets taped inside the card. Interview on, 09/24/14 at 3:48 PM, the DON stated the medication looked like [MEDICATION NAME] and [MEDICATION NAME]. 4. Review of Resident #3's narcotic count sheet for [MEDICATION NAME] 2 mg, ordered every 4 hours as needed, for the month of August, dated 08/01/14 with signatures dated 08/01/14 through 08/06/14 and a second narcotic sheet dated 08/06/14 with signature dates of 08/06/14 through 08/11/14, revealed RN #1 removed three (3) [MEDICATION NAME] tablets, one (1) each on 08/03/14 at 10:00 AM, 12:00 PM and 2:00 PM. In addition, RN #1 removed the last [MEDICATION NAME] tablet on 08/06/14 at 12:00 PM, on the second sheet. RN #1 removed one (1) [MEDICATION NAME] tablet on 08/06/14 at 10:00 AM and then again at 2:00 PM, which was every two (2) hours instead of the every four (4) hours as needed, as the medication was ordered. Review of the MAR revealed the administration times were listed as 2:00 AM, 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. The 12:00 PM dose was not documented as administered. In addition, the RN removed narcotics from two (2) different blister packs on the same date at the same time and documented they were administered to Resident #3. On the same two narcotic count sheets, RN #1 documented on the first count sheet she removed the last tablet on 08/06/14 at 10:00 AM leaving a balance of zero. She then removed one tablet from the second count sheet at 10:00 AM on 08/06/14. She then scratched out her initials for 10:00 AM on the first sheet and documented she removed a tablet at 12:00 PM as a PRN dose leaving a balance of zero on an already zero balanced count sheet. The RN documented she removed a medication from a narcotic count sheet that already had a zero balance. Review of the clinical record for Resident #3 revealed a 06/13/14 Quarterly Assessment that indicated Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15). Interview with Resident #3, on 09/23/14 at 8:57 AM, revealed the facility had ran out of multiple medications for him/her and had to reorder them early, he/she further stated he/she suffered from pain all the time and wondered if he/she was receiving the pain medications. Review of Resident #3's, [MEDICATION NAME], 2 mg, revealed two narcotic sheets. The first narcotic count sheet, dated 08/27/14 through 09/01/14; and, the second narcotic count sheet dated 08/31/14 through 09/06/14. The first narcotic count sheet, revealed RN #1 removed narcotics on 08/30/14 at 10:00 AM, 2:00 PM and 6:00 PM, which left six (6) available tablets in the narcotic blister pack. Then on the second narcotic count sheet, RN #1 removed narcotics on 08/30/14 at 10:00 AM and 2:00 PM. RN #1 documented she removed tablets on the same date at the same time from two separate blister packs. [MEDICATION NAME] was removed from the blister packs without documentation of administration on the MAR. 5. Review of Unsampled Resident A's Physician Orders, dated 08/09/14, revealed an order for [REDACTED]. The narcotic count sheet, revealed on 09/04/14 at 12:00 PM, RN #1 removed two (2) tablets leaving a total of two (2) tablets in the blister pack. RN #1 then removed two (2) [MEDICATION NAME] APAP 5/325 mg at 6:00 PM on 09/04/14 and finished the blister pack. RN #1 then removed [MEDICATION NAME] APAP 5/325 mg from a new narcotic count sheet on 09/04/14 at 6:00 PM. RN #1 documented on the Medication Administration Record and the narcotic count sheet that Unsampled Resident A received a total of six (6) tablets within six (6) hours. 6. Review of Unsampled Resident B's narcotic sheet for the month of July dated 07/24/14 through 07/26/14, revealed Unsampled Resident B was ordered [MEDICATION NAME] IR, one 5 mg tablet every four (4) hours, as needed. On 07/26/14 at 7:30 PM, RN #1 removed one (1) tablet, the last narcotic, from the blister pack. On a new narcotic sheet for the same drug, RN #1 removed two (2) tablets on 07/26/14 at 7:30 PM from the second narcotic count sheet: for a total of three (3), 5 mg tablets at the same time. 7. Review of Resident #6's, MAR for the month of May 2014, revealed Resident #6's [MEDICATION NAME] [MEDICATION]), 50 mg, was not given on 05/01/14, 05/02/14, 05/04/14, 05/05/14, 05/06/14, 05/07/14, 05/08/14, 05/09/14, 05/10/14, 05/13/14, 05/15/14, 05/16/14, 05/24/14, and 05/29/14. There was no documentation for the reason the medication was not given, except for 05/10/14, 05/14/14, 05/24/14, when it was documented the medication was not available and on 05/06/14, 05/07/14 and 05/24/14 when it was documented the resident refused the medication. Review of Resident #6's MAR for the month of June 2014, revealed Resident #6's [MEDICATION NAME], 50 mg, was not given on 06/07/14, 06/11/14, 06/14/14, 06/15/14, 06/16/14, 06/17/14, 06/18/14, 06/19/14, 06/20/14, 06/21/14, 06/22/14, and 06/24/14. There was no documentation to indicate why the medications were circled for the days of the 05/07/14, 05/19/14, 05/21/14, and 05/24/14. The dates of 05/11/14 and 05/14/14 were blank with no initials or documentation as why the boxes were left blank. Review of Resident #6's, MAR for the month of July 2014, revealed Resident #6's [MEDICATION NAME], 50 mg, was not given on 07/02/14, 07/03/14, 07/04/14, 07/05/14, 07/06/14 and 07/07/14. There was no documentation as to why this medication was not administered except for 07/02/14 and 07/05/14 it was indicated the medication was not available and pharmacy was notified. Review of the Work Order Fill form, not dated, revealed this medication was replaced by pharmacy at the facility's expense. 8. Review of the narcotic count sheets, the corresponding blister packs, and the contents of two sharps containers (labeled men and women) confiscated by the local Police Department, on 10/01/14 at 8:10 AM, revealed slits were cut into the foil backing of the blister packs, taped closed with paper tape and contained all sizes of tablets cut in half. These tablets could not be identified because of their size and the manufacture's marking was obliterated. In addition, there were two (2) Sharps boxes, one labeled Men's and one Women's Sharps that had also been confiscated by the police and determined to be used by RN #1. The Women's Sharps box was observed to have paper tape, clear pill crusher sleeves with white residue, nine (9) opened, empty blister packs of [MEDICATION NAME] (diuretic) 20 mg, clear plastic cigarette wrapper with white residue in it, a partial pill (unidentifiable) and straws, one of which was found still in a clear pill crusher sleeve. The Men's Sharps box was observed to have four (4) straws, clear pill crusher sleeves with powder residue in them and two (2) partial pills to small to identify. Unsuccessful attempts were made to interview RN #1, on 09/24/14 at 2:29 PM; and, on 09/25/14 at 9:18 AM on her home phone and, at 9:20 AM on her cell phone. Messages were left three (3) times to call back. No return calls were received. Interview with LPN #2, on 10/10/14 at 9:30 AM, revealed he did not know when he found the narcotic blister packs with tape across the back for Resident #1 at the end of August that it was misappropriation of property. However, the Loss and Theft of Medications policy indicated the facility staff should immediately report suspected theft or loss of drugs to a supervisor/manager or Director of Nursing. Interview with LPN #6, on 10/10/14 at 3:30 PM, revealed she was not aware the missing narcotics was misappropriation of property at the time. Interview with LPN #3, on 10/01/14 at 2:02 PM, revealed at the time she did not consider the medication being given more than one time to be abuse. She identified it to be more of a medication error. She was aware to report abuse immediately and now she recognized that she should have reported the incident sooner. LPN #3 stated she knew the residents' pain probably was not being addressed and could cause increased pain for the residents. LPN #3 stated the resident could have also had an allergy to the unknown medication which could lead to an allergic reaction or death. Interview with the Unit Manager, on 09/30/14 at 10:00 AM, revealed it did not cross her mind that the medication had been tampered. She stated she should have immediately informed the DON of the paper tape to the back of the medication blister pack because of possible misappropriation; however, she was not aware at the time that it was neglect. Interview with the DON, on 09/25/14 at 2:37 PM, revealed she was not thinking about abuse at the time, she was trying to figure everything out in her mind. The DON stated she did not notify the Administrator at the time, because she was trying to wrap her brain around the use of tape. Continued interview with the DON, on 09/25/14, revealed when she went to interview the staff, the staff stated they were borrowing medications from other residents, so the residents without medications could have their medications. The DON stated she had repeatedly informed the staff not to borrow medications from residents. At that time, the DON stated she could not see the bigger picture. She was not thinking about abuse at the time, she was trying to figure everything out in her mind. Interview with the Administrator, on 09/25/14 at 4:06 PM, revealed she was made aware of the diversion of medication on 09/08/14 and not before that time. The Administrator and the DON initiated an investigation on 09/08/14 and determined Resident #1 received all the medication as ordered, terminated RN #1 for failure to document on the MAR that the [MEDICATION NAME] had been administered, not completing a pain assessment prior to administering the pain medication, nor indicating the pain medication was effective or not. Interview with the Administrator on 10/02/14 at 4:58 PM, revealed taking of resident medication was misappropriation of property. Interview with the Medical Director, on 09/25/14 at 3:47 PM, revealed he was made aware of the [MEDICATION NAME] medication error, but not the narcotic concerns. He was not notified of the misappropriation of property until 09/08/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/09/14 alleging the Immediate Jeopardy was removed 10/09/14; however, the State Survey Agency verified that staff training was completed on 10/10/14 and the Immediate Jeopardy was removed on 10/11/14. The facility took the following steps to remove the Immediate Jeopardy. 1. Residents #1, #2, #3, #5 and #6 were assessed and interviewed, with no negative outcomes. RN #1 was immediately suspended on 09/08/14 pending the investigation. 2. Licensed staff was interviewed and the allegation reported to the Office of Inspector General (OIG), Kentucky Board of Nursing (KBN), the Department of Community Based Services (DCBS) and Law Enforcement. 3. All medications found to be tampered with were reordered at the facility's expense. 4. Resident #1's tampered medications were pulled from circulation on 09/08/14 by the DON and destroyed on 09/10/14. 5. Resident #2's medications were pulled on 09/03/14 and locked up, when the resident was admitted to the hospital. Upon the resident's return on 09/10/14, the narcotics were determined to have been tampered with and the Police were immediately notified. Narcotics and their containers were turned over to the local Police Department. Medications were reordered at the facility's expense. 6. On 09/16/14, the Pharmacist auditing the medication carts suggested to the DON and the ADON, that Resident #5's narcotics should be destroyed. 7. The DON and facility Administrator conducted 100 % audit of narcotic orders and reconciliation sheets for any discrepancies that may indicate diversion on 09/08/14. The DON continued to complete audits daily to ensure there has been no breach of narcotic medication administration, documentation, reconciliation and or tampering of packages. 8. The Consultant Manager from the pharmacy (facility contracted), on 10/03/14, reviewed and analyzed narcotic medications dispensed and being administered for any discrepancies of tampered packaging, documentation of narcotic sheets, medication administration records for reconciliation and the Emergency Drug Kit (EDK). In addition, all Consulting Pharmacists visits starting 10/03/14 will include at a minimum a review of the entire narcotic dispensing system and analyzing narcotic counts, records, MARs, labels and packaging which will be compared to current orders to ensure there has been no tampering. 9. Education provided to the nursing staff by the DON included medication misappropriation (tampering of medication packaging or appearance of falsification of narcotic sheets), immediate notification to the DON, supervisor or the Administrator. 10. The DON was educated by the Regional Nurse Consultant for Preferred Care Partners Management Group on 09/12/14, on Misappropriation and Diversion of Narcotics, EDK Process, Pharmacy Training Guide, Notification to Administration and Pharmacy, Destruction of Narcotics, Pain Assessment, Accuracy of Notes, Change of Condition, Abuse and Neglect and the Narcotic Balance. 11. All licensed staff was educated by the Nursing Consultants on 10/07/14, which was attended by fourteen (14) licensed nursing staff. This includes seven (7) RNs and seven (7) LPNs, the Director of Nursing and the Unit Manger. In-services provided on the 7th were taken to QA on the 7th. 12. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following programs: Pain Assessment and Management; Accuracy of Notes, Documenting change of Condition; PRN Medication Management; Medication Pass-Indicators, Side Effects, reporting errors; Prevent/Recognize and Reporting Patient abuse; Pharmacy Training Guide; EDK Process; and, State Regulations controlled substance Notification. This training was completed by all nursing staff on the computer program SilverChair by 09/28/14. 13. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following Policies: Adverse Reaction to Medications; Controlled Substances- Misappropriation; Adverse Consequences and Medication Errors; Accepting Delivery of Medications; Administering Medications; Loss or Theft of Medications; Discarding or Destroying of Medications; and, Security of the Medication Carts. This training was provided by the DON and completed by all nursing staff by 10/06/14. 14. The Quality Assurance Committee consisted of the Administrator, DON, Unit Managers, Social Services, Activities Director, Dietary Director, Medical Director and Consulting Pharmacist, met Monday through Friday, in which the DON and or the Administrator reported on Narcotic Count Records as well as the MAR and reviewed narcotic medications. If suspicion was identified, the DON would immediately contact the Pharmacy and begin an internal investigation. All proper Authorities would be notified including OIG, DCBS, local police and/or KBN. This practice would continue 5 x weekly and/or PRN as needed through 10/31/14. 15. Any discrepancies discovered on the weekend, the weekend nurse would immediately notify the nurse on call, the nurse on call would notify the Administrator or DON. 16. The Pharmacy Consultant would also review for any possible administration of narcotics that may elude a suspicious activity and review the list of destroyed narcotics with each visit. Also a copy of current narcotic orders would be provided from pharmacy for the consultant pharmacist to reconcile with the current orders on the resident's chart to ensure ordering accuracy from pharmacy. 17. The Administrator contacted the Corporate Regional Team on 09/08/14. She and the DON organized the collection of narcotics, and narcotic count sheets on 09/08/14. The DON contacted local law enforcement agency. The Administrator reviewed policies and procedures on 09/08/14 with no revisions. Through observation, interview and record review the State Survey Agency (SSA) validated the Allegation of Compliance with removal of Immediate Jeopardy on 10/11/14 prior to exit on 10/13/14. 1. Interview with Resident #1, on 09/23/14 at 11:30 AM and Resident #3, on 09/23/14 at 8:57 AM, revealed no negative outcomes. Review of Residents #1, #2, #3, #5, and #6's clinical record revealed no adverse outcomes. Review of RN #1's employee file, revealed the facility terminated RN #1 on 09/12/14. Interview with the DON, 09/24/14 at 3:48 PM, revealed RN #1 had not worked since 09/04/14, was suspended on 09/08/14 and was officially terminated on 09/12/14. 2. Review of the facility's investigation, dated 09/08/14, revealed the facility faxed a report to the Office of Inspector General (OIG) and the Department of Community Based Services (DCBS) on 09/08/14. The Local Police Department (opened case #14-2423) was also notified regarding misappropriation of controlled medications. The Kentucky Board of Nursing was notified of the allegation in regards to RN #1 on 09/11/14. 3. Review of the facility's charges from the Pharmacy revealed the facility purchased the reordered medications that were destroyed. Review of the Product Destruction Summary, dated 09/26/14, revealed medications were being destroyed as of 09/17/14. Interview on 09/26/14 at 1:29 PM, with the DON revealed the facility replaced the narcotic medications that were destroyed. 4. Review of Resident #1's Controlled Substance Inventory Form, revealed two (2) bottles of [MEDICATION NAME] were destroyed on 09/10/14 by the DON and Assistant Director of Nursing (ADON). Interview with the ADON, on 09/25/14 at 9:28 AM, revealed she was present when Resident #1's medication was being destroyed. Interview with the DON, on 09/24/14 at 3:48 PM, revealed she destroyed any medications that appeared tampered. 5. Interview with the DON, on 09/24/14 at 3:48 PM, revealed the police were given Resident #2's medication cards. Review of Resident #2's two (2) [MEDICATION NAME] narcotic cards, which were in police custody at the Police Department, revealed one card was tampered; however, this medication was not dispensed to Resident #1. The other [MEDICATION NAME] narcotic card showed no evidence that it had been tampered. Review of the facility's charges from the Pharmacy, revealed the facility purchased the re-ordered medications which were destroyed. 6. Review of Resident #5's [MEDICATION NAME] and [MEDICATION NAME] narcotic sheets, revealed the two (2) medications were destroyed on 09/15/14 by the DON. Interview with the DON, on 09/26/14 at 1:29 PM, revealed the DON had destroyed [MEDICATION NAME] and [MEDICATION NAME] on 09/15/14. 7. Record review of audits of narcotic orders and reconciliation sheets for discrepancies, revealed they started to be completed on 09/15/14. Interview with the DON, on 09/26/14 at 2:37 PM, revealed she began to audit MARs and physician orders [REDACTED]. Interview with the DON, on 10/13/14 at 10:29 AM, revealed every morning she reviewed the controlled substances, to ensure the narcotic counts were right and would report that to the QA team every morning, 10/06/14 through 10/10/14. 8. Review of the Pharmacy Clinical Manager MAR to Cart Audit Form, dated 10/03/14, revealed she completed a 100% audit to look at all orders, verified the MAR matched the orders, and that the pink narcotic sheets matched the drug labels. Then all narcotic counts were verified. The review revealed no signs of diversion for any of the residents. Interview with the Pharmacy Clinical Manager, on 10/13/14 at 11:34 AM, via telephone, revealed she came into the facility to review controlled substances orders, make sure the directions of the orders matched the narcotic sheets. She did an inventory with nursing and inspected the medications and ensured that the narcotic counts matched. The Pharmacy Clinical Manager stated she did not identify any concerns except the orders did not match the directions on the narcotic cards, especially when the medication changed from routine to PRN. She stated she reviewed all four (4) medication carts and looked at the Emergency Drug Kit (EDK) box, which revealed no concerns with the shift change counts. She then provided the facility with a report. Interview with the Administrator, on 10/13/14 at 2:02 PM, revealed on 10/03/14 the Pharmacy Clinical Manager came in and did a 100% audit and would provide oversight until 11/30/14. 9. Review of the education content confirmed the education was completed on 09/30/14 by the DON for eleven (11) LPNs, and five (5) RNs, there was no PRN staff, none on FMLA (Family Medical Leave Act) or vacation and the facility did not use contract staffing. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3 on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7 on 10/13/14 at 1:26 PM; and ,RN #4, on 10/10/14 at 10:36 AM revealed all were knowledgeable of what abuse and misappropriation was and how to report to the DON or Administrator immediately. 10. Interview with the DON, on 10/13/14 at 10:29 AM, revealed she received training on 09/12/14 by the Regional Nurse Consultant. She was educated on medication pass, audits, what information she needed to obtain from the pharmacy, such as a record of all the items that needed to be ordered by pharmacy and then use the information to audit the MAR and compare to what was in the drawer and the physician's orders [REDACTED]. Interview with the Regional Nurse Consultant, on 10/13/14 at 3:42 PM, revealed she completed education on 09/08/14 and 09/12/14 with the DON and Administrator. She went over documentation, narcotic sheets and the protocol for nursing. She also compared MARs and the Pain assessment sheets. The DON was educated on not throwing away evidence. The DON was educated on abuse and misappropriation of medications. The Regional Nurse Consultant stated she talked to the DON about replacing all medications because it was the resident's property. The DON was educated on monitoring the narcotic sheets, MARs and Pain assessment sheets daily. The destruction of medication a

Based on observation, interview, record review and review of the facility's policies, Pharmacy job descriptions and Pharmacy contract, it was determined the facility failed to ensure the Consultant Pharmacist established an effective system for monitoring, reconciliation and destruction of medications and failed to ensure Pharmacy determined drug records were in order, maintained and reconciled. In addition, the facility failed to ensure resident medications were not borrowed for the use of another resident even though staff had been inserviced on not borrowing medication in [DATE]. These failures affected five (5) of nine (9) sampled residents (Residents #1, #2, #3, #5 and #6); and, two (2) of two (2) unsampled residents (Unsampled Residents A and B). Interview and record review revealed narcotic blister packs were tampered with for Residents #1 and Resident #2. On [DATE] during shift change, Licensed Practical Nurse (LPN) #6 and LPN #2 completed a narcotic review of the narcotic lock box on the medication cart for Lincoln Lane. The review included one (1) Morphine Sulfate (narcotic pain medicine) narcotic blister pack, for Resident #1, containing thirty (30) tablets which revealed twelve (12) blisters were empty or missing, and eighteen (18) blisters contained a tablet; however, these tablets were not the same size as the Morphine 15 milligrams (mg) tablets. The back of the narcotic blister pack contained paper tape to hold the pill inside the foil enclosure. The nursing staff recognized there was tape on the back side of the whole narcotic blister pack; however, they failed to report this immediately to a supervisor, as per policy. Instead, LPN #6 and LPN #2 made copies of the narcotic blister pack and placed it under the door of the Director of Nursing (DON). Staff administered six (6) doses of the unidentified tablets that were in the Morphine Sulfate 15 milligrams (mg) blister pack, to Resident #1. Interview with the DON revealed Resident #1's Morphine Sulfate had been replaced with a different medication the resident was not ordered. The DON stated after the Morphine was replaced with an unknown tablet by Registered Nurse (RN) #1, she did not remove any more tablets from that blister pack and started removing tablets from a second blister pack. Staff interview revealed on [DATE], they discovered three (3) doses of Morphine Sulfate 15 mg that was removed on [DATE]; however, this was not Resident #1's normal pattern for taking this medication. Interview with Resident #1 revealed the Morphine was only taken one time at night and he/she had never requested three doses. Resident #2 had a Oxycodone 2.5 mg, narcotic blister pack with paper tape across more than half of the tablets. Interview and record review revealed the narcotic count sheet balances did not reconcile and entries indicated double dosing for Resident #3, Unsampled Resident A and Unsampled Resident B. Review of the narcotic count sheets for the Hydromorphone 2.5 mg revealed doses were removed on the same date and at the same time on two different narcotic count sheets for administration to Resident #3. Unsampled Resident A had Oxycodone ,[DATE] mg, ordered two tablets every six (6) hours; however, it was documented as four (4) tablets administered at 6:00 PM. RN #1 documented the removal of Oxycodone 5 mg on two different narcotic count sheets for the same day at the same time. Unsampled Resident B had Oxycodone IR 5 mg, every four (4) hours; however, RN #1 documented on [DATE] at 7:30 PM that three (3) tablets were administered for a total of 15 mg. Interview and record review revealed Resident #5 was administered three doses of a narcotic after the pharmacy instructed the facility to destroy it. Interview with the DON revealed Resident #5's Lorazepam 1 mg, and Morphine 5 mg, may have been tampered. Pharmacy instructed the DON on [DATE] to destroy these medications; however, they were not destroyed until [DATE]. Resident #5 received three (3) doses of these medications on [DATE], [DATE] and [DATE]. In addition, Buspirone and Escitolopram were reordered too soon for Resident #3 and Resident #6 who received Primidone. The documentation on the Medication Administration Record [REDACTED]. The facility's failure to ensure an effective system was in place to prevent/detect misappropriation/drug diversion and tampering of resident medications including controlled substances placed residents at risk in a situation that has caused or likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on [DATE] and determined to exist of [DATE]. The facility provided an acceptable Allegation of Compliance on [DATE] that alleged removal of Immediate Jeopardy on [DATE]. However, the State Survey Agency determined the Immediate Jeopardy was removed on [DATE], after training of facility staff was verified completed [DATE], at 42 CFR 483.60 Pharmacy Services (F431) with a scope and severity lowered to an "E" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy regarding Inventory Control for Controlled Substances, revised [DATE], revealed the facility would ensure staff immediately reported suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation and timely follow-up in accordance with facility policy. Upon receipt of such a report, the facility would ensure the appropriate facility personnel confirmed the discrepancy and followed facility policy and applicable laws regarding documentation of the incident. The facility would also conduct an investigation to determine: if a dose was in fact administered and, if so, the reason the administration was not charted and if a dose was refused. A facility representative would regularly check the inventory records to reconcile inventory. The facility would regularly reconcile the current and discontinued inventory of controlled substances against the log used in the facility's controlled medication inventory system. The current inventory should be compared to the controlled medication declining inventory record and to the residents' Medication Administration Record [REDACTED]. Review of the facility's policy regarding Loss and Theft, effective [DATE], revealed when facility staff suspect theft or loss of medication, the facility staff would take such actions as required by applicable laws and facility policy. Appropriate actions may include: immediately reporting suspected theft or loss of drugs to a supervisor/manager or the Director of Nursing for appropriate investigation and follow-up. Investigating and reconciling discrepancies and notifying the appropriate Administration of controlled substance discrepancies and if such discrepancies are not reconciled, notifying the appropriate law enforcement agencies according to applicable laws and facility policy. Review of the facility's policy, regarding Documentation of Medication Administration, revised [DATE], revealed a nurse or Certified Medication Aide would document all medications administered to each resident's Medication Administration Record [REDACTED]. Review of the facility's policy, regarding Administering Medications, revised [DATE], revealed medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication would initial and circle the MAR indicated [REDACTED]. If a resident used an as needed (PRN) medication frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist, as needed, would re-evaluate the situation, examine the individual as needed, determine if there was a clinical reason for the frequent PRN use, and consider whether a standing dose of medication was clinically indicated. Review of the Consultant Pharmacist's job description, effective [DATE], revealed the consultant pharmacist's key responsibilities included: ensure facility remains compliant with federal regulations; clinical reviews as required by federal and state regulations; own issue resolution and communicate early warning signs of potential issues; conduct executive reviews and other customer meetings as required; perform medication regimen reviews and provide written reports of these reviews; utilize the MDS 3.0 to identify specific residents needing targeted focus; complete the quality improvement consultant pharmacist summary report for all facilities; provide quarterly reports reflecting facility-level drug utilization; attend quarterly Quality Assurance Committee meetings and provide written reports; and, coordinate or perform review of controlled substance utilization, reconciliation and documentation. Review of the Consultant Extender job description (referred to self as the Quality Assurance Technician QAT), effective date [DATE], revealed the QAT inspects medication storage and medication pass audits; conducts inspections of all drug storage areas per Federal and State regulations and requirements; review narcotic proof of use sheets and narcotic change of shift logs for completeness; provides education to licensed staff; and, reports to the Consultant Pharmacist. Review of the Pharmacy contract, effective [DATE], revealed the pharmacy would maintain a drug profile on each facility resident serviced by pharmacy; make a representative of pharmacy available for attendance at facility's quality assurance committee, infection control committee and other committee meetings that relate to pharmacy products and services; provide drug information and consultation to the facility's licensed professional staff regarding pharmacy products ordered; provide pharmacy policy and procedures; and, collaborate with the facility to coordinate pharmacy documentation processes. The contract further stated Required Consultant Services included: the consultant shall provide consultation regarding all material aspects of providing pharmaceutical services to the facility; a written report regarding the provision of pharmaceutical services would be provided to the facility quarterly; the consultant shall collaborate with the Medical Director; shall conduct a medication regimen review for each facility resident at least once a month; shall identify any irregularities as defined in the State Operations Manual (SOM); shall within three (3) business days of conducting a medication regimen review, provide the facility with a written report; shall assist the facility in reviewing the safe and secure storage of medications in locked compartments; and, shall assist the facility in developing and implementing safeguards and systems to control, account for, and periodically reconcile controlled medications. Optional Consultant Services included: medication observation evaluations; non-financial audits relating to the provisions of medications; potential narcotic diversion investigation; drug utilization and/or evaluation activities; narcotic and/or drug destruction, regardless of whether such task is required by applicable law; and, services provided by consultant as part of corrective action plans. 1. Interview and record review revealed the narcotic blister packs were tampered with for Residents #1 and Resident #2. Review of Resident #1's clinical record, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) Admission Assessment, dated [DATE], revealed the facility assessed Resident #1 with a Brief Interview of Mental Status (BIMS) score of twelve (12), which indicated Resident #1 was interviewable. Resident #1 was also identified on the Admission Assessment to have pain. Review of Resident #1's Morphine Sulfate IR, (immediate release) 5 mg, narcotic card with a quantity of thirty (30) tablets, revealed tablet number twenty-one (21) and number twenty-four (24) through thirty (30) were empty. Further review of the medication revealed blister number one (1) through twenty (20), twenty-two (22) and twenty-three (23) were full. Documentation on the Morphine Sulfate IR, 15 mg, Narcotic Sheet, for [DATE] revealed LPN #2 and LPN #6 had signed and verified blister #21 was missing a pill. Review of the back of the Morphine Sulfate IR, 15 mg, card revealed all thirty (30) tablets had been cut; replaced with an unknown medication; and, paper tape placed across the back of the card. Interview with LPN #2, on [DATE] at 8:38 AM, revealed LPN #2 and LPN #6 were counting narcotics (could not give a time frame), when LPN #2 discovered a tablet had fallen out of Resident #1's Morphine Sulfate Narcotic Card (tablet number twenty-one (21)). LPN #2 stated he then addressed it with the Unit Manager and the Unit Manager had him make a copy of the narcotic card. LPN #2 stated the Unit Manager told him she would have the DON take care of it. Interview with LPN #6, on [DATE] at 2:33 PM, revealed around [DATE], she and LPN #2 were counting Resident #1's Morphine Sulfate card and noticed a missing tablet at the bottom of the card and LPN #2 noticed a small slit in the foil backing. LPN #6 informed LPN #2 she just noticed the discrepancy and it was a mistake because there was no pill in the blister at all and there was a micro cut in the foil backing. LPN #6 stated sometimes the pills would get out and if someone so much as rubbed against the card it would push a pill out and then she would just re-enforce the foil with tape. LPN #6 stated she did not observe tape a lot and never really looked at the back of the medication cards. Interview with the Unit Manager, on [DATE] at 10:00 AM, revealed it was at the end of August, 2014 when LPN #2 and LPN #6 had brought to her attention Resident #1's narcotic card. The staff seemed to think the medication had come from pharmacy taped. The Unit Manager stated she did not remove the narcotic card to ensure non-use of the medication. She stated she was not aware if the staff continued to give the narcotic after she was informed of the missing medications. Further interview with the Unit Manager revealed she did not observe the narcotic card, nor did it cross her mind that the narcotic had been tampered. The Unit Manager stated she had been a nurse since 2007 and never witnessed the pharmacy deliver narcotics with paper tape to the back of the narcotic card. She stated she should have pulled the narcotic card right then and there and destroyed the medication. The Unit Manager stated she thought she sent word through a text to the DON to inform her of Resident #1's medication, but she should have immediately informed the DON of the paper tape to the back of the narcotic card. However, interview with the DON, on [DATE] at 6:00 PM, revealed she had no evidence of a text from the UM only the information placed under her office door by LPN #2 on [DATE]. Review of Resident #1's Morphine Sulfate IR, 15 mg, narcotic count sheet, dated [DATE], revealed it originally contained thirty (30) tablets that were taped across the back of the blister pack and seven (7) tablets had been removed with number 21 missing. Interview with Registered Nurse (RN) #4 revealed the DON was notified on [DATE] by LPN #3 and RN #4 of the suspicious blister packs with tape; however, the facility continued to administer three (3) additional doses of the unidentified medication on [DATE], [DATE], and [DATE], for a total of eleven (11) unknown tablets being administered. There were eighteen (18) tampered narcotics left on the card. In addition to record review, an interview with LPN #3, on [DATE] at 3:20 PM, revealed that on [DATE], while LPN #3 and RN #4 were completing their narcotic count, it was discovered RN #1 had removed three (3) doses of Morphine Sulfate IR, 15 mg, on [DATE] at 10:00 AM, 2:00 PM; and, at 6:00 PM on a separate Morphine Sulfate IR, 15 mg Narcotic Count Sheet (the new narcotic card that had not been tampered). Interview with LPN #3, on [DATE] at 3:20 PM, revealed she was aware Resident #1 liked to receive his/her pain medications at night. When she and RN #4 went to count the narcotic sheet at the beginning of her shift on [DATE], she realized that both narcotic cards for Morphine Sulfate, 15 mg, had been used. LPN #3 stated RN #1 had pulled three (3) doses of Morphine Sulfate, 15 mg, all on [DATE] at 10:00 AM, 2:00 PM and 6:00 PM while using a new narcotic card for Resident #1. LPN #3 stated this was really odd for Resident #1 to obtain three (3) doses in one day, so she made a copy of both of the Morphine Sulfate, 15 mg, narcotic sheets and slid the copies under the DON's door for review. Interview with the DON, on [DATE] at 3:48 PM, revealed on [DATE] when she came to work, she found the copies and was wondering why RN #1 would pull narcotics from a different narcotic card. Interview with Resident #1, on [DATE] at 11:30 AM, revealed he/she had always asked for pain medication at night because he/she suffered from pain to the right leg. Resident #1 stated he/she had five (5) surgeries to his/her leg. Resident #1 stated he/she did not receive the pain medications that the nurse documented he/she had received on [DATE]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 2:45 PM, revealed while she was conducting an assessment of Resident #1, she was reviewing Resident #1's Medication Administration Record [REDACTED]. Resident #1 had verbalized to her he/she did not like to take his/her pain medication because it made him/her sleepy. The MDS Coordinator stated she suggested to Resident #1 to take his/her Tylenol (pain medication) as this medication would not make him/her sleepy and he/she could participate in therapy and become stronger. Sometime during the week of [DATE] the MDS Coordinator informed the DON of what she had found and the DON stated she was doing an investigation and instructed her to obtain a statement from Resident #1. The MDS Coordinator stated Resident #1 verbalized he/she did not receive any of the medication. Continued interview with the DON, on [DATE] at 3:48 PM revealed the DON discovered on [DATE] that Resident #1's narcotic cards had been cut open, narcotics replaced and then taped closed. The DON stated she felt she had to call the police and start an investigation to identify how many residents had been affected. Closed record review for Resident #2 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's MDS Admission Assessment, dated [DATE], revealed the facility assessed Resident #2 with a Brief Interview of Mental Status score of fifteen (15) which meant the resident was interviewable. Review of Resident #2's Nurses Notes, revealed on [DATE] at 6:30 PM, Resident #2 had complained about having pain everywhere. Resident #2 complained that his/her pacemaker was burning him/her and he/she was having left side hand and neck pain. The nurse administered Diazepam and Oxycodone for pain as prescribed, but Resident #2 continued to have pain. At 6:45 PM and 7:40 PM, the doctor was notified and orders were written to send Resident #2 to the hospital for evaluation and treatment. Interview with the DON, on [DATE] at 3:48 PM, revealed she locked Resident #2's Oxycodone cards and narcotic sheets in a locked box, so that when Resident #2 came back to the facility Resident #2's pain medication would be available. Further interview with the DON, on [DATE] at 3:48 PM, revealed when Resident #2 came back to the facility on [DATE], she went to remove Resident #2's narcotics from the locked box and discovered tape to the back of the Oxycodone 2.5 mg, narcotic card. Review of Resident #2's, Oxycodone, 2.5 mg, revealed there were two (2) narcotic cards. The first Oxycodone 2.5 mg, revealed Resident #2 had received a total of twelve (12) of thirty (30) half tablets that had no evidence of cuts in the foil backing or any tape applied. The second Oxycodone, 2.5 mg, narcotic card, had paper tape behind more than half of the blisters. Per interview with the DON, on [DATE], it was determined by the DON Resident #2 did not receive any of the the Oxycodone because the blister pack still had an unknown tablet taped inside the card. The DON stated the medication looked like Lexapro (antidepressant medication) and Lasix (diuretic). Continued interview with the DON, on [DATE] at 3:48 PM, revealed when she interviewed the nurses, the nurses verbalized the narcotic cards were coming from pharmacy with tape on the back of the narcotic cards. Interview with LPN #2, on [DATE] at 3:29 PM, revealed he told the DON during the investigation he thought pharmacy was delivering the narcotic cards with the tape on the back of them because it began to seem like a normal thing to him. LPN #2 stated he felt it had been going on for a couple of months. He also stated he always observed a few narcotics taped, though he never studied the backs of the narcotic cards. LPN #2 stated he was not aware that diversion of drugs should be reported immediately to a supervisor, as stated in the policy. Interview with LPN #7, on [DATE] at 4:42 PM, revealed she saw the tape on the back of the narcotic cards ever since she started at the facility in [DATE]. LPN #7 stated she had not questioned the paper tape behind the narcotics. Interview with LPN #3, on [DATE] at 2:02 PM, revealed she had noticed the tape on the backs of the narcotic cards as early as [DATE]. LPN #3, stated she attempted to remove a narcotic from the blister and had a hard time pushing the medication through the foil backing. LPN #3 stated she did not think the narcotics were coming from pharmacy taped, she just thought the staff was placing the tape too tight to the back of the card. LPN #3 stated she had not observed any others blister packs with tape, but she was not looking either to identify if there were anymore packs with tape. Interview with the DON, on [DATE] at 3:48 PM, revealed she reviewed the narcotics on all four (4) medication carts and could not identify any concerns with tampering of the medications on the Heritage Hall. The DON stated Residents #1 and #2 all lived on the Lincoln Hall and received medications from the odd hall cart utilized by RN #1. The DON stated she then destroyed any narcotics cards that looked like they were "bent" to prove a point to staff that the narcotic cards did not come from pharmacy in that condition. The DON stated she then informed the staff that if they saw tape on the back side of a narcotic card, they needed to report to her immediately. Further interview with the DON, on [DATE] at 2:37 PM, revealed the Consulting Pharmacist came into the building on [DATE] and [DATE] to review carts and narcotics for any discrepancies. The DON began to check the orders and narcotic administration records to ensure the orders and MARs matched what was in the computer. Also to ensure the narcotics matched the count by the end of the month. The DON stated she asked the Consulting Pharmacist to pay special attention to the Lincoln Lane medication carts on [DATE] even though the pharmacist completed monthly medication checks. However, review of the Pharmacy Quality Assurance Summary Report, dated [DATE] revealed there was a special focus on the Heritage Hall carts (which was not identified to be the hall in question). The controlled substances on Heritage Hall were observed to be: double locked; controlled substances were not tampered; controlled substances were within date; timed orders were completed and pulled; the controlled substances were signed by two (2) nurses when the narcotics were counted at the end of shift; and, the controlled substance count matched the count sheets on Heritage Hall. However, there was no documented evidence that Lincoln Hall's Controlled Substance Storage/Documentation or carts had been checked. Post survey interview with the DON, on [DATE] at 2:07 PM, revealed she informed the Consulting Pharmacist to look at both halls when the diversion occurred. However, the DON did not monitor the Pharmacist to ensure the audit was completed, nor did she know what the Pharmacist actually reviewed. 2. Interview and record review revealed Resident #5 was administered three (3) doses of a narcotic after the pharmacy instructed the facility to destroy it. Review of Resident #5's record, revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's Physician Orders, dated [DATE], revealed Resident #5 had an order for [REDACTED]. Review of the Narcotic sheets revealed two (2) of Resident #5's Lorazepam, 1 mg; and, one (1) Morphine (Roxanol), 5 mg had been destroyed on [DATE] for fear the medication had been tampered. Although pharmacy had instructed the DON to destroy this medication on [DATE], the facility continued to administer this medication to Resident #5; three (3) doses were given, one on [DATE], [DATE], and [DATE]. Review of the Quality Improvement: Consultant Pharmacist Summary, period covered [DATE] through [DATE], revealed Consultant Pharmacist checked the remaining controlled medication for tampering. She suggested for Resident #5 that one (1) thirty (30) milliliters (ml) Morphine be destroyed and also one (1) Lorazepam thirty (30) ml, as both of the medications were open and the contents could not be verified. Interview with the Consulting Pharmacist, on [DATE] at 8:35 AM, revealed on [DATE], the DON decided she wanted a sense of security to ensure what was remaining in the medication carts had not been tampered. There was some Morphine that had been opened for Resident #5. The Consulting Pharmacist stated the Morphine liquid was blue and the Lorazepam liquid was clear. The Consulting Pharmacist stated she informed the DON to dispose of the medications because she was unaware if the medication had been tampered. The Consultant Pharmacist did not destroy the medication with the DON. Post survey interview with the DON, on [DATE] at 2:07 PM, revealed she could not remember when the pharmacist told her to destroy these medications and thought it was on [DATE] the day she destroyed the medications. 3. Interview and record review revealed the facility staff was reordering medications too soon due to not being available for use for Resident #3 and Resident #6 although the pharmacy had sent the medications. In addition, review of Resident #6's MAR indicated [REDACTED]. Review of Resident #3's record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's MDS Quarterly Assessment, dated [DATE], revealed the facility assessed Resident #3 with a BIMS score of fifteen (15), which meant Resident #3 was interviewable. Review of Resident #3's May, 2014 Physician orders, revealed orders for Buspirone HCL (anti-anxiety) 15 mg, by mouth three times a day (TID); Escitalopram, (anti-depressant) 20 mg, by mouth daily; and, Dilaudid, (narcotic pain analgesic) 2 mg, by mouth every four (4) hours as needed. Review of Resident #3's September, 2014 Physician Orders, revealed Resident #3 was currently taking: Buspirone HCL, 15 mg, by mouth three times a day; Dilaudid, 2 mg, by mouth every four hours per resident request; Lorazepam, (anti-anxiety) 0.5 mg, by mouth three times a day; and, Benadryl, (anti-histamine) 25 mg, by mouth every six hours for itching. Review of a pharmacy invoice for the months of April, May and [DATE], revealed the facility had to reorder multiple doses of Buspirone and Escitalopram. Review of the [DATE], invoice revealed Resident #3's Buspirone HCL, 15 mg, and Escitalopram, 20 mg, had to be reordered and paid for by the facility. Review of Resident #6's record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's physician orders [REDACTED]. Review of Resident #6's, MAR for the month of [DATE], revealed Resident #6's Primidone, 50 mg, was not given on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the MAR indicated [REDACTED]. There was no documentation to indicate why the medications were not administered on the other dates. Review of the pharmacy's Work Order Fills form, for Resident #6 for the month of [DATE], revealed the Pharmacy sent a total of thirty (30), Primidone tablets on [DATE] and again on [DATE], for a total of sixty (60) tablets. However, review of Resident #6's MAR indicated [REDACTED]. Review of Resident #6's, MAR for the month of [DATE], revealed Resident #6's Primidone, 50 mg, was not given on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on [DATE]. There was no documentation to indicate why the medications were not administered. Review of the pharmacy's Work Order Fills form, for Resident #6 for the month of [DATE], revealed the Pharmacy sent a total of thirty (30) Primidone tablets on [DATE]. However, review of Resident #6's MAR indicated [REDACTED]. Review of Resident #6's, MAR for the month of [DATE], revealed Resident #6's Primidone, 50 mg, was not given on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the MAR indicated [REDACTED]. There was no documentation to indicate why the medications were not administered on the other dates. Review of Resident #6's, Advanced Practice Registered Nurse (APRN) worksheet, dated [DATE], revealed upon review of the MARs it was identified that Resident #6 had been without Primidone (anti-seizure medication) medication for the entire month because the pharmacy had failed to send the medication. The plan was to call the pharmacy to send the Primidone to the facility. Attempted interview with the APRN, on [DATE] at 11:00 AM, revealed a refusal to interview because she did not work for the facility any longer. Review of the pharmacy's Work Order Fills Form, for Resident #6 for the month of [DATE], revealed the Pharmacy sent nine (9) tablets of Primidone on [DATE] and nine (9) tablets on [DATE]. Interview with LPN #6, on [DATE] at 2:33 PM, revealed she kept reordering the Primidone, because it would be there one day and not the next. Post survey interview with the Medical Director, on [DATE] at 2:38 PM, revealed if he had identified that Resident #6 was not receiving h

Based on observation, interview, record review and review of the facility's policies and the Administrator's job description it was determined the Administrator failed to use available resources to ensure an effective system was in place to ensure staff was knowledgeable of the facility's policies and procedures for narcotic and medication administration and to prevent misappropriation/drug diversion and tampering of resident medications and controlled substances for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #5 and #6); and, two (2) of two (2) unsampled residents (Unsampled Residents A and B). The Administrator failed to ensure medications and narcotics were administered, reconciled, and monitored. (Refer to F224, F431, F514 and F520) The Administrator had a concern with reordering medications in June and July of 2014; this was taken to Quality Assurance (QA) and considered resolved as of 07/28/14. This was the last QA meeting on record. However, it was never identified by QA that narcotics were being diverted during this time. The Administrator was not made aware on 08/31/14 of the narcotic blister packs, that were identified by Licensed Practical Nurse (LPN) #2, #3 and #6, as having been tampered and taped. She became aware of this on 09/08/14, by the Director of Nursing and initiated audits to determine how many residents were effected. The audits determined twenty-five (25) additional residents were effected; however, this was never taken to QA for review, monitoring or resolution. Although the Administrator contacted the pharmacy for assistance, the Administrator never reviewed the audits for 09/09/14 and 09/15/14 to ensure it covered the suspected medication cart on Lincoln Lane. In addition, the Administrator did not make sure all of the licensed staff was educated on the facility's policy and procedures for reconciling and documenting narcotic counts. The Administrator did not ensure the Abuse education provided to staff after 09/08/14, clarified that theft/diversion of resident drugs was defined as misappropriation of resident property and should be reported immediately, per the facility's policy. The failure of the Administrator to effectively use available resources to detect misappropriation/diversion of medications and narcotics, ensure the Quality Assurance Committee developed action plans and monitored the reconciliation of narcotics, and administration of medications placed residents at risk in a situation that has caused or was likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was identified on 10/02/14 and determined to exist on 08/31/14. The facility provided an acceptable Allegation of Compliance on 10/09/14 that alleged removal of Immediate Jeopardy on 10/09/14. However, the State Survey Agency determined the Immediate Jeopardy was removed on 10/11/14, after training of facility staff was verified completed 10/10/14, at 42 CFR 483.75 Administration (F490) with a scope and severity lowered to an "E" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the job description for the Administrator, not dated or signed, revealed the purpose of the position was to direct the day to day functions of the facility in accordance with current federal, state and local standards, guidelines, and regulations that govern nursing facilities. The essential function of the position was: compliance management; to ensure excellent care for residents is maintained by overseeing and monitoring patient care services delivered; works with and supervises personnel to ensure complete understanding of responsibilities; and, to ensure maintenance of accurate medical records for billing, auditing, and regulatory compliance. Review of the Inventory Control of Controlled Substances Policy, revised 01/01/13, revealed the facility representative should regularly check the inventory records to reconcile inventory. The Facility should regularly reconcile: Current and discontinued inventory of controlled substances to the log used in the facility's controlled medication inventory system: Current inventory to the controlled medication declining inventory record and to the residents' Medication Administration Record (MAR) and unused controlled substances held in storage destruction to the declining inventory record. Review of the Loss and Theft Policy, effective 12/01/07, revealed appropriate actions may include: immediately reporting suspected theft or loss of drugs to a supervisor/manager or the Director of Nursing for appropriate investigation and follow-up. Investigating and reconciling discrepancies; and, notifying the appropriate Facility Administrator of controlled substance discrepancies and if such discrepancies are not reconciled, notifying the appropriate law enforcement agencies according to applicable law and facility policy. Review of the facility's policy, "Recognizing Signs and Symptoms of Abuse", revised April 2011, revealed the facility would not condone any form of resident abuse. To aid in abuse prevention, all personnel were to report any signs and symptoms of abuse to their supervisor or to the Director of Nursing Services immediately. Signs of actual physical neglect would be improper use/administration of medications. Review of the facility's policy, "Documentation of Medication Administration", revised April 2007, revealed a nurse or Certified Medication Aide would document all medications administered on each resident's Medication Administration Record (MAR). Administration of medication must be documented immediately after (never before) it was given. Review of the facility's policy, "Medical Records", revised August 2006, revealed a medical/clinical record was maintained for each resident admitted to the facility. All data contained in the resident's chart maintained at the nurses's station reflects the medical history of [REDACTED]. Review of the facility's policy regarding Adverse Consequences and Medication Error, revised February 2014, revealed the interdisciplinary team reviews the resident's medication regimen for efficiency and actual or potential medication-related problems on an ongoing basis. The QA Committee would conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements were effective in reducing errors. Review of the training records revealed licensed staff borrowing medications was not included in either training conducted on 06/04/14 or 06/10/14. Education provided on 09/17/14 after the drug diversion was suspected did not cover misappropriation of resident property. Review of the computer education regarding Abuse revealed it did not cover drug diversion as misappropriation of resident property. (Refer to F224) The Administrator did not ensure education provided on 06/04/14, 06/10/14, and 09/17/14 addressed identification of diversion of medications/narcotics, monitoring narcotics, reporting suspicion of diversion of drugs, or following the facility policies. (Refer to F431) The Administrator did not ensure narcotic count sheets were monitored for irregularities or inaccurate documentation. The Administrator did not ensure Pharmacy was reviewing the narcotic count sheets for accuracy. The Administrator did not ensure education provided on 06/04/14, 06/10/14 and 09/17/14 addressed monitoring the accuracy of the medication/narcotic documentation. (Refer to 514) Interview, on 09/25/14 at 4:06 PM, with the Administrator, revealed the facility did not monitor, reconcile and/or destroy medications according to policy. Interview with the Director of Nursing (DON), on 09/24/14 at 3:48 PM, revealed she destroyed evidence (narcotic blister packs and liquids) when diversion of drugs was suspected and continued to destroy evidence once law enforcement had initiated an active case. From 09/15/14 until 10/13/14 twenty-five (25) additional residents were identified as possible victims of the drug diversion. The Administrator failed to ensure a QA meeting was held to develop a plan of action and monitor the investigation process after she was notified of the suspected diversion of drugs on 09/08/14. (Refer to 520) Interview with the Administrator, on 09/25/14 at 4:06 PM, revealed she was made aware of the diversion on 09/08/14 by the DON. She stated there was no QA meeting held after 09/08/14 to address the magnitude of the diversion of drugs; however, there was a QA meeting scheduled for the week after 09/25/14. In addition, she did not make contact with the pharmacy consultant about the information discovered on 09/08/14 due to the pharmacist had been working with the DON. Continued interview with the Administrator, on 10/01/14 at 3:01 PM, revealed she was alerted to medication errors before and they were addressed. As of now and looking at them today and knowing what has happened, she would look at the medication errors differently. The Administrator stated she was not aware the DON was not looking at the narcotic sheets or the empty blister packs. She stated she was aware there were some concerns with pharmacy and the delay of medications, but she felt the facility was at fault because the time lines in which medications were given. The facility provided an acceptable Allegation of Compliance (AOC) on 10/09/14 alleging the Immediate Jeopardy was removed 10/09/14; however, the State Survey Agency verified that staff training was completed on 10/10/14 and the Immediate Jeopardy was removed on 10/11/14. The facility took the following steps to remove the Immediate Jeopardy. 1. Residents #1, #2, #3, #5 and #6 were assessed and interviewed, with no negative outcomes. RN #1 was immediately suspended on 09/08/14 pending the investigation. 2. Licensed staff was interviewed and the allegation reported to the Office of Inspector General (OIG), Kentucky Board of Nursing (KBN), the Department of Community Based Services (DCBS) and Law Enforcement. 3. All medications found to be tampered with were reordered at the facility's expense. 4. Resident #1's tampered medications were pulled from circulation on 09/08/14 by the DON and destroyed on 09/10/14. 5. Resident #2's medications were pulled on 09/03/14 and locked up, when the resident was admitted to the hospital. Upon the resident's return on 09/10/14, the narcotics were determined to have been tampered with and the Police were immediately notified. Narcotics and their containers were turned over to the local Police Department. Medications were reordered at the facility's expense. 6. On 09/16/14, the Pharmacist auditing the medication carts suggested to the DON and the ADON, that Resident #5's narcotics should be destroyed. 7. The DON and facility Administrator conducted 100 % audit of narcotic orders and reconciliation sheets for any discrepancies that may indicate diversion on 09/08/14. The DON continued to complete audits daily to ensure there has been no breach of narcotic medication administration, documentation, reconciliation and or tampering of packages. 8. The Consultant Manager from the pharmacy (facility contracted), on 10/03/14, reviewed and analyzed narcotic medications dispensed and being administered for any discrepancies of tampered packaging, documentation of narcotic sheets, medication administration records for reconciliation and the Emergency Drug Kit (EDK). In addition, all Consulting Pharmacists visits starting 10/03/14 will include at a minimum a review of the entire narcotic dispensing system and analyzing narcotic counts, records, MARs, labels and packaging which will be compared to current orders to ensure there has been no tampering. 9. Education provided to the nursing staff by the DON included medication misappropriation (tampering of medication packaging or appearance of falsification of narcotic sheets), immediate notification to the DON, supervisor or the Administrator. 10. The DON was educated by the Regional Nurse Consultant for Preferred Care Partners Management Group on 09/12/14, on Misappropriation and Diversion of Narcotics, EDK Process, Pharmacy Training Guide, Notification to Administration and Pharmacy, Destruction of Narcotics, Pain Assessment, Accuracy of Notes, Change of Condition, Abuse and Neglect and the Narcotic Balance. 11. All licensed staff was educated by the Nursing Consultants on 10/07/14, which was attended by fourteen (14) licensed nursing staff. This includes seven (7) RNs and seven (7) LPNs, the Director of Nursing and the Unit Manger. In-services provided on the 7th were taken to QA on the 7th. 12. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following programs: Pain Assessment and Management; Accuracy of Notes, Documenting change of Condition; PRN Medication Management; Medication Pass-Indicators, Side Effects, reporting errors; Prevent/Recognize and Reporting Patient abuse; Pharmacy Training Guide; EDK Process; and, State Regulations controlled substance Notification. This training was completed by all nursing staff on the computer program SilverChair by 09/28/14. 13. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following Policies: Adverse Reaction to Medications; Controlled Substances- Misappropriation; Adverse Consequences and Medication Errors; Accepting Delivery of Medications; Administering Medications; Loss or Theft of Medications; Discarding or Destroying of Medications; and, Security of the Medication Carts. This training was provided by the DON and completed by all nursing staff by 10/06/14. 14. The Quality Assurance Committee consisted of the Administrator, DON, Unit Managers, Social Services, Activities Director, Dietary Director, Medical Director and Consulting Pharmacist, met Monday through Friday, in which the DON and or the Administrator reported on Narcotic Count Records as well as the MAR and reviewed narcotic medications. If suspicion was identified, the DON would immediately contact the Pharmacy and begin an internal investigation. All proper Authorities would be notified including OIG, DCBS, local police and/or KBN. This practice would continue 5 x weekly and/or PRN as needed through 10/31/14. 15. Any discrepancies discovered on the weekend, the weekend nurse would immediately notify the nurse on call, the nurse on call would notify the Administrator or DON. 16. The Pharmacy Consultant would also review for any possible administration of narcotics that may elude a suspicious activity and review the list of destroyed narcotics with each visit. Also a copy of current narcotic orders would be provided from pharmacy for the consultant pharmacist to reconcile with the current orders on the resident's chart to ensure ordering accuracy from pharmacy. 17. The Administrator contacted the Corporate Regional Team on 09/08/14. She and the DON organized the collection of narcotics, and narcotic count sheets on 09/08/14. The DON contacted local law enforcement agency. The Administrator reviewed policies and procedures on 09/08/14 with no revisions. Through observation, interview and record review the State Survey Agency (SSA) validated the Allegation of Compliance with removal of Immediate Jeopardy on 10/11/14 prior to exit on 10/13/14. 1. Interview with Resident #1, on 09/23/14 at 11:30 AM and Resident #3, on 09/23/14 at 8:57 AM, revealed no negative outcomes. Review of Residents #1, #2, #3, #5, and #6's clinical record revealed no adverse outcomes. Review of RN #1's employee file, revealed the facility terminated RN #1 on 09/12/14. Interview with the DON, 09/24/14 at 3:48 PM, revealed RN #1 had not worked since 09/04/14, was suspended on 09/08/14 and was officially terminated on 09/12/14. 2. Review of the facility's investigation, dated 09/08/14, revealed the facility faxed a report to the Office of Inspector General (OIG) and the Department of Community Based Services (DCBS) on 09/08/14. The Local Police Department (opened case #14-2423) was also notified regarding misappropriation of controlled medications. The Kentucky Board of Nursing was notified of the allegation in regards to RN #1 on 09/11/14. 3. Review of the facility's charges from the Pharmacy revealed the facility purchased the reordered medications that were destroyed. Review of the Product Destruction Summary, dated 09/26/14, revealed medications were being destroyed as of 09/17/14. Interview on 09/26/14 at 1:29 PM, with the DON revealed the facility replaced the narcotic medications that were destroyed. 4. Review of Resident #1's Controlled Substance Inventory Form, revealed two (2) bottles of [MEDICATION NAME] were destroyed on 09/10/14 by the DON and Assistant Director of Nursing (ADON). Interview with the ADON, on 09/25/14 at 9:28 AM, revealed she was present when Resident #1's medication was being destroyed. Interview with the DON, on 09/24/14 at 3:48 PM, revealed she destroyed any medications that appeared tampered. 5. Interview with the DON, on 09/24/14 at 3:48 PM, revealed the police were given Resident #2's medication cards. Review of Resident #2's two (2) [MEDICATION NAME] narcotic cards, which were in police custody at the Police Department, revealed one card was tampered; however, this medication was not dispensed to Resident #1. The other [MEDICATION NAME] narcotic card showed no evidence that it had been tampered. Review of the facility's charges from the Pharmacy, revealed the facility purchased the re-ordered medications which were destroyed. 6. Review of Resident #5's [MEDICATION NAME] and [MEDICATION NAME] narcotic sheets, revealed the two (2) medications were destroyed on 09/15/14 by the DON. Interview with the DON, on 09/26/14 at 1:29 PM, revealed the DON had destroyed [MEDICATION NAME] and [MEDICATION NAME] on 09/15/14. 7. Record review of audits of narcotic orders and reconciliation sheets for discrepancies, revealed they started to be completed on 09/15/14. Interview with the DON, on 09/26/14 at 2:37 PM, revealed she began to audit MARs and physician orders [REDACTED]. Interview with the DON, on 10/13/14 at 10:29 AM, revealed every morning she reviewed the controlled substances, to ensure the narcotic counts were right and would report that to the QA team every morning, 10/06/14 through 10/10/14. 8. Review of the Pharmacy Clinical Manager MAR to Cart Audit Form, dated 10/03/14, revealed she completed a 100% audit to look at all orders, verified the MAR matched the orders, and that the pink narcotic sheets matched the drug labels. Then all narcotic counts were verified. The review revealed no signs of diversion for any of the residents. Interview with the Pharmacy Clinical Manager, on 10/13/14 at 11:34 AM, via telephone, revealed she came into the facility to review controlled substances orders, make sure the directions of the orders matched the narcotic sheets. She did an inventory with nursing and inspected the medications and ensured that the narcotic counts matched. The Pharmacy Clinical Manager stated she did not identify any concerns except the orders did not match the directions on the narcotic cards, especially when the medication changed from routine to PRN. She stated she reviewed all four (4) medication carts and looked at the Emergency Drug Kit (EDK) box, which revealed no concerns with the shift change counts. She then provided the facility with a report. Interview with the Administrator, on 10/13/14 at 2:02 PM, revealed on 10/03/14 the Pharmacy Clinical Manager came in and did a 100% audit and would provide oversight until 11/30/14. 9. Review of the education content confirmed the education was completed on 09/30/14 by the DON for eleven (11) LPNs, and five (5) RNs, there was no PRN staff, none on FMLA (Family Medical Leave Act) or vacation and the facility did not use contract staffing. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3 on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7 on 10/13/14 at 1:26 PM; and ,RN #4, on 10/10/14 at 10:36 AM revealed all were knowledgeable of what abuse and misappropriation was and how to report to the DON or Administrator immediately. 10. Interview with the DON, on 10/13/14 at 10:29 AM, revealed she received training on 09/12/14 by the Regional Nurse Consultant. She was educated on medication pass, audits, what information she needed to obtain from the pharmacy, such as a record of all the items that needed to be ordered by pharmacy and then use the information to audit the MAR and compare to what was in the drawer and the physician's orders [REDACTED]. Interview with the Regional Nurse Consultant, on 10/13/14 at 3:42 PM, revealed she completed education on 09/08/14 and 09/12/14 with the DON and Administrator. She went over documentation, narcotic sheets and the protocol for nursing. She also compared MARs and the Pain assessment sheets. The DON was educated on not throwing away evidence. The DON was educated on abuse and misappropriation of medications. The Regional Nurse Consultant stated she talked to the DON about replacing all medications because it was the resident's property. The DON was educated on monitoring the narcotic sheets, MARs and Pain assessment sheets daily. The destruction of medication and ensuring two (2) nurses were present. Also, monitoring the EDK box and ensuring the serial numbers matched everyday. The DON was also educated on different methods of tampering with medication and not having tape placed on the back of narcotic cards. 11. Interview with LPN #3, on 10/10/14 at 1:20 PM, revealed she was not educated by the Clinical Services Nurse. LPN #3 stated she was not in the building on 10/06/14, 10/07/14 or 10/08/14 in which the Consulting Pharmacists were present in the building. LPN #3 stated she did not obtain a packet from the DON, but had obtained 1:1 training with the DON. LPN #3 had been working the whole shift on 10/10/14 without being educated. Review of the In-service Education on 10/08/14, by the Clinical Services Nurse from pharmacy for the loss/theft of medications, revealed only six (6) LPNs were educated, one (1) RN, and the ADON was educated out of a total of sixteen (16) licensed staff members. LPN #3 was not on the sign in list as being educated. Interview with the Regional Nurse Clinician for pharmacy, revealed she completed a quick training with the staff because she was told the staff had already been in-serviced. The training was supposed to be a quick reference tool. She stated she observed a shift to shift narcotic count. The Regional Nurse Clinician stated she wanted to ensure the nurses, when counting narcotics, monitored the card numbers and looked at the narcotic sheets to ensure they matched. The DON stated she knew LPN #3 was not trained and was going to train LPN #3 at the end of her shift. The DON stated LPN #3, knew she had been trained on most of the information; however, she was not trained on how to destroy narcotic medication and who was responsible to destroy the medications. Everything the Regional Nurse Clinician educated staff on, the DON had already went over with the staff. So though the Regional Nurse Clinician did not get the opportunity to educate all the nursing staff, all nurses were provided the same information. Review of the daily QA meetings on 10/06/14 through 10/10/14, revealed no documented evidence that the training went to QA; however, there was evidence on the 10/07/14 QA meeting where they talked about the pharmacy and their role and participation in the correction of the deficiency. Interview with the Regional Director of Operations, on 10/10/14 at 2:21 PM, revealed staff was not to work unless they had been educated. He stated he was not aware LPN #3 was on the floor the whole shift. He stated he was at fault for this. The Regional Director of Operations (RDO) stated he knew he stated in the Allegation of Compliance (AOC), all the nursing staff was educated, but he meant to say the staff could not work if all were not educated and would fix it immediately. Interview with the RDO, on 10/10/14 at 2:04 PM, revealed he had the information in the AOC wrong. Review of the training for loss or theft of medications revealed an additional six (6) nurses were educated on 10/10/14 by the DON. 12. Review of the Pain Assessment and Management training provided from 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-served on pain medications. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of pain assessments and the fact they had to be completed before and after administration of pain medications. The trainings were completed on 09/27/14. Review of the training on the Ins and Outs of Documentation, provided 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-serviced on documentation. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of accurate documentation of the MAR's and narcotic sheets. The training was completed for all nursing staff by 09/28/14. Review of the training on PRN Medication Management, provided on 09/01/14 through 10/05/14, revealed all licensed staff, eleven (11) LPNs and five (5) RNs had been in-serviced on PRN medication management and ensuring an assessment was completed on all residents before and after PRN medication was given. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of PRN medication management. The training was completed by all nursing staff by 09/29/14. Review of the training on Medication Pass, provided on 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-serviced on the proper way to perform a medication pass, side effects of giving the wrong medications and reporting errors immediately to the DON or Administrator. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable about the Medication Pass requirements. The training was completed on 09/29/14. Review of the training on Preventing, Recognizing and Reporting Resident Abuse, provided on 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs were educated on abuse, misappropriation and the importance of notifying the DON and Administrator as soon as abuse was observed. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of identifying and reporting abuse. The training was completed by all nursing staff by 09/30/14. Review of the training on the Pharmacy Training Guide, EDK Process and KAR's Controlled Substance Notification, provided on 09/17/14, revealed nine (9) LPN's and five (5) RN's were educated and two LPN's were educated on a later date. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of the physician order [REDACTED]. The training was completed by all nursing staff by 10/10/14. 13. Review of a training provided by the Regional Nurse Clinician and the DON on Policies and Procedures with copies provided on the following: loss and theft of medications; adverse consequences; medication destruction and disposal of controlled substances; security of the medication cart; documentation medication administration; administering medications; and, accepting delivery of medications and controlled substances. Review revealed all eleven (11) LPNs and five (5) RNs were inserviced from 10/07/14 through 10/10/14. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of the policies and procedures for narcotics and medication administration. The training was completed by all nursing staff on 10/10/14. 14. Review of the QA meetings minutes and sign in sheets, dated 10/06/14, 10/07/14, 10/08/14, 10/09/14 and 10/10/14, revealed the Administrator, DON, Unit Manger, Medical Director, Consulting Pharmacist and Regional Director of Operations had attended daily meetings Monday through Friday. Interview with the DON, on 10/13/14 at 10:29 AM, revealed there was a QA meeting every morning. Review of the Controlled Substance Audit, dated 10/06/14 through 10/10/14, revealed the audits were completed without concerns. The DON stated she would report back to the QA committee with any diversion they would initiate an investigation immediately and report to all agencies. Interview with the Regional Director of Operations, on 10/13/14 at 2:28 PM, revealed he would attend QA daily while he was in the facility. 15. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable to call the DON immediately if they observed any discrepancies with narcotics. The staff was also aware to report to the DON if they had witnessed tape behind a narcotic medication card. 16. Review of the Pharmacy consults, dated 10/03/14, revealed the MARs were verified to match the pharmacy delivery tickets; and, matched the labels. All counts, and all tablets were verified to be accurate and no signs of diversion. Direction change stickers (to be placed on the Narcotic count sheets when the directions for administering the narcotics is changed) were applied. Interview with the Pharmacy Consultant Manager, on 10/13/14 at 11:34 AM, revealed on 10/13/14, she came in and reviewed 100% of the control substance orders, made sure the directions matched the narcotic pinks sheets. She conducted an inventory of what narcotics were available, with the nursing staff. Interview with the Pharmacy Regional Manager, on 10/13/14 at 9:31 AM, revealed to his understanding the new Consultant Pharmacist would be completing 100% audits, looking at narcotic cards and narcotic count sheets. The Regional Manager, stated the Consultant would ensure the narcotic count was accurate and there had been no tampering with the medications. The Consultant was expected to exit with the facility, attend QA meetings monthly and quarterly and review weekly Narcotic delivery worksheets. 17. Interview with the Regional Director of Operations, on 10/13/14 at 2:28 PM, revealed the Administrator notified him on 09/08/14. A conference call with the Regional Nurse Consultant took place on 09/08/14, to discuss Resident #1 in which it was stated it was pretty evident Resident #1 did not receive all of his/her medications. Review of the narcotic count sheets revealed a collection of count sheets on the DON's desk. Interview with Detective #1, 09/22/14 at 3:23 PM, revealed the facility had contacted them to report the allegation of drug diversion. Review of the signature section of the policies and procedures revealed they were reviewed by the DON and ADON on 10/06/14 with no changes to the policies and procedures.

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to maintain accurate clinical records and have an effective system in place for monitoring narcotics sheets and monitoring Medication Administration Records (MARs) for four (4) of nine (9) sampled residents (Residents #1,#2, #3 and #6); and two (2) of two (2) unsampled residents (Residents A and B). (Refer to F431) RN #1 altered narcotic count sheets to make the balance appear accurate on paper although the actual narcotic tablets had been removed from the blister packs and substituted with an unknown medication. In addition, RN #1 did not sign for the narcotics as they were removed from the blister pack, she would complete the documentation as the shift to shift count occurred. RN #1 made changes on the narcotic count sheets by obliterating her signature, date and time, without a witness or supervisor review. RN #1 documented the removal of narcotic tablets for the same date and time on two (2) separate count sheets. The Medication Administration Records (MARS) did not reflect the administration of the narcotics removed by RN #1. The MAR reflected missing doses or medications that were not available. There was no documented evidence of follow up with the pharmacy for the missing medications. The narcotic count sheets were filed in medical records when completed without any review by the Director of Nursing, Assistant Director of Nursing, Administrator, Medical Records Director or Pharmacy. The facility's failure to have an effective system in place to ensure narcotic and medication administration records were accurately documented placed residents at risk in a situation that has caused or was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/02/14 and determined to exist on 08/31/14. The facility provided an acceptable Allegation of Compliance on 10/09/14 that alleged removal of Immediate Jeopardy on 10/09/14. However, the State Survey Agency determined the Immediate Jeopardy was removed on 10/11/14, after training of facility staff was verified completed 10/10/14, at 42 CFR 483.75 Administration (F514) with the scope and severity lowered to an "E" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy, Inventory Control of Controlled Substances, revised 01/01/13, revealed the facility's representative would regularly check the inventory records to reconcile inventory. The facility would regularly reconcile: current and discontinued inventory of controlled substances against the log used in facility's controlled medication inventory system; current inventory against the controlled medication declining inventory record; and, to the residents' Medication Administration Record (MAR) and unused controlled substances held in storage destruction to the declining inventory record. Review of the facility's policy, "Documentation of Medication Administration", revised April 2007, revealed a nurse or Certified Medication Aide would document all medications administered to each resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it was given. Review of the facility's policy regarding Medical Records, revised August 2006, revealed a medical/clinical record was maintained for each resident admitted to the facility. All data contained in the resident's chart maintained at the Nurses's Station should reflect the medical history of [REDACTED]. 1. Review of Resident #1's [MEDICATION NAME] IR, (immediate release) 15 mg, narcotic blister pack with a quantity of thirty (30) tablets, revealed blisters number twenty-four (24) through thirty (30) were empty and blister number twenty-one (21) was empty, blisters number one (1) through twenty (20), twenty-two (22) and twenty-three (23) were full. Documentation on the [MEDICATION NAME] IR, 15 mg, narcotic sheet, on 08/31/14 revealed, LPN #2 and LPN #6 had signed and verified blister #21 was missing a pill. Review of the back of the [MEDICATION NAME] IR, 15 mg, card revealed all thirty (30) tablets had been cut, replaced with an unknown medication and paper tape placed across the back of the card. Review of the [MEDICATION NAME] IR, 15 mg, from the untampered narcotic card, dated 09/04/14, revealed Resident #1 received medication at 10:00 AM, 2:00 PM and 6:00 PM all by RN #1 when there was eighteen (18) tablets available on the first narcotic sheet of [MEDICATION NAME] IR, 15 mg. Interview with LPN #6, on 09/26/14 at 2:33 PM, revealed she was informed to always use up all the medication on the first narcotic card and then move to the second narcotic card. This would be keeping an accurate clinical record. If she had seen where the nurse was pulling from one narcotic sheet and then pulling from another when narcotics were available on the first sheet, she would have notified her supervisor. Interview with LPN #3, on 09/24/14 at 3:20 PM, revealed she was aware Resident #1 liked to receive his/her pain medications at night. So when LPN #3 reviewed the narcotic count sheet it revealed RN #1 had pulled three (3) doses of [MEDICATION NAME] 15 mg all on 09/04/14 at 10:00 AM, 2:00 PM and 6:00 PM while utilizing a new medication card for Resident #1. LPN #3 stated this was really odd for Resident #1 to receive three (3) doses in one day. She stated this was not reported to the supervisor on duty, she just made a copy placed it under the DON's door for review on Monday. Interview with Resident #1, on 09/23/14 at 11:30 AM, revealed he/she had always asked for pain medication at night because he/she suffered from pain to the right leg. Resident #1 stated he/she had five (5) surgeries to his/her leg. Resident #1's right leg was observed to be lying to the right severely and contracted. Resident #1 stated he/she did not receive the pain medications that the nurse documented he/she had received on 09/04/14. 2. Review of Resident #2's [MEDICATION NAME], 2.5 mg, every eight (8) hours as needed revealed out of a total of thirty (30) tablets, #13 and #4 tablets were removed from the medication card, with no signature as to what happened to the medications. Signature space for #28 had one (1) line through the error with one signature and it was not witnessed by two (2) nurses. Further review of the narcotic count sheet revealed the dates of removal were out of order. Tablet #5 was removed at 6:30 AM on 08/28/14 with a balance of 4, tablet #4 was noted as empty with a balance of 3, and tablet #3 was removed on 08/27/14 at 10:30 AM, after it was documented tablet #5 was removed on 08/28/14. Interview with the DON, on 09/25/14 at 6:00 PM, revealed she had a concern with the tape on the blister packs; however, she did not have any concerns with narcotic counts because she had not reviewed the narcotic count sheets and had focused on pharmacy from 09/01/14 through 09/08/14 as the source of the tape being on the back of the blister packs. On 09/05/14, she received a copy of a second set of narcotic count sheets with a note from LPN #3. The narcotic count sheet revealed three (3) doses were removed on 09/04/14 by RN #1; however, the note stated Resident #1 never takes three (3) doses in one day. 3. Review of Resident #3's [MEDICATION NAME], 0.5 mg, by mouth three (3) times a day as needed, dated from 05/27/14 through 06/29/14, revealed tablets #11, #13, two (2) #22's, and #23 were scribbled through with multiple lines. Tablet #23, two #22's and #11 were observed to have been scribbled through by RN #1. "Error" was documented on signature line for tablets #11 and #13. Review also revealed there was no documentation of two (2) nurses to witness the error, as per policy. Review of Resident #3's [MEDICATION NAME] 2 milligrams (mg) every four (4) hours as needed for pain, narcotic sheet, revealed there were two (2) narcotic cards, one for the month of June dated 06/15/14 through 06/20/14; and, a second narcotic dated 06/19/14 through 06/25/14. The first sheet had multiple lines going through 06/17/14 over RN #1's name, date and time of medication. There was no "error" documented above RN #1's name, nor an initial to document the error. Interview with the DON, on 09/26/14 at 3:18 PM, revealed nurses were to draw a line through the error, write "error" above the line and initial with a witness. Interview with LPN #2, on 09/26/14 at 3:29 PM, revealed the poor documentation on the narcotic count sheets had become routine and acceptable over time. He further stated he was not aware of the procedure for correcting the narcotic count sheets. Interview with LPN #3, on 10/01/14 at 2:02 PM, revealed when she would do the shift to shift count of narcotics, she did not recognize the scratching out of the signatures as a concern. Review of Resident #3's physician's orders [REDACTED]. Review of the first narcotic sheet, dated 08/01/14, and a second narcotic sheet dated 08/06/14, revealed RN #1 removed three (3) narcotics on 08/03/14 at 10:00 AM, 12:00 PM and 2:00 PM. RN #1 documented this medication was removed from the blister pack every two (2) hours instead of every (4) hours as ordered. Interview with Resident #3, on 09/23/14 at 8:57 AM, revealed the facility ran out of multiple medications before, such as his/her pain medications and [MEDICATION NAME]. Resident #3 stated it had occurred ever since he/she got out of the hospital in December 2013. Resident #3 stated he/she suffered from pain all the time. Interview with LPN #2, on 09/26/14 at 3:29 PM, revealed a lot of times when he and RN #1 would count the narcotic sheets and blister packs, RN #1 would have to either sign the narcotic sheet to balance the total tablets or she would scribble her signature due to signing on the wrong line of the narcotic sheet. LPN #2 stated when a nurse passes out a narcotic medication they should sign the narcotic out immediately. LPN #2 stated RN #1 would have to correct the narcotic sheets frequently and he did not suspect any thing was wrong at the time; although he was aware the narcotic was to be signed for when removing the tablet. Interview with the DON, on 09/25/14 at 6:00 PM, revealed she pulled narcotic count sheets and focused on RN #1's documentation and she identified through her audits that RN #1 had given medications too close, there were transcription errors noted, and narcotics were given at the same time. Additional interview with the DON, on 09/26/14 at 3:18 PM, revealed when the nurse had an error, the nurse was to document a line through the narcotic sheet and then write error above the line and sign with an initial. The nurse was to also have a nurse witness the error and notify her of any errors or inconsistencies in documentation. 4. Review of Resident #6's, MAR for the month of May 2014, revealed Resident #6's [MEDICATION NAME], 50 mg, was not given on 05/01/14, 05/02/14, 05/04/14, 05/05/14, 05/06/14, 05/07/14, 05/08/14, 05/09/14, 05/10/14, 05/13/14, 05/15/14, 05/16/14, 05/24/14, 05/29/14 and, days 05/04/14, and 05/29/14 had no initial in the day provided. There was no documentation for the reason the medication was not given, except for 05/10/14, 05/14/14, 05/24/14, it was documented the medication was not available; and, on 05/06/14, 05/07/14 and 05/24/14 it was documented the resident refused the medication. Review of Resident #6's Nurses Notes, dated 05/06/14, revealed Resident #6 had refused to take the [MEDICATION NAME], and no other documentation was provided. Review of Resident #6's pharmacy Work Order Fills form, for the month of May 2014, revealed the pharmacy sent a total of thirty (30), [MEDICATION NAME] tablets on 05/05/14; and again on 05/30/14, which meant the medications were available for use. Review of Resident #6's, MAR for the month of June 2014, revealed Resident #6's [MEDICATION NAME], 50 mg, were not given on 06/07/14, 06/11/14, 06/14/14, 06/15/14, 06/16/14, 06/17/14, 06/18/14, 06/19/14, 06/20/14, 06/21/14, 06/22/14, 06/24/14. There was no documentation to indicate why the medications were circled for the days of the 05/07/14, 05/19/14, 05/21/14, and 05/24/14. The dates of 05/11/14 and 05/14/14 were blank with no initials or documentation as why the boxes were left blank. Review of Resident #6's Nurses Notes, dated 06/05/14, revealed Resident #6 had refused all medications for the day. No other documentation was provided as to why the medication was refused. Review of Resident #6's pharmacy Work Order Fills form, for the month of June 2014, revealed the Pharmacy sent a total of thirty (30) [MEDICATION NAME] tablets on 06/24/14. Review of Resident #6's, MAR for the month of July 2014, revealed Resident #6's [MEDICATION NAME], 50 mg, were circled as not given on 07/02/14, 07/03/14, 07/04/14, 07/05/14, 07/06/14 and 07/07/14. There was no documentation as to why this medication was not administered except for 07/02/14 and 07/05/14 it was indicated the medication was not available and pharmacy was notified. Interview with LPN #6, on 09/26/14 at 2:33 PM, revealed she received counseling for circling the [MEDICATION NAME] because she had circled for a couple of days in a row and then some days her initials did not have circles. LPN #6 stated she would call pharmacy and would be notified that it was too early to reorder. Further interview with LPN #6, on 09/30/14 at 3:17 PM, revealed she could remember at one point the medication had come in and then she would come in at a later date and see that the medication was being circled again. LPN #6 stated this had occurred for a long time. LPN #6 stated she did not know why she did not inform the DON of this occurrence. Interview with the DON, on 10/01/14 at 12:30 PM, revealed not one nurse had ever talked to her about the medication coming up missing. The DON stated she talked to the nurses and informed them that someone was stealing the medication and was not sure if this concern had went to QA. 5. Review of Unsampled Resident A's [MEDICATION NAME], 5/325 mg, revealed it was ordered two (2) tables every six (6) hours for pain. Review of the narcotic count sheet for 09/04/14 at 12:00 PM revealed two (2) tablets had been removed by RN #1. Two (2) more tablets were then given at 6:00 PM on 09/04/14, which was the last pill on the narcotic sheet. On a new narcotic sheet, RN #1 then removed two (2) more medications on 09/04/14 at 6:00 PM. Thus RN #1 appeared to have administered four (4) tablets at 6:00 PM which was not how the medication was ordered. 6. Review of Unsampled Resident B's [MEDICATION NAME], 5 mg, revealed it was ordered one (1) to two (2) tablet every four (4) hours as needed for pain. Review of the narcotic count sheet for 07/26/14 at 7:30 PM revealed RN #1 had removed the last one (1) tablet and finished the narcotic sheet. On a new sheet, same medication, RN #1 then removed two (2) tablets at the same time. Interview with the DON, on 09/25/14 at 6:00 PM, revealed she recognized RN #1 had given medication too close and there were transcription errors noted when she completed her audits. Further interview with the DON, on 10/02/14 at 4:58 PM, revealed there were improvements needed for the nurses at this time in regards to making the nurses document changes in the Nurses Notes. The DON stated she always strived to have an accurate clinical record. In reviewing of the narcotic sheets, she recognized the nurses were documenting times to close, documenting giving medications at the same time and appearing to double dose the resident. She stated she was not sure if the staff was stealing or giving the wrong medications. The DON stated scribbling on the narcotic sheets was not appropriate as well and she could not understand how anyone could miss it. Interview with the Administrator, on 10/01/14 at 3:01 PM, revealed she was alerted to medication errors before and they were addressed. As of now and looking at them today and knowing what has happened, she would look at the medication errors differently. The Administrator stated she was not aware the DON was not looking at the narcotic sheets or the empty blister packs. The Administrator stated she was aware there were some concerns with pharmacy and the delay of medications, but felt the facility was at fault because the time lines in which medications were given. The facility provided an acceptable Allegation of Compliance (AOC) on 10/09/14 alleging the Immediate Jeopardy was removed 10/09/14; however, the State Survey Agency verified that staff training was completed on 10/10/14 and the Immediate Jeopardy was removed on 10/11/14. The facility took the following steps to remove the Immediate Jeopardy. 1. Residents #1, #2, #3, #5 and #6 were assessed and interviewed, with no negative outcomes. RN #1 was immediately suspended on 09/08/14 pending the investigation. 2. Licensed staff was interviewed and the allegation reported to the Office of Inspector General (OIG), Kentucky Board of Nursing (KBN), the Department of Community Based Services (DCBS) and Law Enforcement. 3. All medications found to be tampered with were reordered at the facility's expense. 4. Resident #1's tampered medications were pulled from circulation on 09/08/14 by the DON and destroyed on 09/10/14. 5. Resident #2's medications were pulled on 09/03/14 and locked up, when the resident was admitted to the hospital. Upon the resident's return on 09/10/14, the narcotics were determined to have been tampered with and the Police were immediately notified. Narcotics and their containers were turned over to the local Police Department. Medications were reordered at the facility's expense. 6. On 09/16/14, the Pharmacist auditing the medication carts suggested to the DON and the ADON, that Resident #5's narcotics should be destroyed. 7. The DON and facility Administrator conducted 100 % audit of narcotic orders and reconciliation sheets for any discrepancies that may indicate diversion on 09/08/14. The DON continued to complete audits daily to ensure there has been no breach of narcotic medication administration, documentation, reconciliation and or tampering of packages. 8. The Consultant Manager from the pharmacy (facility contracted), on 10/03/14, reviewed and analyzed narcotic medications dispensed and being administered for any discrepancies of tampered packaging, documentation of narcotic sheets, medication administration records for reconciliation and the Emergency Drug Kit (EDK). In addition, all Consulting Pharmacists visits starting 10/03/14 will include at a minimum a review of the entire narcotic dispensing system and analyzing narcotic counts, records, MARs, labels and packaging which will be compared to current orders to ensure there has been no tampering. 9. Education provided to the nursing staff by the DON included medication misappropriation (tampering of medication packaging or appearance of falsification of narcotic sheets), immediate notification to the DON, supervisor or the Administrator. 10. The DON was educated by the Regional Nurse Consultant for Preferred Care Partners Management Group on 09/12/14, on Misappropriation and Diversion of Narcotics, EDK Process, Pharmacy Training Guide, Notification to Administration and Pharmacy, Destruction of Narcotics, Pain Assessment, Accuracy of Notes, Change of Condition, Abuse and Neglect and the Narcotic Balance. 11. All licensed staff was educated by the Nursing Consultants on 10/07/14, which was attended by fourteen (14) licensed nursing staff. This includes seven (7) RNs and seven (7) LPNs, the Director of Nursing and the Unit Manger. In-services provided on the 7th were taken to QA on the 7th. 12. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following programs: Pain Assessment and Management; Accuracy of Notes, Documenting change of Condition; PRN Medication Management; Medication Pass-Indicators, Side Effects, reporting errors; Prevent/Recognize and Reporting Patient abuse; Pharmacy Training Guide; EDK Process; and, State Regulations controlled substance Notification. This training was completed by all nursing staff on the computer program SilverChair by 09/28/14. 13. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following Policies: Adverse Reaction to Medications; Controlled Substances- Misappropriation; Adverse Consequences and Medication Errors; Accepting Delivery of Medications; Administering Medications; Loss or Theft of Medications; Discarding or Destroying of Medications; and, Security of the Medication Carts. This training was provided by the DON and completed by all nursing staff by 10/06/14. 14. The Quality Assurance Committee consisted of the Administrator, DON, Unit Managers, Social Services, Activities Director, Dietary Director, Medical Director and Consulting Pharmacist, met Monday through Friday, in which the DON and or the Administrator reported on Narcotic Count Records as well as the MAR and reviewed narcotic medications. If suspicion was identified, the DON would immediately contact the Pharmacy and begin an internal investigation. All proper Authorities would be notified including OIG, DCBS, local police and/or KBN. This practice would continue 5 x weekly and/or PRN as needed through 10/31/14. 15. Any discrepancies discovered on the weekend, the weekend nurse would immediately notify the nurse on call, the nurse on call would notify the Administrator or DON. 16. The Pharmacy Consultant would also review for any possible administration of narcotics that may elude a suspicious activity and review the list of destroyed narcotics with each visit. Also a copy of current narcotic orders would be provided from pharmacy for the consultant pharmacist to reconcile with the current orders on the resident's chart to ensure ordering accuracy from pharmacy. 17. The Administrator contacted the Corporate Regional Team on 09/08/14. She and the DON organized the collection of narcotics, and narcotic count sheets on 09/08/14. The DON contacted local law enforcement agency. The Administrator reviewed policies and procedures on 09/08/14 with no revisions. Through observation, interview and record review the State Survey Agency (SSA) validated the Allegation of Compliance with removal of Immediate Jeopardy on 10/11/14 prior to exit on 10/13/14. 1. Interview with Resident #1, on 09/23/14 at 11:30 AM and Resident #3, on 09/23/14 at 8:57 AM, revealed no negative outcomes. Review of Residents #1, #2, #3, #5, and #6's clinical record revealed no adverse outcomes. Review of RN #1's employee file, revealed the facility terminated RN #1 on 09/12/14. Interview with the DON, 09/24/14 at 3:48 PM, revealed RN #1 had not worked since 09/04/14, was suspended on 09/08/14 and was officially terminated on 09/12/14. 2. Review of the facility's investigation, dated 09/08/14, revealed the facility faxed a report to the Office of Inspector General (OIG) and the Department of Community Based Services (DCBS) on 09/08/14. The Local Police Department (opened case #14-2423) was also notified regarding misappropriation of controlled medications. The Kentucky Board of Nursing was notified of the allegation in regards to RN #1 on 09/11/14. 3. Review of the facility's charges from the Pharmacy revealed the facility purchased the reordered medications that were destroyed. Review of the Product Destruction Summary, dated 09/26/14, revealed medications were being destroyed as of 09/17/14. Interview on 09/26/14 at 1:29 PM, with the DON revealed the facility replaced the narcotic medications that were destroyed. 4. Review of Resident #1's Controlled Substance Inventory Form, revealed two (2) bottles of [MEDICATION NAME] were destroyed on 09/10/14 by the DON and Assistant Director of Nursing (ADON). Interview with the ADON, on 09/25/14 at 9:28 AM, revealed she was present when Resident #1's medication was being destroyed. Interview with the DON, on 09/24/14 at 3:48 PM, revealed she destroyed any medications that appeared tampered. 5. Interview with the DON, on 09/24/14 at 3:48 PM, revealed the police were given Resident #2's medication cards. Review of Resident #2's two (2) [MEDICATION NAME] narcotic cards, which were in police custody at the Police Department, revealed one card was tampered; however, this medication was not dispensed to Resident #1. The other [MEDICATION NAME] narcotic card showed no evidence that it had been tampered. Review of the facility's charges from the Pharmacy, revealed the facility purchased the re-ordered medications which were destroyed. 6. Review of Resident #5's [MEDICATION NAME] and [MEDICATION NAME] narcotic sheets, revealed the two (2) medications were destroyed on 09/15/14 by the DON. Interview with the DON, on 09/26/14 at 1:29 PM, revealed the DON had destroyed [MEDICATION NAME] and [MEDICATION NAME] on 09/15/14. 7. Record review of audits of narcotic orders and reconciliation sheets for discrepancies, revealed they started to be completed on 09/15/14. Interview with the DON, on 09/26/14 at 2:37 PM, revealed she began to audit MARs and physician orders [REDACTED]. Interview with the DON, on 10/13/14 at 10:29 AM, revealed every morning she reviewed the controlled substances, to ensure the narcotic counts were right and would report that to the QA team every morning, 10/06/14 through 10/10/14. 8. Review of the Pharmacy Clinical Manager MAR to Cart Audit Form, dated 10/03/14, revealed she completed a 100% audit to look at all orders, verified the MAR matched the orders, and that the pink narcotic sheets matched the drug labels. Then all narcotic counts were verified. The review revealed no signs of diversion for any of the residents. Interview with the Pharmacy Clinical Manager, on 10/13/14 at 11:34 AM, via telephone, revealed she came into the facility to review controlled substances orders, make sure the directions of the orders matched the narcotic sheets. She did an inventory with nursing and inspected the medications and ensured that the narcotic counts matched. The Pharmacy Clinical Manager stated she did not identify any concerns except the orders did not match the directions on the narcotic cards, especially when the medication changed from routine to PRN. She stated she reviewed all four (4) medication carts and looked at the Emergency Drug Kit (EDK) box, which revealed no concerns with the shift change counts. She then provided the facility with a report. Interview with the Administrator, on 10/13/14 at 2:02 PM, revealed on 10/03/14 the Pharmacy Clinical Manager came in and did a 100% audit and would provide oversight until 11/30/14. 9. Review of the education content confirmed the education was completed on 09/30/14 by the DON for eleven (11) LPNs, and five (5) RNs, there was no PRN staff, none on FMLA (Family Medical Leave Act) or vacation and the facility did not use contract staffing. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3 on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7 on 10/13/14 at 1:26 PM; and ,RN #4, on 10/10/14 at 10:36 AM revealed all were knowledgeable of what abuse and misappropriation was and how to report to the DON or Administrator immediately. 10. Interview with the DON, on 10/13/14 at 10:29 AM, revealed she received training on 09/12/14 by the Regional Nurse Consultant. She was educated on medication pass, audits, what information she needed to obtain from the pharmacy, such as a record of all the items that needed to be ordered by pharmacy and then use the information to audit the MAR and compare to what was in the drawer and the physician's orders [REDACTED]. Interview with the Regional Nurse Consultant, on 10/13/14 at 3:42 PM, revealed she completed education on 09/08/14 and 09/12/14 with the DON and Administrator. She went over documentation, narcotic sheets and the protocol for nursing. She also compared MARs and the Pain assessment sheets. The DON was educated on not throwing away evidence. The DON was educated on abuse and misappropriation of medications. The Regional Nurse Consultant stated she talked to the DON about replacing all medications because it was the resident's property. The DON was educated on monitoring the narcotic sheets, MARs and Pain assessment sheets daily. The destruction of medication and ensuring two (2) nurses were present. Also, monitoring the EDK box and ensuring the serial numbers matched everyday. The DON was also educated on different methods of tampering with medication and not having tape placed on the back of narcotic cards. 11. Interview with LPN #3, on 10/10/14 at 1:20 PM, revealed she was not educated by the Clinical Services Nurse. LPN #3 stated she was not in the building on 10/06/14, 10/07/14 or 10/08/14 in which the Consulting Pharmacists were present in the building. LPN #3 stated she did not obtain a packet from the DON, but had obtained 1:1 training with the DON. LPN #3 had been working the whole shift on 10/10/14 without being educated. Review of the In-service Education on 10/08/14, by the Clinical Services Nurse from pharmacy for the loss/theft of medications, revealed only six (6) LPNs were educated, one (1) RN, and the ADON was educated out of a total of sixteen (16) licensed staff members. LPN #3 was not on the sign in list as being educated. Interview with the Regional Nurse Clinician for pharmacy, revealed she completed a quick training with the staff because she was told the staff had already been in-serviced. The training was supposed to be a quick reference tool. She stated she observed a shift to shift narcotic count. The Regional Nurse Clinician stated she wanted to ensure the nurses, when counting narcotics, monitored the card numbers and looked at the narcotic sheets to ensure they matched. The DON stated she knew LPN #3 was not trained and was going to train LPN #3 at the end of her shift. The DON stated LPN #3, knew she had been trained on most of the information; however, she was not trained on how to destroy narcotic medication and who was responsible to destroy the medications. Everything the Regional Nurse Clinician educated staff on, the DON had already went over with the staff. So though the Regional Nurse Clinician did not get the opportunity to educate all the nursing staff, all nurses were provided the same information. Review of the daily QA meetings on 10/06/14 through 10/10/14, revealed no documented evidence that the training went to QA; however, there was evidence on the 10/07/14 QA meeting where they talked about the pharmacy and their role and participation in the correction of the deficiency. Interview with the Regional Director of Operations, on 10/10/14 at 2:21 PM, revealed staff was not to work unless they had been educated. He stated he was not aware LPN #3 was on the floor the whole shift. He stated he was at fault for this. The Regional Director of Operations (RDO) stated he knew he stated in the Allegation of Compliance (AOC), all the nursing staff was educated, but he meant to say the staff could not work if all were not educated and would fix it immediately. Interview with the RDO, on 10/10/14 at 2:04 PM, revealed he had the information in the AOC wrong. Review of the training for loss or theft of medications revealed an additional six (6) nurses were educated on 10/10/14 by the DON. 12. Review of the Pain Assessment and Management training provided from 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-served on pain medications. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of pain assessments and the fact they had to be completed before and after administration of pain medications. The trainings were completed on 09/27/14. Review of the training on the Ins and Outs of Documentation, provided 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-serviced on documentation. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4,

Based on observation, interview, record review and review of the facility's policies and job descriptions, it was determined the facility failed to have an effective Quality Assurance Committee (QA) to ensure the identification of quality deficiencies, implementation of plans of action, and monitoring of the plans of action to prevent misappropriation/drug diversion and tampering of resident medications and controlled substances, for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #5 and #6); and, two (2) of two (2) unsampled residents (Residents A and B). The facility failed to identify and report diversion of medications/narcotics when staff found tape on the back side of narcotic cards. Narcotics were replaced with other medications, and staff borrowed resident medications for other residents' use. The facility failed to monitor, reconcile and destroy medications according to standards of practice. The facility failed to ensure the resident's clinical record was maintained in an accurate format to detail the care provided. The facility further failed to include Pharmacy in the QA Committee meetings to assist with the investigation of drug diversion. (Refer to F224, F431, F490 and F514) The facility staff identified suspicion of diversion of drugs; however, failed to report this to the Administrative staff. Once the Administrative staff was made aware of the suspicion of drug diversion they did not take this information to QA for review and possible plan of action. The staff continued to borrow medication from residents after education was provided by the Director of Nursing in June 2014, and the borrowing of medications was not reviewed by the QA Committee. Pharmacy provided the QA Committee with reports; however, they did not identify borrowing of medications or diversion of narcotics as a concern. The QA Committee did not review the narcotic reconciliation process to determine if the process met the facility's policy. The QA committee did not identify, monitor, or develop plans of action to ensure the accuracy of the medical record. The facility's failure to ensure an effective QA Committee was in place to identify quality deficiencies, develop action plans and monitor the effectiveness of the plans for narcotic reconciliation, monitoring of medication administration, and accurate documentation to prevent misappropriation/drug diversion and tampering of resident medications and controlled substances placed residents at risk in a situation that has caused is likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 10/02/14 and determined to exist on 08/31/14. The facility provided an acceptable Allegation of Compliance on 10/09/14 that alleged removal of Immediate Jeopardy on 10/09/14. However, the State Survey Agency determined the Immediate Jeopardy was removed on 10/11/14, after training of facility staff was verified completed 10/10/14, at 42 CFR 483.75 Administration (F520) with the scope and severity lowered to an "E" while the facility monitors the effectiveness of the implemented plan of correction. The findings include: Review of the facility's policy, Adverse Consequences and Medication Error, revised February 2014, revealed the interdisciplinary team reviews the resident's medication regimen for efficiency and actual or potential medication-related problems on an ongoing basis. The QA Committee would conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements were effective in reducing errors. Interview with the Assistant Director of Nursing (ADON), on 09/25/14 at 9:28 AM, revealed such drugs as [MEDICATION NAME] and [MEDICATION NAME] were reordered too soon. The ADON stated she discovered it was easy to see on the Pharmacy System the drugs that needed to be reordered and the drugs the facility had to pay for reimbursement. The ADON stated she could not remember which residents were effected. She further stated she did not monitor anything, just the medications which needed to be reordered. The ADON stated the nurses had to be trained and the circumstance did not go to the QA Committee. The ADON stated it should have gone. Interview with the Director of Nursing (DON), on 09/24/14 at 3:48 PM, revealed she had repeatedly educated the staff about not borrowing medications and acknowledged she had educated the staff back in June 2014. The DON stated she began to complete medication checks, sometimes triple checks of the house drugs and was wondering why the facility was being charged for drugs. The DON stated she really did not know what to do with the information that was being presented to her. The DON stated she called a Pharmacy Representative and asked how could the facility be ordering multiple medications. However, post survey interview with the DON, on 11/04/14 at 2:07 PM, revealed there was no conversation with the pharmacy on how the pharmacy would help resolve the reordering of medications. Per interview, the pharmacy always faxed over a "reorder to soon document" in which the DON or Administrator would have to sign to receive the medications. The DON stated no one from pharmacy called her to inform her about too many drugs being reordered by the facility. Interview with the Consulting Pharmacist, on 09/25/14 at 5:01 PM, revealed she had a phone conversation with the DON regarding the review of delivery tickets for [MEDICATION NAME] by the DON, but could not recall the [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] ([MEDICATION NAME]) (both are anti-depressants) being in the conversation. Continued interview with the DON on 09/24/14 at 3:48 PM, revealed the issue was taken to QA; however, she could not specify a date. The action plan instructed the DON to check the orders to see if they match what was on the narcotic cards. Also check to see if the amount of medication ordered balanced with the MARs. Further interview with the DON, on 09/25/14 at 2:37 PM, revealed she did not receive empty narcotic cards or narcotic sheets, as all of the narcotic sheets went to Medical Records to be filed; however, this was not reviewed in QA. Interview with the Administrator, on 09/25/14 at 4:06 PM, revealed the DON had brought to her attention the facility had to replace medications which were coming up missing and this information was taken to the QA committee on 06/06/14. The plan at that time was to monitor and triple check the nurses documentation of the MAR to ensure there was enough medications available. The Unit Manager was responsible to check the AHT (medical record in the computer system) to make sure the medication orders were placed on the MAR and AHT. The DON was responsible to update the care plans and educate the nursing staff on the importance of reviewing the five (5) rights and three (3) checks of the medication pass as well as the importance of ensuring the accuracy of the transcription of medication orders. Interview with the Medical Director, on 09/25/14 at 3:47 PM, revealed the facility had to reorder medications. The Medical Director stated there was a plan of action to get to the bottom of the problem on 06/06/14. He stated the QA talked about possible diversion of medication and foul play. The Medical Director stated he felt the action plan was consistent with the goals of the facility, but he could not specify the plan. Interview with the Consulting Pharmacist, on 09/25/14 at 5:01 PM, revealed she did not attend QA meetings; however, provided a QA report on what she had found quarterly. The Consulting Pharmacist stated she did not complete a 100% audit, but did complete a 10% spot check in which she did not identify any concerns with narcotics or control sheets. Based on the facility's census on 09/23/14, this would only be six (6) residents reviewed related to narcotics and control sheets. However, per the Consultant Pharmacist's job description, the Pharmacist would conduct a Medication Regimen Review on each resident in the facility monthly and would coordinate or perform review of controlled substance utilization, reconciliation and documentation. Although the Pharmacist's job description did not specify a measured quantity to review, it stated the Pharmacist should follow the regulations and per post survey interview with the Pharmacy General Manager, on 11/05/14 at 9:30 AM, the Pharmacist was to look at 100% of the 30 day reviews. The Pharmacy General Manager stated there was no rule that a Pharmacist had to look at ten (10) percent of the census for additional audits. They normally looked at enough residents to determine if there was a pattern to their concerns. Interview with the Administrator, on 09/25/14 at 4:06 PM, revealed she followed up on 06/30/14 in the QA meeting and what was reported was the in-service had been completed and the DON had worked individually with nurses who had issues with medication errors and there had been great improvements. Pharmacy came and checked their records to see if the nurses were reordering and comparing the information to the MARs. The Administrator stated she thought in July 2014, the Consulting Pharmacist stated to her the medications looked "really really good". The Administrator stated then on July 28th the QA Committee discontinued monitoring the reordering of medication concerns; however, never discussed the diversion of narcotics. Further interview with the Administrator, on 09/25/14 at 4:06 PM, revealed the DON reported the monitoring would continue and the licensed nursing staff would be educated as issues arose. No other QA meetings after the 07/28/14 meeting was provided; although diversion of narcotics was identified on 08/31/14. Post survey interview with the Administrator, on 11/04/14 at 1:37 PM, revealed she talked to the Pharmacy when the reordering concern was brought to QA. The Administrator stated she talked to the pharmacy in regards to the new orders and the mix up on quantities of medications available. She stated she was trying to figure out what was sent and not sent for the residents. The Administrator stated she thought the problem was fixed when she asked the Pharmacy to send resident medications at their cost. She further stated the facility took on the responsibility to fix the reordering problem. Pharmacy was not identified as a source to help with the monitoring process or help the QA Committee find the root cause of the reordering concern. However, review of the Consultant Pharmacist's job description, effective 03/09/11, revealed the consultant pharmacist's key responsibilities included attending the facility's quarterly QA Committee meetings. Review of the pharmacy contract, effective 07/01/12, revealed the pharmacy would make a representative of pharmacy available for attendance at the facility's QA Committee meetings. Post survey interview with the Pharmacy General Manager (GM), on 11/05/14 at 9:30 AM, revealed if there was any correspondence between the pharmacy and the facility regarding assistance with QA they would have come to him. However, review of his correspondences revealed there were none from the facility. Through facility audit reviews of narcotic sheets after 08/31/14, it was identified by the facility that twenty-five (25) additional residents were involved in the possible diversion of medications. However, the additional information was not discussed in the QA meetings, per interview with the Administrator, on 09/25/14, as there had been no QA meetings since 07/28/14. The facility provided an acceptable Allegation of Compliance (AOC) on 10/09/14 alleging the Immediate Jeopardy was removed 10/09/14; however, the State Survey Agency verified that staff training was completed on 10/10/14 and the Immediate Jeopardy was removed on 10/11/14. The facility took the following steps to remove the Immediate Jeopardy. 1. Residents #1, #2, #3, #5 and #6 were assessed and interviewed, with no negative outcomes. RN #1 was immediately suspended on 09/08/14 pending the investigation. 2. Licensed staff was interviewed and the allegation reported to the Office of Inspector General (OIG), Kentucky Board of Nursing (KBN), the Department of Community Based Services (DCBS) and Law Enforcement. 3. All medications found to be tampered with were reordered at the facility's expense. 4. Resident #1's tampered medications were pulled from circulation on 09/08/14 by the DON and destroyed on 09/10/14. 5. Resident #2's medications were pulled on 09/03/14 and locked up, when the resident was admitted to the hospital. Upon the resident's return on 09/10/14, the narcotics were determined to have been tampered with and the Police were immediately notified. Narcotics and their containers were turned over to the local Police Department. Medications were reordered at the facility's expense. 6. On 09/16/14, the Pharmacist auditing the medication carts suggested to the DON and the ADON, that Resident #5's narcotics should be destroyed. 7. The DON and facility Administrator conducted 100 % audit of narcotic orders and reconciliation sheets for any discrepancies that may indicate diversion on 09/08/14. The DON continued to complete audits daily to ensure there has been no breach of narcotic medication administration, documentation, reconciliation and or tampering of packages. 8. The Consultant Manager from the pharmacy (facility contracted), on 10/03/14, reviewed and analyzed narcotic medications dispensed and being administered for any discrepancies of tampered packaging, documentation of narcotic sheets, medication administration records for reconciliation and the Emergency Drug Kit (EDK). In addition, all Consulting Pharmacists visits starting 10/03/14 will include at a minimum a review of the entire narcotic dispensing system and analyzing narcotic counts, records, MARs, labels and packaging which will be compared to current orders to ensure there has been no tampering. 9. Education provided to the nursing staff by the DON included medication misappropriation (tampering of medication packaging or appearance of falsification of narcotic sheets), immediate notification to the DON, supervisor or the Administrator. 10. The DON was educated by the Regional Nurse Consultant for Preferred Care Partners Management Group on 09/12/14, on Misappropriation and Diversion of Narcotics, EDK Process, Pharmacy Training Guide, Notification to Administration and Pharmacy, Destruction of Narcotics, Pain Assessment, Accuracy of Notes, Change of Condition, Abuse and Neglect and the Narcotic Balance. 11. All licensed staff was educated by the Nursing Consultants on 10/07/14, which was attended by fourteen (14) licensed nursing staff. This includes seven (7) RNs and seven (7) LPNs, the Director of Nursing and the Unit Manger. In-services provided on the 7th were taken to QA on the 7th. 12. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following programs: Pain Assessment and Management; Accuracy of Notes, Documenting change of Condition; PRN Medication Management; Medication Pass-Indicators, Side Effects, reporting errors; Prevent/Recognize and Reporting Patient abuse; Pharmacy Training Guide; EDK Process; and, State Regulations controlled substance Notification. This training was completed by all nursing staff on the computer program SilverChair by 09/28/14. 13. All Registered Nurses (RN) and Licensed Practical Nurses (LPN), who handle a medication cart have been in-serviced on the following Policies: Adverse Reaction to Medications; Controlled Substances- Misappropriation; Adverse Consequences and Medication Errors; Accepting Delivery of Medications; Administering Medications; Loss or Theft of Medications; Discarding or Destroying of Medications; and, Security of the Medication Carts. This training was provided by the DON and completed by all nursing staff by 10/06/14. 14. The Quality Assurance Committee consisted of the Administrator, DON, Unit Managers, Social Services, Activities Director, Dietary Director, Medical Director and Consulting Pharmacist, met Monday through Friday, in which the DON and or the Administrator reported on Narcotic Count Records as well as the MAR and reviewed narcotic medications. If suspicion was identified, the DON would immediately contact the Pharmacy and begin an internal investigation. All proper Authorities would be notified including OIG, DCBS, local police and/or KBN. This practice would continue 5 x weekly and/or PRN as needed through 10/31/14. 15. Any discrepancies discovered on the weekend, the weekend nurse would immediately notify the nurse on call, the nurse on call would notify the Administrator or DON. 16. The Pharmacy Consultant would also review for any possible administration of narcotics that may elude a suspicious activity and review the list of destroyed narcotics with each visit. Also a copy of current narcotic orders would be provided from pharmacy for the consultant pharmacist to reconcile with the current orders on the resident's chart to ensure ordering accuracy from pharmacy. 17. The Administrator contacted the Corporate Regional Team on 09/08/14. She and the DON organized the collection of narcotics, and narcotic count sheets on 09/08/14. The DON contacted local law enforcement agency. The Administrator reviewed policies and procedures on 09/08/14 with no revisions. Through observation, interview and record review the State Survey Agency (SSA) validated the Allegation of Compliance with removal of Immediate Jeopardy on 10/11/14 prior to exit on 10/13/14. 1. Interview with Resident #1, on 09/23/14 at 11:30 AM and Resident #3, on 09/23/14 at 8:57 AM, revealed no negative outcomes. Review of Residents #1, #2, #3, #5, and #6's clinical record revealed no adverse outcomes. Review of RN #1's employee file, revealed the facility terminated RN #1 on 09/12/14. Interview with the DON, 09/24/14 at 3:48 PM, revealed RN #1 had not worked since 09/04/14, was suspended on 09/08/14 and was officially terminated on 09/12/14. 2. Review of the facility's investigation, dated 09/08/14, revealed the facility faxed a report to the Office of Inspector General (OIG) and the Department of Community Based Services (DCBS) on 09/08/14. The Local Police Department (opened case #14-2423) was also notified regarding misappropriation of controlled medications. The Kentucky Board of Nursing was notified of the allegation in regards to RN #1 on 09/11/14. 3. Review of the facility's charges from the Pharmacy revealed the facility purchased the reordered medications that were destroyed. Review of the Product Destruction Summary, dated 09/26/14, revealed medications were being destroyed as of 09/17/14. Interview on 09/26/14 at 1:29 PM, with the DON revealed the facility replaced the narcotic medications that were destroyed. 4. Review of Resident #1's Controlled Substance Inventory Form, revealed two (2) bottles of [MEDICATION NAME] were destroyed on 09/10/14 by the DON and Assistant Director of Nursing (ADON). Interview with the ADON, on 09/25/14 at 9:28 AM, revealed she was present when Resident #1's medication was being destroyed. Interview with the DON, on 09/24/14 at 3:48 PM, revealed she destroyed any medications that appeared tampered. 5. Interview with the DON, on 09/24/14 at 3:48 PM, revealed the police were given Resident #2's medication cards. Review of Resident #2's two (2) [MEDICATION NAME] narcotic cards, which were in police custody at the Police Department, revealed one card was tampered; however, this medication was not dispensed to Resident #1. The other [MEDICATION NAME] narcotic card showed no evidence that it had been tampered. Review of the facility's charges from the Pharmacy, revealed the facility purchased the re-ordered medications which were destroyed. 6. Review of Resident #5's [MEDICATION NAME] and [MEDICATION NAME] narcotic sheets, revealed the two (2) medications were destroyed on 09/15/14 by the DON. Interview with the DON, on 09/26/14 at 1:29 PM, revealed the DON had destroyed [MEDICATION NAME] and [MEDICATION NAME] on 09/15/14. 7. Record review of audits of narcotic orders and reconciliation sheets for discrepancies, revealed they started to be completed on 09/15/14. Interview with the DON, on 09/26/14 at 2:37 PM, revealed she began to audit MARs and physician orders [REDACTED]. Interview with the DON, on 10/13/14 at 10:29 AM, revealed every morning she reviewed the controlled substances, to ensure the narcotic counts were right and would report that to the QA team every morning, 10/06/14 through 10/10/14. 8. Review of the Pharmacy Clinical Manager MAR to Cart Audit Form, dated 10/03/14, revealed she completed a 100% audit to look at all orders, verified the MAR matched the orders, and that the pink narcotic sheets matched the drug labels. Then all narcotic counts were verified. The review revealed no signs of diversion for any of the residents. Interview with the Pharmacy Clinical Manager, on 10/13/14 at 11:34 AM, via telephone, revealed she came into the facility to review controlled substances orders, make sure the directions of the orders matched the narcotic sheets. She did an inventory with nursing and inspected the medications and ensured that the narcotic counts matched. The Pharmacy Clinical Manager stated she did not identify any concerns except the orders did not match the directions on the narcotic cards, especially when the medication changed from routine to PRN. She stated she reviewed all four (4) medication carts and looked at the Emergency Drug Kit (EDK) box, which revealed no concerns with the shift change counts. She then provided the facility with a report. Interview with the Administrator, on 10/13/14 at 2:02 PM, revealed on 10/03/14 the Pharmacy Clinical Manager came in and did a 100% audit and would provide oversight until 11/30/14. 9. Review of the education content confirmed the education was completed on 09/30/14 by the DON for eleven (11) LPNs, and five (5) RNs, there was no PRN staff, none on FMLA (Family Medical Leave Act) or vacation and the facility did not use contract staffing. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3 on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7 on 10/13/14 at 1:26 PM; and ,RN #4, on 10/10/14 at 10:36 AM revealed all were knowledgeable of what abuse and misappropriation was and how to report to the DON or Administrator immediately. 10. Interview with the DON, on 10/13/14 at 10:29 AM, revealed she received training on 09/12/14 by the Regional Nurse Consultant. She was educated on medication pass, audits, what information she needed to obtain from the pharmacy, such as a record of all the items that needed to be ordered by pharmacy and then use the information to audit the MAR and compare to what was in the drawer and the physician's orders [REDACTED]. Interview with the Regional Nurse Consultant, on 10/13/14 at 3:42 PM, revealed she completed education on 09/08/14 and 09/12/14 with the DON and Administrator. She went over documentation, narcotic sheets and the protocol for nursing. She also compared MARs and the Pain assessment sheets. The DON was educated on not throwing away evidence. The DON was educated on abuse and misappropriation of medications. The Regional Nurse Consultant stated she talked to the DON about replacing all medications because it was the resident's property. The DON was educated on monitoring the narcotic sheets, MARs and Pain assessment sheets daily. The destruction of medication and ensuring two (2) nurses were present. Also, monitoring the EDK box and ensuring the serial numbers matched everyday. The DON was also educated on different methods of tampering with medication and not having tape placed on the back of narcotic cards. 11. Interview with LPN #3, on 10/10/14 at 1:20 PM, revealed she was not educated by the Clinical Services Nurse. LPN #3 stated she was not in the building on 10/06/14, 10/07/14 or 10/08/14 in which the Consulting Pharmacists were present in the building. LPN #3 stated she did not obtain a packet from the DON, but had obtained 1:1 training with the DON. LPN #3 had been working the whole shift on 10/10/14 without being educated. Review of the In-service Education on 10/08/14, by the Clinical Services Nurse from pharmacy for the loss/theft of medications, revealed only six (6) LPNs were educated, one (1) RN, and the ADON was educated out of a total of sixteen (16) licensed staff members. LPN #3 was not on the sign in list as being educated. Interview with the Regional Nurse Clinician for pharmacy, revealed she completed a quick training with the staff because she was told the staff had already been in-serviced. The training was supposed to be a quick reference tool. She stated she observed a shift to shift narcotic count. The Regional Nurse Clinician stated she wanted to ensure the nurses, when counting narcotics, monitored the card numbers and looked at the narcotic sheets to ensure they matched. The DON stated she knew LPN #3 was not trained and was going to train LPN #3 at the end of her shift. The DON stated LPN #3, knew she had been trained on most of the information; however, she was not trained on how to destroy narcotic medication and who was responsible to destroy the medications. Everything the Regional Nurse Clinician educated staff on, the DON had already went over with the staff. So though the Regional Nurse Clinician did not get the opportunity to educate all the nursing staff, all nurses were provided the same information. Review of the daily QA meetings on 10/06/14 through 10/10/14, revealed no documented evidence that the training went to QA; however, there was evidence on the 10/07/14 QA meeting where they talked about the pharmacy and their role and participation in the correction of the deficiency. Interview with the Regional Director of Operations, on 10/10/14 at 2:21 PM, revealed staff was not to work unless they had been educated. He stated he was not aware LPN #3 was on the floor the whole shift. He stated he was at fault for this. The Regional Director of Operations (RDO) stated he knew he stated in the Allegation of Compliance (AOC), all the nursing staff was educated, but he meant to say the staff could not work if all were not educated and would fix it immediately. Interview with the RDO, on 10/10/14 at 2:04 PM, revealed he had the information in the AOC wrong. Review of the training for loss or theft of medications revealed an additional six (6) nurses were educated on 10/10/14 by the DON. 12. Review of the Pain Assessment and Management training provided from 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-served on pain medications. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of pain assessments and the fact they had to be completed before and after administration of pain medications. The trainings were completed on 09/27/14. Review of the training on the Ins and Outs of Documentation, provided 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-serviced on documentation. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of accurate documentation of the MAR's and narcotic sheets. The training was completed for all nursing staff by 09/28/14. Review of the training on PRN Medication Management, provided on 09/01/14 through 10/05/14, revealed all licensed staff, eleven (11) LPNs and five (5) RNs had been in-serviced on PRN medication management and ensuring an assessment was completed on all residents before and after PRN medication was given. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable of PRN medication management. The training was completed by all nursing staff by 09/29/14. Review of the training on Medication Pass, provided on 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs had been in-serviced on the proper way to perform a medication pass, side effects of giving the wrong medications and reporting errors immediately to the DON or Administrator. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable about the Medication Pass requirements. The training was completed on 09/29/14. Review of the training on Preventing, Recognizing and Reporting Resident Abuse, provided on 09/01/14 through 10/05/14, revealed eleven (11) LPNs and five (5) RNs were educated on abuse, misappropriation and the importance of notifying the DON and Administrator as soon as abuse was observed. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of identifying and reporting abuse. The training was completed by all nursing staff by 09/30/14. Review of the training on the Pharmacy Training Guide, EDK Process and KAR's Controlled Substance Notification, provided on 09/17/14, revealed nine (9) LPN's and five (5) RN's were educated and two LPN's were educated on a later date. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of the physician order [REDACTED]. The training was completed by all nursing staff by 10/10/14. 13. Review of a training provided by the Regional Nurse Clinician and the DON on Policies and Procedures with copies provided on the following: loss and theft of medications; adverse consequences; medication destruction and disposal of controlled substances; security of the medication cart; documentation medication administration; administering medications; and, accepting delivery of medications and controlled substances. Review revealed all eleven (11) LPNs and five (5) RNs were inserviced from 10/07/14 through 10/10/14. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were all knowledgeable of the policies and procedures for narcotics and medication administration. The training was completed by all nursing staff on 10/10/14. 14. Review of the QA meetings minutes and sign in sheets, dated 10/06/14, 10/07/14, 10/08/14, 10/09/14 and 10/10/14, revealed the Administrator, DON, Unit Manger, Medical Director, Consulting Pharmacist and Regional Director of Operations had attended daily meetings Monday through Friday. Interview with the DON, on 10/13/14 at 10:29 AM, revealed there was a QA meeting every morning. Review of the Controlled Substance Audit, dated 10/06/14 through 10/10/14, revealed the audits were completed without concerns. The DON stated she would report back to the QA committee with any diversion they would initiate an investigation immediately and report to all agencies. Interview with the Regional Director of Operations, on 10/13/14 at 2:28 PM, revealed he would attend QA daily while he was in the facility. 15. Interview with LPN #2, on 10/10/14 at 9:30 AM, LPN #3, on 10/10/14 at 1:20 PM, LPN #4, on 10/13/14 at 1:50 PM, LPN #6 on 10/10/14 at 3:30 PM, and LPN #7, on 10/13/14 at 1:26 PM and RN #4, on 10/10/14 at 10:36 AM, revealed they were knowledgeable to call the DON immediately if they observed any discrepancies with narcotics. The staff was also aware to report to the DON if they had witnessed tape behind a narcotic medicat